PULMONARY ARTERIAL

HYPERTENSION
Dr Kirsty Mair
 Pulmonary Circulation
Right ventricle – Pulmonary artery – Capillary blood vessels – Pulmonary veins – Left atrium

A compliant, low pressure,

low resistance system easily adaptable
to variable flow.

1
 Pulmonary capillaries

• Pulmonary capillaries form a

meshwork around aveoli.
• These capillary sheets form part of
the inter-alveolar septum:
– tissue between adjacent alveoli which
consists of a close-meshed capillary
network covered on both surfaces by
very thin alveolar epithelial cells.
• Blood and gas separated by very
thin membrane ~1µm – aids gas
exchange.

Polak D J Br Med Bull 2011;bmb.ldr022

2
Inter-alveolar septum

3
Epithelium E = Endothelium
Aveolus

*
*
Red blood cell

Capillary

*
Systemic versus Pulmonary Circulation -
Pressure
15mmHg - 5mmHg =
10mmHg

(mean = ~15mmHg)

Rest of (mean = ~100mmHg)

WHAT
BodyDOES THIS TELL
US ABOUT VASCULAR
RESISTANCE TO
BLOOD FLOW? 100mmHg – 2mmHg
= 98mmHg 5
Δpressure = Blood flow x Vascular Resistance

(Change in pressure (Δ pressure)) = Blood flow (cardiac output) x Vascular Resistance

input pressure - output pressure
Vascular Resistance =
blood flow
(Same for both systemic and pulmonary circulation)

15 mmHg - 5 mmHg
mean PA pressure - left atrial pressure = 10 mmHg Pressure difference
across the
mean aorta pressure - right atrial pressure = 98 mmHg pulmonary circulation
is much lower
100 mmHg – 2mmHg

Therefore
Pulmonary Vascular Resistance PVR is
is ~10% of1/10 of SVR Vascular Resistance
Systemic
6
Reasons Why Pressures Are Different in
Pulmonary and Systemic Circulations?
• Pulmonary:
– Function: gas exchange
– Blood and air separated by very thin membrane
– High pressure in pulmonary circulation may cause fluid to leak from
pulmonary capillaries into alveoli

• Systemic:
– Function: to provide tissues with oxygen and nutrients
– Blood must be pumped around the entire body
– Must be able to redirect blood to areas of increased demand
– 75-80% of resistance in arterioles

7
 Consequence of pressure differences

• Consequences of pressure differences:

– Left ventricle work load is much greater than right ventricle
– Differences in wall thickness indicates differences in work load.

8
 Characteristics of Pulmonary
Circulation
• Compliant arteries com•pli•ant
(kəmˈplaɪ ənt)
• Stretch easily
adj.1. complying; obeying, obliging, or yielding
• 7 times more compliant than systemic
arteries
• Thin walled – very little vascular smooth
muscle.
• Keeps resistance low when more blood
is flowing (e.g. exercise)
• Less work for heart
• Right heart smaller than left but pumps Aorta
Pulmonary artery
same amount of blood

9
 Characteristics of Pulmonary
Circulation
Because of their functional
anatomy pulmonary vessels are:
-Distensible
-Compressible
Pulmonary
blood flow

Increase blood flow

Allows vessels to
adapt easily to
changes in blood
flow
Recruitment Distension
10
 Characteristics of Pulmonary
Circulation
• Normally dilated
• Larger diameter than equivalents in Aorta
Pulmonary artery
systemic circulation

• Must be able to match blood flow (perfusion) with air flow (ventilation)
• This ensures optimal oxygenation of the blood

• Must be able to accommodate increased blood flow in response to

exercise
• Capillary blood volume increased from 75mls to ~200mls during exercise

11
 Pulmonary Vascular Resistance
and Blood Flow During Exercise
• During exercise cardiac output increases (e.g. 5-fold),
but with little change in mean pulmonary artery pressure
– How is this possible?

