Pulmonary Arterial Hypertension Special Issues and Current Therapeutic Approaches: Part Two

Size: px
Start display at page:

Download "Pulmonary Arterial Hypertension Special Issues and Current Therapeutic Approaches: Part Two"

Transcription

1 The online version of this article, along with access to discussion threads on NATF s eforum, is available at: (January, 2010) Pulmonary Arterial Hypertension Special Issues and Current Therapeutic Approaches: Part Two Carlos Jerjes-Sanchez, MD, Edgar Garcia-Badillo, MD Alicia Ramírez- Rivera, MD, Susana Ramírez-Rivera, MD Pulmonary Arterial Hypertension Clinic Unidad de Investigación Clínica en Medicina S.C., Monterrey, NL, Mexico Pulmonary arterial hypertension treatment The treatment of PAH has advanced dramatically in the last decade through the results of several well-designed clinical trials demonstrating the efficacy of several therapies that target specific abnormalities present in PAH Currently, standard treatment including diet, oral anticoagulation, diuretic and digoxin, are part of the modern therapeutic approach. Standard treatment Diet A low-salt diet and judicious use of diuretics can be helpful in reducing volume overload in patients with PAH and right ventricular failure. Because the right heart is dependent on preload, care should be taken to avoid excessive diuresis and further reduction of cardiac output.

2 1 Oral anticoagulation Anticoagulation use is based on the improved survival data from two small retrospective studies as well as evidence of microscopic in situ thrombosis 34. In the absence of contraindications, anticoagulation is recommended to keep the target INR at Anticoagulation use is controversial in scleroderma associated PAH and in CHD-PAH with hemoptysis, for high risk of bleeding complications 35, 36. Diuretics In the setting of PAH, three kinds of diuretics have been used: thiazide, loop, and potassium-sparing diuretics. These drugs are recommended for right ventricular failure. It is not known whether diuretics alter mortality or morbidity in PAH 37, 38. Loop diuretics are traditionally used and bumetanide, in addition to metolazone, could be another option 39. Spironolactone Sympathetic system stimulation, followed by activation of the renin, angiotensin, and aldosterone system, are important contributors to the vicious circle of chronic heart failure. Accounting for this excessive neurohormonal response resulted in major and highly effective changes in therapeutic approach to chronic heart failure, primarily due to left ventricular dysfunction. Right ventricular dysfunction due to severe PAH ultimately results in similar changes in systemic hemodynamic, trigger neurohormonal response, low cardiac index and hypotension. Spironolactone remains the only classical neurohormonal modulator, which found place in the treatment of isolated RV failure. It is used in PAH as an adjunct to loop diuretics, but also with the hope of limiting the aldosterone-induced myocardial fibrosis 40. In addition, advances in the knowledge of the molecular mechanisms involved in PAH suggest that endothelial dysfunction with chronic impaired production of vasoactive mediators plays a key role. Reduced production of vasoactive mediators, such as NO and prostacyclin, along with prolonged overexpression of vasoconstrictors, such as endothelin-1 (ET-1), not only affect vascular tone but also promotes vascular remodeling. Thus, these substances represent

3 2 logical pharmacological targets. Experimental studies showed ET-1 could stimulate aldosterone secretion in different species, both in vivo and in vitro. Spironolactone should not be used in patients with serum creatinine > 2.5 mg/dl or potassium > 5.0 meq/l 41. Digoxin This drug has been used in right ventricular failure and flutter or atrial fibrillation patients, although it has not been studied extensively in PAH 42, 43. If used as an inotropic agent, trough levels should be kept between 0.5 and 1.0 ng/ml to prevent its adverse effects. Considering that it has no activity of blood pressure, renal function and ejection fraction, it is an attractive option for PAH patients with flutter or atrial fibrillation. In addition, digoxin could induce favorable acute hemodynamic effects and decrease plasma norepinephrine 35 in patients with right ventricular failure and IPAH. However, the long-term consequences of this treatment are unknown 44. Oxygen It is recommended in patients with proven hypoxemia, PaO2 < 55 mmhg or SaO2 < 89% at rest, during sleep or with ambulation to keep SaO2 > 90% at all times 45, 46. Patients may require supplementation at night and during air travel even when during daytime the level of oxygenation is normal. Because hypoxia is a potent pulmonary vasoconstrictor, it is critical to identify and reverse hypoxemia. Low-flow supplemental oxygen therapy prolongs survival in hypoxemic patients 47. Failure to recognize and correct hypoxemia may be the error most frequently made in the treatment of PAH patients. Maximizing supplemental oxygen therapy in a short-term period had beneficial effects as a selective pulmonary vasodilator in adult patients with PAH and was independent of baseline oximetry, hemodynamic, and echocardiographic right ventricular function. Improvement in pulmonary vascular resistance in response to maximum supplemental oxygen therapy may also serve as a marker of pulmonary vasoreactivity in adult and pediatric PAH and CHD populations. Supplementing arterial oxygen tension beyond the minimum target of 60 mm Hg may improve pulmonary vascular resistance and cardiac index. These short-

4 3 term effects are likely due at least partially to releasing hypoxic pulmonary vasoconstriction, but may also be due to additional mechanisms as yet unidentified 47. Role of calcium channels blockers. Three kinds of calcium channels blockers (CCBs) are used in the treatment of patients with PAH: nifedipine, diltiazem and recently, amlodipine. Currently, we have strong evidence obtained through several clinical studies regarding nifedipine and diltiazem use There are no studies specifically evaluating the long-term effects of amlodipine in acute vasodilator responders. One small short-term study including only 6 patients with PAH (5 with chronic thromboembolic disease and one with IPAH) showed that amlodipine, up to a dose of 40 mg, was well-tolerated 53. A mpap and PVR > 20%, decreased with mild effects on systemic blood pressure in two patients was observed. The use of amlodipine in long-term treatments is based in part in the efficacy and safety shown in patients with congestive heart failure and perhaps on its long half-life, which may provide additional safety from hemodynamic deterioration that may occur after CCB withdrawal Despite a high average dose of CCBs, the doses of nifedipine and diltiazem ranged from 60 to 120mg daily and 180 to 720 mg respectively, indicating that some patients had long-term improvement with conventional doses of CCBs 55. Whether these doses in Hispanics and Latin- Americans patients are safe is not known. No randomized clinical trials have been designed comparing treatment with low versus high doses of CCBs for chronic treatment based on the dose required for an acute vasodilator effect. Special recommendations Hot baths or showers are discouraged because the resultant peripheral vasodilatation can produce systemic hypotension and syncope. We discourage exposure to high altitudes (more than approximately 1800 m above sea level), as this may produce hypoxic pulmonary vasoconstriction and further compromise oxygen transport. Air travel can be problematic and traveling with oxygen is highly recommended. Nocturnal hypoxemia occurs in more than 75% of patients with IPAH without sleep apnea. The use of vasoconstricting sinus or cold medications or the use of serotonergic medications for migraine headaches