• Pressure = Cardiac output (CO) x Resistance

• If pressure does not change, and CO increases then

vascular resistance must decrease with increased blood
flow
• Passive effect (seen in isolated lung prep)
– Recruitment: Opening of previously collapsed capillaries
– Distensibility: Increase in diameter of open capillaries.

12
Regulation of blood flow: Recruitment
and distension
Because of their functional
anatomy pulmonary vessels are:
- Distensible
- Compressible
Pulmonary
blood flow Passive process – no energy

Exercise

Therefore:
The pulmonary circulation is a
compliant, low pressure, low
resistance system easily adaptable
Recruitment to variable flow.
Distension
13
 Regulation of blood flow: Active

Vasoconstrictors Vasodilators
Thromboxane A2 β-adrenoreceptors
Prostacyclin Vasoconstrictors
α-adrenoreceptors
Vasodilators
Histamine EDHF
Angiotensin II Acetylcholine
Prostaglandins Bradykinin
Neuropeptides Dopamine
Leukotrienes Urotensin-II
5HT Oxygen
Endothelin-1

Hypoxia

14
 Hypoxia

• Pulmonary arteries constrict to hypoxia, systemic arteries

vasodilate.
• Hypoxic pulmonary vasoconstriction (HPV)

• Physiological aspects of HPV

• Foetal circulation
• Ventilation/perfusion matching

15
 The Foetal Circulation

• In utero, foetus suspended in amniotic fluid

• Placenta provides oxygen

• Lungs have no function in utero therefore

blood diverted away from them

• Approx 90% of blood in the right atria is

pumped through a shunt (foramen ovale) to
the left atria therefore by passing the lungs

• A further shunt exists between the

pulmonary artery and the aorta (ductus
arteriosus)

16
 At birth……..

• At birth baby takes its first breath

• Inhaled air inflates bronchial tree and

most of alveoli

• O2 in a pulmonary vasodilator and so

the pulmonary circulation dilates

• PVR falls massively drawing blood into

the pulmonary circulation

17
Ventilation / Perfusion matching

• Throughout life HPV essential for ventilation / perfusion

matching (moving blood away from non- oxygenated
areas)

Hypoxic area

Oxygenated area

18
 Hypoxic Pulmonary Vasoconstriction

• General hypoxia can cause extensive pulmonary artery

vasoconstriction

Pulmonary oedema COPD

19
Pulmonary/Systemic Differences

Pulmonary Systemic
Thin-walled - greater Thicker walled-smaller
internal diameter internal diameter
Less vascular smooth More vascular smooth
muscle muscle
No highly muscular Muscular arterioles
arterioles
Pressure/resistance evenly 75-80% of resistance in
distributed arterioles
Normally fully dilated Normally tonically
vasoconstricted
Constricts to hypoxia Dilates to hypoxia

20
Pulmonary Hypertension

21
 Pulmonary Hypertension

• Characterised by:
• Sustained elevation of pulmonary vascular resistance (PVR) and
pulmonary arterial pressure (PAP).

• Leads to impaired right-heart function and eventually failure

• Clinically – mean PAP 25 mmHg at rest

or 30 mmHg during exercise

• Occurs more commonly in females than males (~4:1)

• Symptoms:
• Fatigue, breathlessness on exercise, fainting,
• dizziness, chest pain
• Symptoms non-specific – diagnosis delayed 22
 Pulmonary Hypertension

• Pulmonary Hypertension World Health Organisation

(WHO) clinical classification system (Dana Point 2008):
• Group 1 - Pulmonary arterial hypertension:
- Idiopathic
- Familial (heritable)
- Related to HIV, Drugs, Toxins etc
- Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Group 2 - Pulmonary Hypertension with left heart disease

• Group 3 - Pulmonary Hypertension with lung disease and / or hypoxemia
• Group 4 – Pulmonary Hypertension secondary to chronic thrombotic and/or
embolic disease
• Group 5 – Pulmonary Hypertension with unclear multifactorial mechanisms
23
 Incidence and Survival

• The incidence of PAH is estimated at:

– 2.4 cases/million annually in France
– 7.6 cases/million annually in Scotland.

• High mortality rate

• Mortality varies depending on classification of PAH
– IPAH 3 year survival rate around 60%
– PAH associated with HIV 3 year survival rate around 20%

24
 Pathobiology of PAH

• Complex and multifactorial

• Disease of the small pulmonary arteries

25
Pulmonary Arterial Hypertension

Two Main Underlying

Pathologies

Pulmonary Vascular Remodelling

Vasoconstriction of Pulmonary Arteries
 Pulmonary Vasoconstriction in PAH

PAH

vasodilation
vasoconstriction vasoconstriction
↓lumen size
↑PVR
↑PAP

↓ Prostacylin ↑Thromboxane A2
↓ Nitric oxide ↑Endothelin-1

27
 Pulmonary Vascular Remodelling

• Vascular remodelling – adaptive process during development

• Contributes to pathobiology of various vascular diseases, including
PAH
• In normal circumstances diameter of pulmonary artery wall
maintained by a balance between apoptosis and proliferation

↑wall thickness
Apoptosis ↓lumen size → occlusion
PAH Proliferation ↓vascular compliance
↑PVR
↑PAP
28
Muscularisation in pulmonary arteries

normal PAH
Small non-muscular arteries become muscularised
29
 Pulmonary vascular remodelling

α-Smooth
muscle actin

No PAH PAH

Complex
Occluded
vascular
lumen
lesions

30
 Plexiform lesions

Normal Pulmonary artery

31
 Pulmonary vascular pruning

Normal adult lung IPAH adult lung

32
 Consequences of Vasoconstriction
and Vascular Remodelling
apoptosis
proliferation

Vascular
remodelling
↓lumen size → occlusion
PAH ↓vascular compliance
↑PVR
↑PAP

vasoconstriction • Vasular pruning

vasodilation • Right ventricular
hypertrophy
33 and

vasoconstriction failure
 Pulmonary Arterial Hypertension
Low pressure
Low resistance

Leads to impaired right-heart

function and eventually failure

Normal lung
High pressure
High resistance
Pulmonary artery
remodelling

Complex/Plexiform
lesions

PAH lung
35
Part 2

36
 What causes PAH?

Risk factors

•Female gender
•BMPR2 mutation
•Ingestion of appetite suppressants such as dexfenfluramine
•Cocaine / metamphetamine misuse
•HIV
•Obesity Multifactorial disease:
•Diabetes
Various underlying factors lead to a
common pathology

37
How do we treat PAH?

38
 General treatments

• Oral anti-coagulants
– Increased PVR, slower movement of blood, increased chance of formation of clot
• Diuretics
– ↑ excretion of water ↓blood volume ↓ blood pressure
– Given to patients with evidence of fluid retention
• Oxygen
– Dilates pulmonary vasculature
• Digoxin
– Cardiac glycoside
– Increases force of contraction
– Used in PAH patient with evidence of right heart failure

39
 Calcium channel blockers (CCBs)

• Patients given acute vasoreactivity test (invasive

procedure)
– Prostacyclin
– Nitric oxide
• Responders given Ca2+ channel blockers
– Nifedipine
– Amlodipine
• Only ~5% of patients respond long term
• CCBs can decrease cardiac output and systemic
vascular resistance without improvement in PAP and
PVR – need to check vasoreactivity regularly

40
 Prostacyclin analogues

• Until 1995 there were no treatments approved for use in PAH

• 1995: synthetic prostacyclin gained approval

• Now various prostacyclin analogues approved for use in PAH:

– Epoprostenol (i.v.)
– Treprostinil (i.v. / s.c. / inhalation)
– Iloprost (i.v. / inhalation)
– Beraprost (oral)
 Prostacyclin (PGI2) analogues

PGI2

Gs AC Vascular smooth
muscle
IP receptor

cAMP ATP

PKA

MLCK

Vasodilation
X
CONTRACTION myosin P + myosin
actin
MLCK = myosin light chain kinase
 Prostacyclin analogues - limitations

• Short half life, quickly degraded

• Given by intravenous (i.v.) or

subcutaneous (s.c.) infusion

Vasodilator:
Additive effect with other vasodilators such as:
•Calcium channel blockers
•diuretics

Potent platelet aggregation inhibitor

•increased risk of bleeding
•especially when taken alongside anticoagulant drugs
 Prostacyclin analogues – side effects

•85% of patients report pain or other reaction at the

infusion site (i.v. and s.c.).