5 4 is not recommended. Immunization against influenza and pneumococcal pneumonia is suggested. Caution should be used with laparoscopic procedures in which carbon dioxide is used for abdominal insufflations, as its absorption can produce hypercarbia, which is a pulmonary vasoconstrictor 1. Optimal treatment Prostanoids Prostacyclins are endogenous substances that are produced by vascular endothelial cells and induce vasodilatation, inhibition of platelet activity, and antiproliferative effects 56, 57. A dysregulation of prostacyclin metabolic pathways has been shown in patients with PAH and this represents the rationale for the exogenous therapeutic administration of this substance. The clinical use of prostacyclin in patients with PAH has been made possible by the synthesis of stable analogs that possess different pharmacokinetic properties but share similar pharmacodynamic effects. Experience in humans has been initially collected with epoprostenol, which is a synthetic salt of prostacyclin 58. Epoprostenol has a short half-life in the circulation and requires continuous administration by the intravenous route by means of infusion pumps and permanent tunnelized catheters. For these reasons, alternatives to intravenous epoprostenol have been sought and this has led to the development of analogs that can be administered subcutaneously (treprostinil), orally (beraprost sodium) or by inhalation (iloprost). Three unblinded clinical trials and several uncontrolled trials have shown that treatment with epoprostenol improved symptoms and exercise capacity in NYHA class III patients, PAH patients, and also survival in patients with IPAH. Subcutaneous treprostinil improved symptoms, exercise, hemodynamics and clinical events in the largest clinical trial ever performed in PAH, but local infusion site reactions limited efficacy in a proportion of patients. Oral beraprost sodium improved exercise capacity only in patients with IPAH and is the only prostacyclin analog that has also been tested in NYHA class II patients Inhaled iloprost has improved symptoms, exercise capacity and clinical events in patients with PAH and inoperable CTPAH. The favorable effects of prostanoids observed in all studies coupled with different profiles of adverse

6 5 events and tolerability for each prostacyclin analog allow the unique opportunity to select the most appropriate compound for the individual patient with PAH Phospodiesterase - 5 inhibitors These drugs catalyse the hydrolysis of cyclic guanosine monophosphate (cgmp) to its inactive 5-nucleotide monophosphate. Inhibitors of PDE5 prevent the breakdown of cgmp, thereby enhancing NO; PDE 5 is expressed in lung tissue. Although the distribution of PDE in tissue is heterogeneous, there is a high deposition in the skeletal muscle, heart and vascular smooth muscle. Small preliminary studies have highlighted the potential for the PDE5 inhibitor sildenafil for the treatment of PAH, and its clinical profile has been evaluated in a larger, double-blind, placebo-controlled, dose ranging study There has been no information of sildenafil interaction with warfarin. Endothelin-Receptor Antagonists Two endothelin-receptor isoforms, endothelin-a (ETA) and endothelin-b have been identified. The ETB receptors are thought to be principally involved in the clearance of endothelin, particularly in the vascular beds of the lung and kidney. Activation of ETB receptors may also cause vasodilatation and NO release. Bosentan It is an orally active, non-peptidic, non-selective, sulphonamide- class ETa/ETb antagonist with twice daily dosing. It was the first ERA to receive approval for the treatment of patients with PAH in NYHA functional class II. Significant benefits of bosentan treatment have been shown in separate studies The Endothelin Antagonist Trial in Mildly Symptomatic PAH Patients (EARLY trial) was the first study specifically designed to evaluate effects of ERAs in PAH patients in functional class II. Primary results from this trial highlight a significant reduction in pulmonary vascular resistance while the other primary endpoint 6- MWT did not reach statistical significance. When CTEPH patients were considered, bosentan led to significant reductions in pulmonary vascular resistance and improved dyspnea score while the 6-MWT remained unchanged

7 6 over the 6 month study period (BENEFIT trial). Bosentan partially induces the cytochrome P450 system, thereby increasing warfarin metabolism and the required dose. Sitaxsentan A highly selective ETa receptor antagonist of the sulphonamide class of ERA has received approval for the treatment of PAH patients with functional class III symptoms at an oral dose of 100 mg once daily (European Union, Canada, and Australia). In USA, sitaxsentan remains to be approved; currently STRIDE 5 is ongoing and at its end additional data will be obtained. The safety and efficacy of sitaxsentan has been clinically tested in the sitaxsentan trials to relieve impaired exercise (STRIDE Program) 75-76, three randomized placebo-controlled trials (STRIDE1 77, STRIDE 2 78, and STRIDE 4), two non-controlled studies (Study 211 and Stride 6) 79 and three long-term studies (STRIDE 1X, STRIDE 2X, and STRIDE 3). Long-term data is available from a small group of patients, suggesting that efficacy and safety are maintained for up to 12 months 80. Data from a subgroup analysis did not exhibit a clinically relevant treatment effect; however, increase in 6-MWT in patients with PAH associated with connective tissue disease was observed Sitaxsentan inhibits the liver isoenzyme CYP2C9; therefore, combing sitaxsentan with warfarin can lead to a decrease dose of warfarin at initiation therapy to avoid bleeding complications. Ambrisentan It is an orally active ETa receptor antagonist belonging to the propanoic acid class. In the USA, ambrisentan has been approved at a dose of 5 10 mg once daily for the PAH patients (WHO functional class II or III) to improve exercise capacity and delay clinical worsening. Results are based on a 12-week, blinded dose (1, 2.5, 5 or 10mg daily) phase II study (improvements in 6-MWT, functional class, Borg score, quality of life and pulmonary hemodynamics) Long-term follow-ups of patients treated with ambrisentan in the two pivotal studies and the open label extension show that 95% were still receiving

8 7 ambrisentan monotherapy with sustained effects 83. Ambrisentan has no interaction with warfarin and has low profile to collateral effects. Combination therapies This therapeutic approach offers the possibility of enhanced efficacy and may permit individual agents to be used in lower doses, minimizing toxicity. The potentially complementary mechanisms of action among the three current pharmacologic approaches provide rationale for investigation of these agents in novel combination regimens. However, the impact of these strategy health systems needs to be analyzed (Table I). Acknowledgment: to Alicia Sanchez - Ramirez for her editorial support

9 8 Table I Combination Regimens. ERA plus Prostanoid. Bosentan plus Epoprostenol 84. Iloprost plus Bosentan 85. Bosentan plus Iloprost 85. PDE5 inhibitor plus prostanoid Sildenafil plus Iloprost 86. Iloprost plus Sildenafil 87. Key finding 36.3% decrease in pulmonary resistance versus 22.6% (placebo) (p=ps). 58 m improvement in 6-MWT (p<0.001). 26 m placebo adjusted improvement in 6-MWT (p=0.051). Maximun change in pulmonary vasodilatory potency seen with sildenafil 50mg plus inhaled iloprost. 44.2% decreased compared with -14.1% decreases with nitric oxide. Sildenafil and Iloprost act synergistically on pulmonary vasculature. Combination Iloprost plus sildenafil reduced mpap more than Iloprost alone (13.8 versus 9.4mm Hg; p<0.009) Sildenafil plus Beraprost 88. Sildenafil plus Epoprostenol 89. ERA plus PDE5 inhibitor Bosentan plus Sildenafil 90. Bosentan plus Sildenafil fold greater reduction in mpap on beraprost plus Sildenafil fold greater reduction in PVR. Sildenafil decrease m PAP by 10% (p<0.05) Sildenafil decrease PVR by 13% (p=ns) 84m improvement in 6MWD (p=0.04) Improvement in NYHA class (0% to 27.7% class I/II, p=0.02) 115m improvement in 6MWD at 3 months (p=0.007) 3.4ml/min/kg increase in peak oxygen consumption (p=0.006)