•IV infusion can lead to sepsis which can be fatal,

therefore s.c. is preferred route

•However, IV infusion is ‘gold standard’ therapy for

patients with the most severe forms of PAH due to
proven improvement in survival

Side Effects:
Headache
Selexipag - an oral selective Systemic Hypotension
IP prostacyclin-receptor Dizziness
agonist is now approved in Oedema (swelling)
USA (2015). nausea
 Endothelin receptor antagonist therapies
for PAH

• Bosentan – Dual ETA/ETB blocker

• Ambrisentan – ETA selective

• Macitentan - Dual ETA/ETB blocker

(50-fold increased selectivity for the ETA subtype compared to the ETB subtype).
 Endothelin (ET-1)

A potent vasoconstrictor peptide

Yanagisawa M, et al. Nature. 1988; 332: 411.
46
 Endothelin – Mechanism of action

ET uptake

ECE = endothelin converting enzyme

47
 Endothelin-1 – Production and
Clearance

Production: pulmonary circulation

Clearance: pulmonary circulation
•50% of ET-1 removed for circulation by ETB receptor in lung
- ETB mediates clearance and reuptake of ET-1 by endothelial cells

•In normal lung: production=clearance

•In PAH: production increases, clearance decreases = ↑ET-1
 Increased expression of ET-1 in
pulmonary hypertension

Control artery Plexiform lesion

Giaid A, et al. N Engl J Med. 1993; 328: 1732 49

Correlation between ET-1 levels and
disease severity

Rubens, C et al (2001) Chest. 120; 1562-1569

50
 Effect of Bosentan (Tracleer) on pulmonary and
systemic haemodynamics in heart failure patients

Kiowski, W. et al (1995) Lancet, 346, 732-736

51
Bosentan (Tracleer) – Licenced for
treatment of PAH

52
 Limitations of Endothelin receptor antagonists

• RISKS OF HEPATOTOXICITY
– monthly monitoring of liver function tests required

• Hormone-based contraception is not possible in women taking

Bosentan, due to a pharmacokinetic interaction
– Pregnancy not advised in women with PAH

• Bosentan is absolutely contraindicated in pregnancy because

of its teratogenicity

53
PDE5 inhibitors as treatment for PAH

• Sildenafil
• Tadalafil

• PDE5 expression is greater in lung than systemic vasculature therefore

dose can be titred for selective pulmonary effects.
 PDE5 – Nitric Oxide/cGMP signalling
pathway

PDE = Phosphodiesterase 55
In PAH?....

56
 X

Therapeutic effect in PAH

57
 Sildenafil and PAH

Ghofrani et al., New England Journal of Medicine 2005

58
 Limitations of sildenafil

•Headache
•Flushing
•Nasal congestion
•Indigestion
•Impaired vision (photophobia / blurred vision / cyanopsia

Rare but serious adverse effects

• Severe hypotension
• Myocardial infarction
• Ventricular arrythmias
• Stroke
• Increased intraocular pressure
• Sudden hearing loss