10 9 References 31. Barst RJ, Rubin LJ, Long WA, et al. For the Primary Pulmonary Hypertension Study Group. A comparison of continuous intravenous epoprostenol with conventional therapy for primary pulmonary hypertension. N Engl J Med 1996; 334: Rubin LJ, Badesch DB, Barst RJ, et al. Bosentan therapy for pulmonary arterial hypertension. N Engl J Med 2002; 346: Galie N, Humbert M, Vachiery JL, et al. Effects of beraprost sodium, an oral prostacyclin analogue, in patients with pulmonary arterial hypertension: a randomized, double blind, placebo- controlled trial. J Am Coll Cardiol 2002; 39: Pietra GG, Edwards WD, Kay JM, et al. Histopathology of primary pulmonary hypertension. A qualitative and quantitative study of pulmonary blood vessels from 58 patients in the National Heart, Lung, and Blood Institute, Primary pulmonary Hypertension Registry. Circulation 1989; 80: Rubin LJ, Badesch DB. Evaluation and management of the patient with pulmonary arterial hypertension. Ann Intern Med. 2005; 143: Duchini A, Sessoms SL. Gastrointestinal hemorrhage in patients with systemic sclerosis and CREST syndrome. Am J Gastroenterology 1998; 93: Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clin Chest Med 2007; 28: Naeije R, Vachiery JL. Medical therapy of pulmonary hypertension: conventional therapies. Clin Chest Med 2001; 22:

11 Runo JR, Loyd JE. Primary pulmonary arterial hypertension. Lancet 2003;361: Kurzyna M, Torbicki A. Neurohormonal modulation in right ventricular failure. Eur Heart J 2007; 9:H35 H Hebei Medical University spironolactone combined with captopril and carvedilol for the treatment of pulmonary arterial hypertension ClinicalTrials.gov processed this record on May 19, Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clin Chest Med 2007; 28: Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clin Chest Med 2007; 28: Rich S, Seidlitz M, Dodin E, et al. The short-term effects of digoxin in patients with right ventricular dysfunction from pulmonary hypertension. Chest 1998; 114: Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clin Chest Med 2007; 28: Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93: Roberts DH, Lepore JJ, Maroo A, et al. Oxygen therapy improves cardiac index and pulmonary vascular resistance in patients with pulmonary hypertension. Chest 2001;120: Palevsky HI, Schloo BL, Pietra GG, et al. Primary pulmonary hypertension. Vascular structure, morphometry, and responsiveness to vasodilator agents. Circulation. 1989; 80:A

12 Rich S, Brundage BH. High-dose calcium channel-blocking therapy for primary pulmonary hypertension: evidence for long-term reduction in pulmonary arterial pressure and regression of right ventricular hypertrophy Circulation 1987; 76: Camerini F, Alberti E, Klugmann S, et al. Primary pulmonary hypertension: effects of nifedipine. Br Heart J 1980; 44: Rubin L, Nicod P, Hillis L, et al. Treatment of primary pulmonary hypertension with nifedipine. A hemodynamic and scintigraphic evaluation. Ann Intern Med 1983; 99: Rich S, Brundage BH, Levy PS. The effect of vasodilator therapy on the clinical outcome of patients with primary pulmonary hypertension Circulation 1985; 71: Woodmansey PA, O'Toole L, Channer KS, et al. Acute pulmonary vasodilatory properties of amlodipine in humans with pulmonary hypertension Heart 1996; 75: Packer M, O'Connor CM, Ghali JK, et al. Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group N Engl J Med 1996; 335: Sitbon O, Humbert M, Jais X, et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension Circulation 2005; 111: Christman B, McPherson C, Newman J, et al. An imbalance between the excretion of thromboxane and prostacyclin metabolites in pulmonary hypertension. N Engl J Med 1992; 327:70 75

13 Tuder R, Cool C, Geraci M, et al. Prostacyclin synthase expression is decreased in lungs from patients with severe pulmonary hypertension. Am J Respir Crit Care Med 1999; 159: Barst R, Rubin L, Long W, et al. A comparison of continuous intravenous epoprostenol with conventional therapy for primary pulmonary hypertension. The Primary Pulmonary Hypertension Study Group. N Engl J Med 1996; 334: Barst R, Rubin L, McGoon M, et al. Survival in primary pulmonary hypertension with long-term continuous intravenous prostacyclin. Ann Intern Med 1994; 121: Shapiro S, Oudiz R, Cao T, et al. Primary pulmonary hypertension (Improved long-term effects and survival with continuous intravenous epoprostenol infusion). J Am Coll Cardiol 1997; 30: McLaughlin V, Genthner D, Panella M, et al. Reduction in pulmonary vascular resistance with long-term epoprostenol therapy in primary pulmonary hypertension. N Engl J Med 1998; 338: McLaughlin V, Shillington A, Rich S. Survival in primary pulmonary hypertension (The impact of epoprostenol therapy). Circulation 2002; 106: Sitbon O, Humbert M, Nunes H, et al. Long-term intravenous epoprostenol infusion in primary pulmonary hypertension. J Am Coll Cardiol 2002; 40: Badesch D, Tapson V, McGoon M, et al. Continuous intravenous epoprostenol for pulmonary hypertension due to the scleroderma spectrum of disease. A randomized, controlled trial. Ann Intern Med 2000; 132:

14 McLaughlin V, Gaine S, Barst R, et al. Efficacy and safety of treprostinil (An epoprostenol analog for primary pulmonary hypertension). J Cardiovasc Pharmacol 2003; 41: Simonneau G, Barst R, Galie N, et al. Continuous subcutaneous infusion of treprostinil, a prostacyclin analogue, in patients with pulmonary arterial hypertension (A double-blind, randomized, placebo-controlled trial). Am J Respir Crit Care Med 2002; 165: Michelakis E D, Tymchak W, Noga M et al. Long-term treatment with oral sildenafil is safe and improves functional capacity and hemodynamics in patients with pulmonary arterial hypertension. Circulation 2003; 108: Sastrys B K S, Narasimhan C, Krishna Reddy N, et al. Clinical efficacy of sildenafil in primary pulmonary hypertension: a randomized, placebocontrolled, double-blind, crossover study, J Am Coll Cardiol 2004 ;43: Derchi G, Forni G L. Therapeutic approaches to pulmonary hypertension in hemoglobinopathies: efficacy and safety of sildenafil in the treatment of severe pulmonary hypertension in patients with hemoglobinopathy. Ann N Y Acad Sci 2005; 54: Galie N, Ghofrani H A, Torbicki A. et al. Sildenafil citrate therapy for pulmonary arterial hypertension. N Engl J Med 2005; 353: Channick R N, Simonneau G, Sitbon O et al. Effects of the dual endothelinreceptor antagonist bosentan in patients with pulmonary hypertension: a randomised placebo-controlled study. Lancet 2001; 358: Rubin L J, Badesch D B, Barst R J et al. Bosentan therapy for pulmonary arterial hypertension. N Engl J Med 2002; 346:

15 Sitbon O, Gressin V, Speich R, et al. Bosentan for the treatment of human immunodeficiency virus- associated pulmonary arterial hypertension. Am J Respir Crit Care Med 2004; 170: Galie N, Beghetti M, Gastroulis M, et al. Bosentan therapy in patients with eisenmenger syndrome a multicenter, double blind, randomized, placebo controlled study. Circulation 2006; 114: Barst R J, Langleben D, Frost A et al. Sitaxsentan therapy for pulmonary arterial hypertension. Am J Respir Crit Care Med 2004 ; 169: Barst RJ. Sitaxsentan: a selective endothelin A receptor antagonist, for the treatment of pulmonary arterial hypertension. Expert Opin Pharmacother 2007; 8: Barst R J, Langleben D, Frost A et al. Sitaxsentan therapy for pulmonary arterial hypertension. Am J Respir Crit Care Med 2004; 169: Barst R J, Langleben D, Badesch D et al. Treatment of pulmonary arterial hypertension with the selective endothelin A receptor antagonist sitaxsentan. J Am Coll Cardiol 2006; 47: Benza R, Mehta S, Keogh A et al. sitaxsentan treatment for patients with pulmonary arterial hypertension discontinuing bosentan. J Heart Lung Transplant 2007; 26: Langleben D, Hirsch A, Shalite E et al. Sustained symptomatic, functional and hemodynamic benefit with the selective endothelin A receptor antagonist, sitaxsentan in patients with pulmonary arterial hypertension: a 1 year follow up study. CHEST 2004; 126: Girgis R, Frost A, Hill N, et al. Selective endothelin A receptor antagonism with sitaxsentan for pulmonary arterial hypertension patients associated with connective tissue disease. Ann Rheum Dis 2007; 66:

16 Galie N, Badesch D, Oudiz R et al. Ambrisentan therapy for pulmonary arterial hypertension. J Am Coll Cardiol 2005; 46: Galie N, Badesch D, Oudiz R, et al. Ambrisentan therapy for pulmonary arterial hypertension. J Am Coll Cardiol 2005; 46: Humbert M, Barst R J, Robbins I M, et al. Combination of bosentan with epoprostenol in pulmonary arterial hypertension: BREATHE-2. Eur Respir J 2004; 24: Hoeper M, Taha N, Bekjarova A, et al. Bosentan treatment in patients with primary pulmonary hypertension receiving nonparenteral prostanoids. Eur Respir J 2003 ;22: McLaughlin V, Oudiz R, Frost A et al. A randomized, double-blind, placebocontrolled study of iloprost inhalation as add-on therapy to bosentan in pulmonary arterial hypertension PAH. Chest 2005: 128: Ghofrani H A, Wiedemann R, Rose F et al. Combination therapy with oral sildenafil and inhaled iloprost for severe pulmonary hypertension. Ann Intern Med 2002; 136: Wilkens H, Guth A, Konig J et al. Effect of inhaled iloprost plus oral sildenafil in patients with primary pulmonary Hypertension. Circulation 2001; 104: Ikeda D, Tsujino I, Ohira H et al. Addition of oral sildenafil to beraprost is a safe and effective therapeutic option for patients with pulmonary hypertension. J Cardiovasc Pharmacol 2005; 45: Kuhn K P, Wickersham N E, Robbins I M, et al. Acute effects of sildenafil in patients with primary pulmonary hypertension receiving epoprostenol. Exp Lung Res 2004; 30:

17 Mathai S C F M, Housten-Harris T, Girgis R E, et al. The addition of sildenafil to bosentan therapy in the treatment of pulmonary arterial hypertension. Chest 2005; 128:

Recently approved drugs offer significant improvements for treatment options in pulmonary arterial hypertension

Recently approved drugs offer significant improvements for treatment options in pulmonary arterial hypertension DISEASE MANAGEMENT Recently approved drugs offer significant improvements for treatment options in pulmonary arterial hypertension Treatment of pulmonary arterial hypertension (PAH) Class I. PAH without

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium sildenafil citrate 20mg tablets (Revatio ) No. (235/06) Pfizer New indication 6 January 2006 The Scottish Medicines Consortium (SMC) has completed its assessment of the above

More information

1. Phosphodiesterase Type 5 Enzyme Inhibitors: Sildenafil (Revatio), Tadalafil (Adcirca)

1. Phosphodiesterase Type 5 Enzyme Inhibitors: Sildenafil (Revatio), Tadalafil (Adcirca) This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutic

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal. Drugs for the treatment of pulmonary arterial hypertension

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal. Drugs for the treatment of pulmonary arterial hypertension NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Health Technology Appraisal Drugs for the treatment of Remit / Appraisal objective: Final scope To appraise the clinical and cost effectiveness of

More information

PAH has an incidence

PAH has an incidence Pulmonary Arterial Hypertension: A Serious Problem Pulmonary arterial hypertension (PAH) is a serious disease with significant morbidity and mortality and no cure. In this article, Dr. Porhownik and Dr.

More information

Clinical Commissioning Policy: Targeted Therapies for Pulmonary Hypertension Functional Class II. April 2013. Reference : NHSCB/A11/P/a

Clinical Commissioning Policy: Targeted Therapies for Pulmonary Hypertension Functional Class II. April 2013. Reference : NHSCB/A11/P/a Clinical Commissioning Policy: Targeted Therapies for Pulmonary Hypertension Functional Class II April 2013 Reference : NHS Commissioning Board Clinical Commissioning Policy: Amendment to National Policy

More information

Riociguat Clinical Trial Program

Riociguat Clinical Trial Program Riociguat Clinical Trial Program Riociguat (BAY 63-2521) is an oral agent being investigated as a new approach to treat chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension

More information

PULMONARY ARTERIAL HYPERTENSION AGENTS

PULMONARY ARTERIAL HYPERTENSION AGENTS Approvable Criteria: PULMONARY ARTERIAL HYPERTENSION AGENTS Brand Name Generic Name Length of Authorization Revatio Sildenafil citrate Calendar Year Adcirca Tadalafil Calendar Year Letairis Ambrisentan

More information

PULMONARY HYPERTENSION. Charles A. Thompson, M.D., FACC, FSCAI Cardiovascular Institute of the South Zachary, Louisiana

PULMONARY HYPERTENSION. Charles A. Thompson, M.D., FACC, FSCAI Cardiovascular Institute of the South Zachary, Louisiana PULMONARY HYPERTENSION Charles A. Thompson, M.D., FACC, FSCAI Cardiovascular Institute of the South Zachary, Louisiana What is Pulmonary Hypertension? What is normal? Pulmonary artery systolic pressure

More information

Pulmonary Artery Hypertension

Pulmonary Artery Hypertension Pulmonary Artery Hypertension Janet M. Pinson, RN, MSN, ACNP Maureen P. Flattery, RN, MS, ANP Virginia Commonwealth University Health System Richmond, VA Pulmonary artery hypertension (PAH) is defined

More information

A Review of Sitaxsentan Sodium in Patients with Pulmonary Arterial Hypertension

A Review of Sitaxsentan Sodium in Patients with Pulmonary Arterial Hypertension A Review of Sitaxsentan Sodium in Patients with Pulmonary Arterial Hypertension The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters.

More information

Pulmonary Arterial Hypertension: Review and Updates. Is it Primary vs Secondary Pulmonary Hypertension? No!! Dated Nomenclature. Veronica Franco, MD

Pulmonary Arterial Hypertension: Review and Updates. Is it Primary vs Secondary Pulmonary Hypertension? No!! Dated Nomenclature. Veronica Franco, MD Pulmonary Arterial Hypertension: Review and Updates Veronica Franco, MD Section of Pulmonary Hypertension Section of Heart Failure and Transplantation Ohio State University Is it Primary vs Secondary Pulmonary

More information

Meta-Analysis of Randomized Controlled Trials on Treatment of Pulmonary Arterial Hypertension

Meta-Analysis of Randomized Controlled Trials on Treatment of Pulmonary Arterial Hypertension Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp Meta-Analysis of Randomized Controlled Trials on Treatment of Pulmonary Arterial Hypertension Bing He, BSc;

More information

Pharmacy Policy Bulletin

Pharmacy Policy Bulletin Pharmacy Policy Bulletin Title: Policy #: Pulmonary Arterial Hypertensive (PAH) agents Rx.01.83 Application of pharmacy policy is determined by benefits and contracts. Benefits may vary based on product

More information

Statement on Disability: Pulmonary Hypertension

Statement on Disability: Pulmonary Hypertension Statement on Disability: Pulmonary Hypertension Ronald J. Oudiz, MD and Robyn J. Barst, MD on behalf of Pulmonary Hypertension Association The Scientific Leadership Council of the Pulmonary Hypertension

More information

OVERVIEW FDA-APPROVED INDICATIONS

OVERVIEW FDA-APPROVED INDICATIONS Tufts Health Together Tufts Health Direct Pharmacy Medical Necessity Guidelines Pulmonary Hypertension Effective: December 9, 2014 Clinical documentation and prior authorization required Not covered Pharmacy

More information

Medical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South

Medical management of CHF: A New Class of Medication. Al Timothy, M.D. Cardiovascular Institute of the South Medical management of CHF: A New Class of Medication Al Timothy, M.D. Cardiovascular Institute of the South Disclosures Speakers Bureau for Amgen Background Chronic systolic congestive heart failure remains

More information

2. Background This drug had not previously been considered by the PBAC.

2. Background This drug had not previously been considered by the PBAC. PUBLIC SUMMARY DOCUMENT Product: Ambrisentan, tablets, 5 mg and 10 mg, Volibris Sponsor: GlaxoSmithKline Australia Pty Ltd Date of PBAC Consideration: July 2009 1. Purpose of Application The submission

More information

*Documentation of pretreatment results from right heart catheterization and PEA required, as applicable

*Documentation of pretreatment results from right heart catheterization and PEA required, as applicable DRUG POLICY BENEFIT APPLICATION Pulmonary Arterial Hypertension Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations

More information

Pharmacy Medical Necessity Guidelines: Pulmonary Hypertension Medications

Pharmacy Medical Necessity Guidelines: Pulmonary Hypertension Medications Pharmacy Medical Necessity Guidelines: Pulmonary Hypertension Medications Effective: January 1, 2016 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review

More information

Therapeutic Class Overview Pulmonary Arterial Hypertension Agents

Therapeutic Class Overview Pulmonary Arterial Hypertension Agents Therapeutic Class Overview Pulmonary Arterial Hypertension Agents Therapeutic Class Overview/Summary: The oral pulmonary hypertension agents are Food Drug Administration (FDA)-approved for the treatment

More information

Copyright 2012 Oregon State University. All Rights Reserved

Copyright 2012 Oregon State University. All Rights Reserved Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

Type II Pulmonary Hypertension: Pulmonary Hypertension due to Left Heart Disease

Type II Pulmonary Hypertension: Pulmonary Hypertension due to Left Heart Disease Heart Failure Center Hadassah University Hospital Type II Pulmonary Hypertension: Pulmonary Hypertension due to Left Heart Disease Israel Gotsman MD The Heart Failure Center, Heart Institute Hadassah University

More information

P pulmonary Hypertension and Its Importance to the Body

P pulmonary Hypertension and Its Importance to the Body Cardiol Clin 22 (2004) 441 452 Diagnosis and treatment of pulmonary arterial hypertension Richard Channick, MD a, *, Timothy L. Williamson, MD b a Division of Pulmonary and Critical Care, University of

More information

Acknowledgements. PAH in Children: Natural History. The Sildenafil Saga

Acknowledgements. PAH in Children: Natural History. The Sildenafil Saga The Sildenafil Saga David L. Wessel, MD Executive Vice President Chief Medical Officer Ikaria Distinguished Professor of Critical Care Children s National Medical Center Washington, DC, USA Acknowledgements

More information

Hypertension and Heart Failure Medications. Dr William Dooley

Hypertension and Heart Failure Medications. Dr William Dooley Hypertension and Heart Failure Medications Dr William Dooley Plan Heart Failure Acute vs. chronic Mx Hypertension Common drugs used Method of action Choice of medications Heart Failure Aims; Short term:

More information

Pulmonary Arterial Hypertension. Matt Hegewald, MD FCCP St Charles Medical Center Intermountain Medical Center University of Utah

Pulmonary Arterial Hypertension. Matt Hegewald, MD FCCP St Charles Medical Center Intermountain Medical Center University of Utah Pulmonary Arterial Hypertension Matt Hegewald, MD FCCP St Charles Medical Center Intermountain Medical Center University of Utah Intermountain Pulmonary Arterial Hypertension Program Outline Causes of

More information

Pulmonary Arterial Hypertension: Assessment of disease s severity

Pulmonary Arterial Hypertension: Assessment of disease s severity Pulmonary Arterial Hypertension: Assessment of disease s severity Carmine Dario Vizza Dept. Cardiovascular and Respiratory Diseases La Sapienza University of Rome e-mail : dario.vizza@uniroma1.it Pulmonary

More information

Pulmonary arterial hypertension (PAH) is a

Pulmonary arterial hypertension (PAH) is a Eur Respir Rev 2010; 19: 118, 279 287 DOI: 10.1183/09059180.00008010 CopyrightßERS 2010 REVIEW Management of severe pulmonary arterial hypertension J-L. Vachiéry* and G. Simonneau # ABSTRACT: Pulmonary

More information

She was 39 years old, gravida 4, para 2. She had an Idiopathic Pulmonary. Arterial Hypertension (PAH) revealed during pregnancy by a New York Heart

She was 39 years old, gravida 4, para 2. She had an Idiopathic Pulmonary. Arterial Hypertension (PAH) revealed during pregnancy by a New York Heart Case #1 (year 1992): She was 39 years old, gravida 4, para 2. She had an Idiopathic Pulmonary Arterial Hypertension (PAH) revealed during pregnancy by a New York Heart Association (NYHA) functional class

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy Pulmonary Hypertension, Drug Management File Name: Origination: Last CAP Review: Next CAP Review: Last Review: pulmonary_hypertension_drug_management 06/1998 3/2015 3/2016 3/2015

More information

HYPERTENSION ASSOCIATED WITH RENAL DISEASES

HYPERTENSION ASSOCIATED WITH RENAL DISEASES RENAL DISEASE v Patients with renal insufficiency should be encouraged to reduce dietary salt and protein intake. v Target blood pressure is less than 135-130/85 mmhg. If patients have urinary protein

More information

Evidence briefing on drug treatments for functional class II pulmonary hypertension

Evidence briefing on drug treatments for functional class II pulmonary hypertension Evidence briefing on drug treatments for functional class II pulmonary hypertension The North of England Specialised Commissioning Group is the lead organisation charged with commissioning targeted therapies