59
 Combination therapy

If patient not improving on monotherapy, combination therapy may be used

Optimal combination for maximum benefit: risk ratio unknown

60
 Bosentan + iloprost

McLaughlin et al 2006 Am J Resp Crit Care Med

Bosentan + iloprost

Bosentan + placebo

61
 Soluble Guanylate Cyclase Stimulators – new PH
treatment

Riociguat - novel drug that is a stimulator of soluble guanylate cyclase

Effects are independent of nitric oxide bioavailability

62
63
 NITRIC OXIDE PROSTACYCLIN ENDOTHELIN
PATHWAY PATHWAY PATHWAY

PDE5 inhibitors Prostacylcin

analogues Endothelin
↑cGMP antagonists

Current drugs do not cure disease – mainly

vasodilators and don’t reverse vascular
remodelling.
Part 3

65
 How can we investigate PAH
pathogenesis?

Molecular approaches
eg. qRT-PCR (measures
Human /
mRNA expression)
animal

66
 Animal models of PAH

• Chronic hypoxic rat/mouse model:

» 10% oxygen
» Normobaric – nitrogen depletion
» Hypobaric – 550 mbar
» Typically 2 weeks hypoxia – can be longer depending on
study
Right ventricular pressure Pulmonary vascular remodelling Right ventricular hypertrophy

control

PAH

67
 PAH - Current research / Future
therapies?
serotonin BMPRII
elastase
oestrogen

Inflammatory
response
miRNA
PAH
PPARγ
K+ pathway
channels

Endothelial
Rho kinase P38 MAP progenitor
kinase cells

68
 BMPR2 - Bone morphogenetic protein receptor-2

• BMPR2 is a receptor member of the TGFβ superfamily of structurally related

cytokines – BMPs, TGFβ and activins.
• TGFβ superfamily induce a multitude of effects:
» Differentiation, Proliferation, Migration, Apoptosis

BMP-4, BMP-9 Pulmonary artery smooth muscle

BMPR2

BMPR1

P
Smad 1/5/8

Smad 1/5/8 P

Smad 4 Smad 1/5/8 P

Smad 1/5/8 P
Smad 4

NUCLEUS

e.g. Id, Msx-1

Antiproliferative

69
 BMPR2

• ‘Heterozygous germline mutations in BMPR2, encoding a TGFβ

receptor, cause familial primary pulmonary hypertension’
Lane et al., 2000, Nature Genetics, 26, 81-84

• Mutations in the BMPR2 gene have been found in approximately

80% of cases of familial PAH.
• Patients with apparently idiopathic PAH may also have BMPR2
mutations in 11 to 40% of cases.

70
 BMPR2 mutations

• BMPR-II dysfunction arises from diverse molecular mechanisms, including

haploinsufficiency

Extracellular domain
Serine/threonine kinase domain
Cytoplasmic domain
Machado et al. Am J Hum Genet (2001); Rudarakanchana
et al. Hum Mol Genet (2002)
71
 BMPR2 mutations

• Mutations in BMPR2 gene are often associated with a loss of

function in BMPR 2 signalling.

• BMPR2 signalling normally anti-proliferative

• Impaired BMPR2 signalling leads to less anti-proliferative effects

Can we restore BMPR2 function?

Will this lower PAP in PAH?

72
 BMPR2 Gene Therapy

Study using
hypoxic rats:
Translatable to
human
disease??
Reynolds A M et al. Am J Physiol Lung Cell Mol Physiol
2007;292:L1182-L1192

©2007 by American Physiological Society

Novel compounds that activate BMPR2 signalling

• FK506 (Tracolimus), is able to activate BMPR2-mediated

signalling and increase BMPR2 expression

• FK506, reverse dysfunctional BMPR2 signalling in pulmonary

artery endothelial cells for patients with PAH

FK506
attenuates PAH
in animal models
of the condition

J Clin Invest. 2013 Aug;123(8):3600-13. doi:

10.1172/JCI65592. Epub 2013 Jul 15 74
FK506 Clinical Trial

Eur Respir J. 2017 Sep 11;50(3). Randomised placebo-

controlled safety and tolerability trial of FK506
(tacrolimus) for pulmonary arterial hypertension.
75
BMP9 – activates BMPR2