More information

Pulmonary Arterial Hypertension (PAH) Agents 12/01/2009

Pulmonary Arterial Hypertension (PAH) Agents 12/01/2009 Pulmonary Arterial Hypertension (PAH) Agents 12/01/2009 Copyright 2006-2009 by Provider Synergies, L.L.C. All rights reserved. Printed in the United States of America. All rights reserved. No part of this

More information

PAH. Salman Bin AbdulAziz University College Of Pharmacy 22/01/35

PAH. Salman Bin AbdulAziz University College Of Pharmacy 22/01/35 Salman Bin AbdulAziz University College Of Pharmacy PAH Therapeutics II PHCL 430 Ahmed A AlAmer PharmD R.W. is a 38-year-old obese woman who presents with increasing symptoms of fatigue and shortness of

More information

CADTH Therapeutic Review Report

CADTH Therapeutic Review Report Canadian Agency for Drugs and Technologies in Health Agence canadienne des médicaments et des technologies de la santé CADTH Therapeutic Review Report March 2015 Drugs for Pulmonary Arterial Hypertension:

More information

PAH: Standard of Care

PAH: Standard of Care PAH: Standard of Care Nazzareno Galiè Istituto di Cardiologia Università di Bologna nazzareno.galie@unibo.it TF 7 Therapy Standard of Care Questions A. Do we have additional information on the role of

More information

Tomas Pulido, Carla Murillo, Paulina Ramírez-Neria, Viridiana Hurtado, Paola de la Garza, Sandra Astorga, María Teresa Miranda and Julio Sandoval

Tomas Pulido, Carla Murillo, Paulina Ramírez-Neria, Viridiana Hurtado, Paola de la Garza, Sandra Astorga, María Teresa Miranda and Julio Sandoval Clinical Medicine Insights: Therapeutics Review Open Access Full open access to this and thousands of other papers at http://www.la-press.com. Management of Pulmonary Arterial Hypertension with Sitaxentan

More information

Nursing 113. Pharmacology Principles

Nursing 113. Pharmacology Principles Nursing 113 Pharmacology Principles 1. The study of how drugs enter the body, reach the site of action, and are removed from the body is called a. pharmacotherapeutics b. pharmacology c. pharmacodynamics

More information

CLINICAL POLICY Department: Medical Management Document Name: Pulmonary Arterial Hypertension Therapies

CLINICAL POLICY Department: Medical Management Document Name: Pulmonary Arterial Hypertension Therapies Page: 1 of 15 IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted

More information

Target therapies for the treatment of pulmonary arterial hypertension in Adults

Target therapies for the treatment of pulmonary arterial hypertension in Adults Paper K2 National Specialised Commissioning Group Commissioning Policy Target therapies for the treatment of pulmonary arterial hypertension in Adults POLICY PUBLISHED: 1 JULY 2008 POLICY REVISED: 14 JANUARY

More information

CADTH CANADIAN DRUG EXPERT REVIEW COMMITTEE FINAL RECOMMENDATION

CADTH CANADIAN DRUG EXPERT REVIEW COMMITTEE FINAL RECOMMENDATION CADTH CANADIAN DRUG EXPERT REVIEW COMMITTEE FINAL RECOMMENDATION RIOCIGUAT (Adempas Bayer HealthCare Inc.) Indication: Pulmonary Arterial Hypertension Recommendation: The CADTH Canadian Drug Expert Review

More information

Pulmonary Arterial Hypertension

Pulmonary Arterial Hypertension Chapter 27 Pulmonary Arterial Hypertension Gandharba Ray, L Ravi Kumar INTRODUCTION ABSTRACT Pulmonary arterial hypertension (PAH) is a syndrome resulting from decreased flow of blood in the pulmonary

More information

RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY. Charles Jazra

RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY. Charles Jazra RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY Charles Jazra NO CONFLICT OF INTEREST TO DECLARE Relationship Between Atrial Fibrillation and Age Prevalence, percent

More information

ELIGIBILITY CRITERIA FOR PULMONARY ARTERIAL HYPERTENSION THERAPY

ELIGIBILITY CRITERIA FOR PULMONARY ARTERIAL HYPERTENSION THERAPY ELIGIBILITY CRITERIA FOR PULMONARY ARTERIAL HYPERTENSION THERAPY Contents ELIGIBILITY CRITERIA FOR INITIATION OF PULMONARY ARTERIAL HYPERTENSION THERAPY... 2 Initial Application for Funding of Pulmonary

More information

How to control atrial fibrillation in 2013 The ideal patient for a rate control strategy

How to control atrial fibrillation in 2013 The ideal patient for a rate control strategy How to control atrial fibrillation in 2013 The ideal patient for a rate control strategy L. Pison, MD Advances in Cardiac Arrhythmias and Great Innovations in Cardiology - Torino, September 28 th 2013

More information

Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension

Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana,

More information

Inpatient Heart Failure Management: Risks & Benefits

Inpatient Heart Failure Management: Risks & Benefits Inpatient Heart Failure Management: Risks & Benefits Dr. Kenneth L. Baughman Professor of Medicine Harvard Medical School Director, Advanced Heart Disease Section Brigham & Women's Hospital Harvard Medical

More information

FREEDOM C: A 16-Week, International, Multicenter, Double-Blind, Randomized, Placebo-Controlled Comparison of the Efficacy and Safety of Oral UT-15C

FREEDOM C: A 16-Week, International, Multicenter, Double-Blind, Randomized, Placebo-Controlled Comparison of the Efficacy and Safety of Oral UT-15C FREEDOM C: A 16-Week, International, Multicenter, Double-Blind, Randomized, Placebo-Controlled Comparison of the Efficacy and Safety of Oral UT-15C SR in Combination with an ERA and/or a PDE-5 Inhibitor

More information

Idiopathic Pulmonary Fibrosis (IPF) Research

Idiopathic Pulmonary Fibrosis (IPF) Research Idiopathic Pulmonary Fibrosis (IPF): Why Early Referral is Critical Even if Your Patient is Not Eligible for a Clinical Trial Idiopathic Pulmonary Fibrosis (IPF) Research Management of IPF requires a confident

More information

Hope in 2011 Clinical Advances Where is the road taking us?

Hope in 2011 Clinical Advances Where is the road taking us? Hope in 2011 Clinical Advances Where is the road taking us? Richard Channick, MD Arlene Schiro, NP Disclosures Arlene Schiro no relevant financial and/or commercial relationships to disclose Hope is like

More information

Cardiovascular System & Its Diseases. Lecture #4 Heart Failure & Cardiac Arrhythmias

Cardiovascular System & Its Diseases. Lecture #4 Heart Failure & Cardiac Arrhythmias Cardiovascular System & Its Diseases Lecture #4 Heart Failure & Cardiac Arrhythmias Dr. Derek Bowie, Department of Pharmacology & Therapeutics, Room 1317, McIntyre Bldg, McGill University derek.bowie@mcgill.ca

More information

Pulmonary Arterial Hypertension (PAH)

Pulmonary Arterial Hypertension (PAH) Pulmonary Arterial Hypertension (PAH) Contents 1. Introduction 3 2. What is PAH? 4 3. Classification of PAH 5 4. How is PAH severity classified? 7 5. How common is PAH? 7 6. Why does PAH develop? 8 7.