76
 BMPR2 is not the full story

• Markedly reduced ‘disease penetrance’ in families

with BMPR2 mutation
• ie only around 20-30% of mutation carriers develop
disease
• “second hit” required ??? serotonin
elastase
oestrogen

Inflammatory
response
miRNA
PAH
PPARγ
K+ channels pathway

Endothelial
Rho kinase P38 MAP progenitor
kinase cells

77
 Serotonin (5HT)

• One of the major vasoconstricting substances in blood – stored

in platelets
• Major neurotransmitter
• Involved in platelet aggregation
• Serotonin can be cleared from the synaptic cleft or taken up
into cells via SERT (serotonin transporter)
• Exerts it physiological effect via a variety of receptors

HO
CH2CH2NH2

N
H 78
 Serotonin
• Serotonin is synthetized by two distinct TPH enzymes in the brain (TPH2) and
in the periphery (TPH1).

79
 Serotonin synthesis

TRYPTOPHAN
COOH COOH
HYDROXYLASE
HO
CH2CH CH2CH

NH2 NH2
N N
H H
5-HYDROXYTRYPTOPHAN
TRYPTOPHAN
L-AROMATIC ACID
DECARBOXYLASE
HO
CH2CH2NH2

5-HYDROXYTRYPTAMINE
N
H (serotonin)

MONOAMINE
OXIDASE

HO HO
CH2CHO CH2CHOOH

N N
H ALDEHYDE H
DEHYDROGENASE
5-HYDROXYINDOLEACETIC ACID
80
 The Serotonin Hypothesis of
Pulmonary Hypertension

• In the 1960s, an epidemic of pulmonary hypertension

occurred in Europe in association with the anorexigen
aminorex fumarate
• In the early 1980s French investigators reported a
cluster of PAH amongst patients using fenfluramine
derivatives
- Fenfluramines – indirect serotonergic agonists

• Dempsie, Y et al 2008 Circulation 117(22):2928-37.

81
Anorexigens can increase serotonin

82
 Serotonin pathways

• Where are the potential therapeutic targets?

» Tryptophan hydroxylase 1
» Serotonin receptors: 5HT1B
» Serotonin transporter

TPH1 serotonin (5HT) Endothelial cell

5HT 5HT

5HT1B SERT
Smooth Muscle
Gi / ↓cAMP Cell

vasoconstriction remodelling
83
 TPH-1: Experimental PAH
• Viable homozygous Tph1-deficient (Tph1−/−) mice.
• Lack serotonin in the periphery.
• Only minor reduction of steady-state serotonin levels in serotonergic
brain regions.

Morecroft I et al. 2007 Hypertension;49(1):232-6. 84

 TPH-1 in human disease

Tryptophan

↑ expression Tph-1

5-hydroxytryptophan
(5HTP)
L-AROMATIC ACID
C iPH C iPH DECARBOXYLASE

5-HT

PCPA = TPH-1 inhibitor

↑ function

Eddahibi, S. et al. Circulation

2006;113:1857-1864
85
 TPH-1 - Conclusions

Experimentally:
• Tph1 -/- mice do no develop hypoxia-induced PAH

Clinically:
• Tryptophan hydroxylase 1 expression and activity is up-
regulated in PA endothelial cells from PAH patients

Tryptophan hydroxylase 1 could be novel target for PAH

86
 Evidence that 5-HT1B receptors play a
role in PAH
• 5-HT1B receptors mediate vasoconstriction in human pulmonary
arteries (Morecroft et al., 1999, Br J Pharmacol., 128, 730-734)

• Launey et al: PAs removed from PAH patients have increased

expression of the 5HT1B-receptor. Nat Med 2002

• PAH development inhibited in the 5-HT1B knockout mouse

(Keegan et al., 2001,Circulation Res., 89, 1231-1239)

• Experimental PAH development inhibited by 5-HT1B receptor

antagonist (Keegan et al., 2001,Circulation Res., 89, 1231-1239)
87
 Evidence that 5-HT1B receptors play a
role in PAH

Hypoxic– induced increases in Hypoxic– induced remodelling is

pulmonary pressure in rats are inhibited in 5-HT1B -/- mice
inhibited by a 5-HT1B receptor
antagonist
Keegan et al. (2001) Circ Res. 89: 1231-1239 88
 5-HT1B - Conclusions

Experimentally:
• 5-HT1B plays a role in development of experimental PAH
• 5-HT1B responsible for constriction of human PAs

Clinically:
• 5-HT1B receptor up-regulated in small cohort of PAH patients
(Launay et al., Nature Medicine)

5-HT1B receptor could be a novel target for PAH

89
 SERT and PAH

• Entry of serotonin into PASMCs plays a crucial role in pulmonary artery smooth
muscle proliferation – may contribute to vascular remodelling in PAH.
ROS = reactive oxygen species
Liu,Y., et al (2004). Circ Res, 95, 579-86.
MEK = ERK kinase

ERK = extracellular-signal-regulated
kinase. Mitogen activated protein
kinase that plays a critical role in cell
growth.

90
 SERT and PAH….Experimentally

•Chronic hypoxia-induced PAH is inhibited in SERT knockout mice

(Eddahibi et al. J Clin Invest. 2000 105:1555-62)

91
 Does over-expression of SERT induce
more severe PAH
• Effect of 2 weeks chronic hypoxia on development of PAH in
SERT+ mice.

NB – only in
female mice

MacLean et al., 2004, Circulation 109, 2149-2154

 SERT and PAH….Clinically

•SERT overexpression and polymorphisms are found in patients

with primary PAH (J Clin Invest, 108, 1141-1150, 2001)
- Not repeatable using larger numbers of patients
- Machado et al., Am J Respir Crit Care Med. 2006;173:793-797
- Willers et al., Am J Respir Crit Care Med. 2006 Apr 1;173:798-802

93
 SERT - Conclusions

Experimentally:
• SERT+ mice develop spontaneous PAH
• SERT KO mice protected against PAH
• SERT critical for serotonin-induced proliferation of PASMCs

Clinically:
• SSRIs may improve survival in PAH patients

The serotonin transporter could be a novel target for PAH

94
However………..
SERT

5-HT
5-HT1B receptors
PASMC 5-HT 5-HT

5-HT

5-HT 5-HT
constriction
5-HT
5-HT
5-HT
proliferation 5-HT
5-HT
5-HT

95
 Future therapeutic target:

Dual inhibition of the 5-HT1B receptor + SERT

96
 Comparison of single inhibition of SERT (citalopram) with dual
inhibition of SERT + 5-HT1B receptor (LY393558) on development of
PAH in mice

Morecroft et al., Cardiovascular Research 2010

98
 Dual SERT/5HT1B inhibition

Experimentally:
• Dual SERT and 5HT1B inhibition has greater effect in reducing
RVSP, PASMC proliferation and vasoconstriction than a SERT
inhibitor on its own.

Clinically:
Dual SERT and 5HT1B inhibition may have a more beneficial
therapuetic effect??

99
 Oestrogen

• Is oestrogen good or bad in terms of

cardiovascular health?

100
 Oestrogen and PAH

• More women develop PAH than men –

ratio of 4:1
• However, male that develop PAH have
much poorer survival rates than women
and there right ventricular function is
more severely affected.

101
 Endogenous Oestrogen and Pulmonary Hypertension

Aromatase
 Aromatase (CYP19A1) is the rate-limiting
enzyme in the conversion of androgens to
estrogens
 Oestrogen synthesised occurs mainly in the ovarian
follicles and corpus luteum. This synthesis occurs in a
lesser extent in non-glandular tissues such as adipose
tissue, liver, skin, muscle and brain.
 Aromatase inhibitors used clinically in the treatment of
oestrogen-sensitive breast cancer – e.g. anastrozole,
letrozole

Aromatase/Oestrogen and pulmonary hypertension?