More information

The efficacy and safety of sildenafil in Chinese patients with pulmonary arterial hypertension

The efficacy and safety of sildenafil in Chinese patients with pulmonary arterial hypertension (29) 32, 911 915 & 29 The Japanese Society of Hypertension All rights reserved 916-9636/9 $32. www.nature.com/hr ORIGINAL ARTICLE The efficacy and safety of sildenafil in Chinese patients with pulmonary

More information

Pulmonary Hypertension in Sickle Cell Disease. Jorge Ramos Hematology Fellows Conference June 28, 2013

Pulmonary Hypertension in Sickle Cell Disease. Jorge Ramos Hematology Fellows Conference June 28, 2013 Pulmonary Hypertension in Sickle Cell Disease Jorge Ramos Hematology Fellows Conference June 28, 2013 Patient Presentation 28F with SCD, genotype SS. Presented to UWMC ER with 1 month progressive DOE and

More information

The author has no disclosures

The author has no disclosures Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author

More information

PAH in. Registry to Evaluate Early and Long-Term PAH Disease Management

PAH in. Registry to Evaluate Early and Long-Term PAH Disease Management PAH in Registry to Evaluate Early and Long-Term PAH Disease Management Ioana R. Preston, MD Co-Director, Pulmonary Hypertension Center Tufts Medical Center, Boston, MA Background What is REVEAL? Multi-center,

More information

Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1

Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Test Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie thomas.suter@insel.ch 1 Heart Failure - Definition European Heart Journal (2008) 29, 2388 2442 Akute Herzinsuffizienz Diagnostik und

More information

Atrial Fibrillation An update on diagnosis and management

Atrial Fibrillation An update on diagnosis and management Dr Arvind Vasudeva Consultant Cardiologist Atrial Fibrillation An update on diagnosis and management Atrial fibrillation (AF) remains the commonest disturbance of cardiac rhythm seen in clinical practice.

More information

ACLS PHARMACOLOGY 2011 Guidelines

ACLS PHARMACOLOGY 2011 Guidelines ACLS PHARMACOLOGY 2011 Guidelines ADENOSINE Narrow complex tachycardias or wide complex tachycardias that may be supraventricular in nature. It is effective in treating 90% of the reentry arrhythmias.

More information

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC

Treating AF: The Newest Recommendations. CardioCase presentation. Ethel s Case. Wayne Warnica, MD, FACC, FACP, FRCPC Treating AF: The Newest Recommendations Wayne Warnica, MD, FACC, FACP, FRCPC CardioCase presentation Ethel s Case Ethel, 73, presents with rapid heart beating and mild chest discomfort. In the ED, ECG

More information

Milwaukee School of Engineering Gerrits@msoe.edu. Case Study: Factors that Affect Blood Pressure Instructor Version

Milwaukee School of Engineering Gerrits@msoe.edu. Case Study: Factors that Affect Blood Pressure Instructor Version Case Study: Factors that Affect Blood Pressure Instructor Version Goal This activity (case study and its associated questions) is designed to be a student-centered learning activity relating to the factors

More information

1p36 and the Heart. John Lynn Jefferies, MD, MPH, FACC, FAHA

1p36 and the Heart. John Lynn Jefferies, MD, MPH, FACC, FAHA 1p36 and the Heart John Lynn Jefferies, MD, MPH, FACC, FAHA Director, Advanced Heart Failure and Cardiomyopathy Services Associate Professor, Pediatric Cardiology and Adult Cardiovascular Diseases Associate

More information

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7

More information

The Global Alliance against Chronic Respiratory Diseases

The Global Alliance against Chronic Respiratory Diseases The Global Alliance against Chronic Respiratory Diseases Pulmonary hypertension Dr Marc Humbert What is the burden of pulmonary hypertension? The true burden of pulmonary hypertension is currently unknown

More information

24. HIV-associated Pulmonary Hypertension

24. HIV-associated Pulmonary Hypertension 24. HIV-associated Pulmonary Hypertension Georg Friese, Mirko Steinmüller and Ardeschir Ghofrani Etiology, pathogenesis, classification 629 Pulmonary hypertension is a severe life-limiting disease, often

More information

Antiplatelet and Antithrombotics From clinical trials to guidelines

Antiplatelet and Antithrombotics From clinical trials to guidelines Antiplatelet and Antithrombotics From clinical trials to guidelines Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University Preisedent of EGYBAC Chairman of WGLVR One of the big stories

More information

ATRIAL FIBRILLATION (RATE VS RHYTHM CONTROL)

ATRIAL FIBRILLATION (RATE VS RHYTHM CONTROL) ATRIAL FIBRILLATION (RATE VS RHYTHM CONTROL) By Prof. Dr. Helmy A. Bakr Mansoura Universirty 2014 AF Classification: Mechanisms of AF : Selected Risk Factors and Biomarkers for AF: WHY AF? 1. Atrial fibrillation

More information

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF)

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT of Atrial Fibrillation (AF) Key priorities Identification and diagnosis Treatment for persistent AF Treatment for permanent AF Antithrombotic

More information

Bosentan in Pulmonary Arterial Hypertension Secondary to Scleroderma

Bosentan in Pulmonary Arterial Hypertension Secondary to Scleroderma Bosentan in Pulmonary Arterial Hypertension Secondary to Scleroderma AMIT JOGLEKAR, FAUSAN S. TSAI, DEBORAH A. McCLOSKEY, JULIANNE E. WILSON, JAMES R. SEIBOLD, and DAVID J. RILEY ABSTRACT. Objective. To

More information

Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements

Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements Salmaan Kanji, Pharm.D. The Ottawa Hospital The Ottawa Hospital Research Institute Conflict of Interest No financial, proprietary

More information

Inotropes/Vasoactive Agents Hina N. Patel, Pharm.D., BCPS Cathy Lawson, Pharm.D., BCPS

Inotropes/Vasoactive Agents Hina N. Patel, Pharm.D., BCPS Cathy Lawson, Pharm.D., BCPS Inotropes/Vasoactive Agents Hina N. Patel, Pharm.D., BCPS Cathy Lawson, Pharm.D., BCPS 1. Definition -an agent that affects the contractility of the heart -may be positive (increases contractility) or

More information

We can learn a lot from you...

We can learn a lot from you... Educational program by Material endorsed by We can learn a lot from you... When it comes to pulmonary arterial hypertension (PAH), the members of your specialist healthcare team are experts on the best

More information

ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol

ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Isoproterenol Major Indications Status Asthmaticus As a last resort for

More information

Recommendations: Other Supportive Therapy of Severe Sepsis*

Recommendations: Other Supportive Therapy of Severe Sepsis* Recommendations: Other Supportive Therapy of Severe Sepsis* K. Blood Product Administration 1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial

More information

Recurrent AF: Choosing the Right Medication.

Recurrent AF: Choosing the Right Medication. In the name of God Shiraz E-Medical Journal Vol. 11, No. 3, July 2010 http://semj.sums.ac.ir/vol11/jul2010/89015.htm Recurrent AF: Choosing the Right Medication. Basamad Z. * Assistant Professor, Department

More information

Pulmonary Arterial Hypertension (PAH)

Pulmonary Arterial Hypertension (PAH) Pulmonary Arterial Hypertension (PAH) Contents Introduction 2 What is PAH? 3 Classifi cation of PAH 5 How common is PAH? 8 Why does PAH develop? 9 What are the symptoms of PAH? 12 How is PAH diagnosed?