 Two promoter SNPs in the gene coding for aromatase have been associated with an increased risk of
portopulmonary hypertension (Roberts et al (2009), Am. J. Respir. Crit. Care Med.).
 In men, increased plasma oestrogen has been associated with PAH - correlates inversely with 6 minute
walk distance (Ventetuolo et al., (2016). Am J Respir Crit Care Med 15;193(10):1168-75.)
 Oestrogen synthesis in the lung

CONTROL PAH

hPASMCs
Aromatase

Aromatase / GAPDH
Aromatase 3 ***
2
1
0
Female Male

α-SMA

Mair et al., (2014). Am J Respir Crit Care Med.

190(4):456-67.
 Effect of aromatase inhibition in a hypoxic model of PH

mice
• C57/b6 mice; 6-8 weeks old
Day 14 - RV pressure
- Lungs for histology (vascular
Dosing phase remodelling)
- Cardiac hypertrophy (RV/LV+S)
-Blood for analysis
Anastrozole 3mg/kg s.c, qd
DAY 28
14 DAYS 10% O2 (HYPOXIA) 14 DAYS 10% O2 (HYPOXIA) END
 Effect of inhibiting endogenous estrogen (using
anastrozole [ANA]) on the development of
experimental PH.

FEMALE MALE

***
50
*** *** Vehicle 50 ** Vehicle
40 ** ANA 0.3 mgkg -1
40
ANA
ANA 3 mgkg-1 3 mgkg-1
RVSP (mmHg)

RVSP (mmHg)
30 30

20 20

10 10

0 0
Normoxic Hypoxic Normoxic Hypoxic

Anastrozole attenuates RVSP, RVH and pulmonary vascular remodelling in

hypoxia-induced PH. ONLY in females.
 Obesity, oestrogen and PH?

• ~ 32% of PAH patients classified as obese

• Higher prevalence of overweight and obese individuals among those
with idiopathic forms of PH.
• Adipose tissue is a source of estrogen production
• Could increased oestrogen production in obesity due to increased
adiposity play a role in the development of PH?
Does endogenous oestrogen play a role in
the development of PH in obese males?
 Effect of aromatase inhibition in male models of obesity

ob/ob mice
• leptin deficient ob/ob mice; 6-8 weeks old
Day 14 - RV pressure
- Lungs for histology (vascular
Dosing phase remodelling)
- Cardiac hypertrophy (RV/LV+S)
-Blood for analysis
Anastrozole 3mg/kg s.c, qd
DAY 28
14 DAYS 10% O2 (HYPOXIA) 14 DAYS 10% O2 (HYPOXIA) END
 Effects of Anastrozole (ANA) in Male ob/ob Mice

**
Right Ventricular * lean Right Ventricular lean
Pressure **
50 *** * ob/ob
Hypertrophy ob/ob
0.4 ***

male RVH (RV/(LV+S))

*** ob/ob + ANA
male RVSP (mmHg)

ob/ob + ANA *** lean + ANA

40 ** * lean + ANA 0.3
30
0.2
20
10 0.1

0 0.0
normoxic hypoxic normoxic hypoxic

ob/ob
lean ob/ob + ANA
% remodelled vessels (male)

*** normoxic
40 * lean
*** male
ob/ob
*** ob/ob + ANA
30
lean + ANA lean ob/ob
20 ** lean + ANA ob/ob + ANA

10 hypoxic
male
0
normoxic hypoxic
 Anastrozole currently in clinical trial for PAH
treatment

• Anastrozole improved the six-minute walk time in a small-scale clinical trial of

post-menopausal women and male PAH patients (Kawut SM, Am J Respir
Crit Care Med. 2017;195:360-368.)

• Currently recruiting for larger scale trial

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 Future treatments???

• The BMPR2 system

– Increase BMPR2 signalling / Gene therapy/
drugs which restore BMPR2 levels?

• The serotonin system

• Tph1 inhibitors / Dual SERT/ 5-HT1B receptor blockers?

• Oestrogen synthesis
– aromatase inhibitors

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