More information

Atrial Fibrillation Management Across the Spectrum of Illness

Atrial Fibrillation Management Across the Spectrum of Illness Disclosures Atrial Fibrillation Management Across the Spectrum of Illness NONE Barbara Birriel, MSN, ACNP-BC, FCCM The Pennsylvania State University Objectives AF Discuss the pathophysiology, diagnosis,

More information

Non-Invasive Risk Predictors in (Children with) Pulmonary Hypertension

Non-Invasive Risk Predictors in (Children with) Pulmonary Hypertension Ideal risk prognosticator Easy to acquire Non-Invasive Risk Predictors in (Children with) Pulmonary Hypertension Safe -- Non-invasive Robust Gerhard-Paul Diller Astrid Lammers Division of Adult Congenital

More information

Anticoagulants in Atrial Fibrillation

Anticoagulants in Atrial Fibrillation Anticoagulants in Atrial Fibrillation Starting and Stopping Them Safely Carmine D Amico, D.O. Overview Learning objectives Introduction Basic concepts Treatment strategy & options Summary 1 Learning objectives

More information

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF Objectives Atrial Fibrillation and Prevention of Thrombotic Complications: Therapeutic Update Andrea C. Flores Pharm.D Pharmacy Resident at the Miami VA Healthcare System Review the epidemiology, pathophysiology

More information

DVT/PE Management with Rivaroxaban (Xarelto)

DVT/PE Management with Rivaroxaban (Xarelto) DVT/PE Management with Rivaroxaban (Xarelto) Rivaroxaban is FDA approved for the acute treatment of DVT and PE and reduction in risk of recurrence of DVT and PE. FDA approved indications: Non valvular

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION

STROKE PREVENTION IN ATRIAL FIBRILLATION STROKE PREVENTION IN ATRIAL FIBRILLATION OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention of ischemic stroke and arterial thromboembolism in patients

More information

Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled Therapeutic Class Review (TCR) March 30, 2015

Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled Therapeutic Class Review (TCR) March 30, 2015 Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled Therapeutic Class Review (TCR) March 30, 2015 No part of this publication may be reproduced or transmitted in any form or by any means, electronic

More information

Medical Direction and Practices Board WHITE PAPER

Medical Direction and Practices Board WHITE PAPER Medical Direction and Practices Board WHITE PAPER Use of Pressors in Pre-Hospital Medicine: Proper Indication and State of the Science Regarding Proper Choice of Pressor BACKGROUND Shock is caused by a

More information

Perioperative management of Dual Antiplatelet therapy post drug eluting stent-changing time

Perioperative management of Dual Antiplatelet therapy post drug eluting stent-changing time Perioperative management of Dual Antiplatelet therapy post drug eluting stent-changing time Robert Chilton DO, FACOI, FACC, FAHA Professor of Medicine University of Texas Health Science Center Director

More information

Hypertension and Diabetes

Hypertension and Diabetes Hypertension and Diabetes C.W. Spellman, D.O., Ph.D., FACOI Professor & Associate Dean Research Dir. Center Diabetes & Metabolic Disorders Texas Tech University Health Science Center Midland-Odessa, Texas

More information

Can Common Blood Pressure Medications Cause Diabetes?

Can Common Blood Pressure Medications Cause Diabetes? Can Common Blood Pressure Medications Cause Diabetes? By Nieske Zabriskie, ND High blood pressure, or hypertension, is a major risk factor for cardiovascular disease. In the United States, approximately

More information

Diagnosis and Management of Life Threatening Cardiac Emergencies

Diagnosis and Management of Life Threatening Cardiac Emergencies Diagnosis and Management of Life Threatening Cardiac Emergencies Carley Saelinger,VMD, DACVIM (Cardiology) Providing the best quality care and service for the patient, the client, and the referring veterinarian.

More information

Vasopressors. Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco

Vasopressors. Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco Vasopressors Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco Overview Define shock states Review drugs commonly used to treat hypotension

More information

STAGES OF SHOCK. IRREVERSIBLE SHOCK Heart deteriorates until it can no longer pump and death occurs.

STAGES OF SHOCK. IRREVERSIBLE SHOCK Heart deteriorates until it can no longer pump and death occurs. STAGES OF SHOCK SHOCK : A profound disturbance of circulation and metabolism, which leads to inadequate perfusion of all organs which are needed to maintain life. COMPENSATED NONPROGRESSIVE SHOCK 30 sec

More information

Diagnosis and Management of Pulmonary Arterial Hypertension: Implications for Respiratory Care

Diagnosis and Management of Pulmonary Arterial Hypertension: Implications for Respiratory Care Diagnosis and Management of Pulmonary Arterial Hypertension: Implications for Respiratory Care Deborah Jo Levine MD Introduction Definition Normal Physiology Pathophysiology Pathogenesis Classification

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND:

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND: STROKE PREVENTION IN ATRIAL FIBRILLATION TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention

More information

Summary Review for Regulatory Action

Summary Review for Regulatory Action Summary Review for Regulatory Action Date (electronic stamp) From Norman Stockbridge Subject Division Director Summary Review NDA/BLA # Supplement # NDA 21-290 Applicant Name Actelion Date of Submission

More information

Procedure for Inotrope Administration in the home

Procedure for Inotrope Administration in the home Procedure for Inotrope Administration in the home Purpose This purpose of this procedure is to define the care used when administering inotropic agents intravenously in the home This includes: A. Practice

More information

Duration of Dual Antiplatelet Therapy After Coronary Stenting

Duration of Dual Antiplatelet Therapy After Coronary Stenting Duration of Dual Antiplatelet Therapy After Coronary Stenting C. DEAN KATSAMAKIS, DO, FACC, FSCAI INTERVENTIONAL CARDIOLOGIST ADVOCATE LUTHERAN GENERAL HOSPITAL INTRODUCTION Coronary artery stents are

More information

Heart Failure: Diagnosis and Treatment

Heart Failure: Diagnosis and Treatment Heart Failure: Diagnosis and Treatment Approximately 5 million people about 2 percent of the U.S. population are affected by heart failure. Diabetes affects 20.8 million Americans and 65 million Americans

More information

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute Dual Antiplatelet Therapy Stephen Monroe, MD FACC Chattanooga Heart Institute Scope of Talk Identify the antiplatelet drugs and their mechanisms of action Review dual antiplatelet therapy in: The medical

More information

INHERIT. The Lancet Diabetes & Endocrinology In press

INHERIT. The Lancet Diabetes & Endocrinology In press INHibition of the renin angiotensin system in hypertrophic cardiomyopathy and the Effect on hypertrophy a Randomized Intervention Trial with losartan Anna Axelsson, Kasper Iversen, Niels Vejlstrup, Carolyn

More information

Chronic Thromboembolic Disease. Chronic Thromboembolic Disease Definition. Diagnosis Prevention Treatment Surgical Nonsurgical

Chronic Thromboembolic Disease. Chronic Thromboembolic Disease Definition. Diagnosis Prevention Treatment Surgical Nonsurgical Chronic Thromboembolic Disease Diagnosis Prevention Treatment Surgical Nonsurgical Chronic Thromboembolic Disease Definition Pulmonary Hypertension due to chronic thromboembolism 6 months post acute PE:

More information