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a tyrosine kinase inhibitor&#44; were disappointing because of the high dropout rate due to adverse events &#40;over 30&#37;&#41; and the high incidence of subdural hematoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Selexipag is a new oral selective PGI2 receptor agonist that targets the prostacyclin pathway&#46; In the placebo-controlled GRIPHON study of 1156 patients with PAH&#44; selexipag reduced the risk of death or PAH-related complications by 40&#37;&#44; an effect that was primarily driven by a reduction in disease progression and hospitalization for PAH&#59; mortality was similar in both study groups&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Importantly though&#44; the treatment effect was consistent across treatment na&#239;ve patients and those receiving background phosphodiesterase type 5 &#40;PDE5&#41; inhibitors and&#47;or endothelin receptor antagonists&#46; Unlike PDE5 inhibitors&#44; riociguat acts by directly stimulating soluble guanylate cyclase&#44; independent of nitric oxide availability&#46; In recently published long-term extension studies of randomized controlled trials of PAH patients &#40;PATENT-2&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and CTEPH patients &#40;CHEST-2&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> riociguat was well tolerated with sustained improvements in functional capacity and 6-minute walk distance in both patient populations&#46; Riociguat is also the only targeted medication currently approved for treating CTEPH&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Combination therapy in PAH has gained momentum&#44; however there remains some debate on the optimal strategy&#58; upfront versus sequential addition of therapies&#46; The COMPASS-2 study evaluated a strategy of sequentially adding bosentan to patients on background sildenafil for at least 12 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> This was a negative study with regards to the primary endpoint&#59; however&#44; a long recruitment period and high dropout rate resulted in the study being underpowered&#46; In contrast&#44; the AMBITION trial evaluated an upfront combination approach using ambrisentan and tadalafil versus monotherapy in treatment na&#239;ve patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There was a 50&#37; reduction in the primary endpoint with initial combination therapy&#44; driven by a reduction in hospitalization for PAH&#46; Based on the results of AMBITION&#44; initial combination therapy with ambrisentan and tadalafil was given a class IB recommendation in the recent European guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This recommendation is supported by a recent analysis from the French registry showing a 3-year survival of 84&#37; in patients treated with initial dual oral combination therapy compared to an expected historical 3-year survival of 66&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although pulmonary endarterectomy remains the gold standard treatment for eligible CTEPH patients&#44; many are not eligible for surgery due to inaccessible distal thromboembolic disease or comorbidities&#46; Balloon pulmonary angioplasty &#40;BPA&#41;&#44; an endovascular procedure to widen narrowed or obstructed pulmonary arteries&#44; has emerged as an exciting alternative treatment option for patients with non-operable CTEPH or patients with persistent pulmonary hypertension after endarterectomy&#46; The first series published in 2001 demonstrated a reduction in mean pulmonary artery pressure &#40;mPAP&#41; of 9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; but reported a 5&#46;6&#37; rate of in-hospital death&#46; Following refinements in the technique&#44; several reports&#44; mainly from Japan&#44; now support the efficacy and safety of BPA&#46; The hemodynamic benefits were summarized in a recent review article&#44; which reported an overall reduction in mPAP of 12&#8211;21<span class="elsevierStyleHsp" style=""></span>mmHg from baseline&#44; and a mortality rate of 0&#46;0&#8211;3&#46;4&#37; after 2&#8211;5 angioplasty sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A recent Japanese study reported the results of 170 patients who underwent BPA over a 7 year period&#46; They found sustained hemodynamic improvements&#44; almost to within the normal range&#44; in mPAP and pulmonary vascular resistance up to 3&#46;5 years after BPA&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In this series&#44; the 1&#44; 3&#44; and 5-year survival rates were 98&#46;7&#37;&#44; 98&#46;0&#37;&#44; and 95&#46;5&#37;&#44; however 1 death was attributed to multi-organ failure secondary to pulmonary artery injury&#44; a known complication of BPA&#46; Severe and fatal complications&#44; including reperfusion edema or pulmonary artery perforation&#44; may be minimized as the learning curve progresses&#46; Although the indications and limitations have not been fully established&#44; BPA has the potential to become a key treatment strategy for patients with non-operable CTEPH&#46; An open-label&#44; randomized controlled trial comparing BPA to riociguat in non-operable CTEPH patients is currently underway in France&#44; with a primary endpoint of change in pulmonary vascular resistance at 26 weeks &#40;RACE trial&#44; <a href="ctgov:NCT02634203">NCT02634203</a>&#41;&#46; This trial may help clarify the relative place of BPA and riociguat in a CTEPH treatment algorithm&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; there have been important advances in the treatment of PAH and CTEPH over the past few years&#46; However&#44; PAH remains a progressive and fatal disease in most cases&#46; Until the development of effective therapies that can slow or reverse vascular proliferation&#44; inflammation and remodeling&#44; parenteral prostanoids&#44; combination therapy and lung transplantation are the only life-prolonging therapies&#46; Patients with CTEPH now benefit from several therapeutic options including possible combinations of surgery&#44; medical therapy and BPA&#46; Riociguat and balloon pulmonary angioplasty are new effective options for CTEPH that result in significant clinical improvements for non-operable patients and those with persistent pulmonary hypertension after endarterectomy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dr&#46; Humbert reports personal fees from Actelion Pharmaceuticals Ltd&#46;&#44; grants and personal fees from Bayer&#44; grants and personal fees from GSK&#44; personal fees from Pfizer&#59; and personal fees from Novartis&#44; outside the submitted work&#46; Dr&#46; Weatherald has received grants from the European Respiratory Society and Canadian Thoracic Society&#59; personal fees and non-financial support from Actelion and Bayer&#44; outside the submitted work&#46; Dr&#46; Taniguchi has no conflict of interest to declare&#46;</p></span></span>"
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Editorial
Novelties in the Treatment of Pulmonary Hypertension
Novedades en el tratamiento de la hipertensión pulmonar
Jason Weatheralda,b,c,d, Yu Taniguchia,b,c,e, Marc Humberta,b,c,
Corresponding author
marc.humbert@aphp.fr

Corresponding author.
a Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
b Service de Pneumologie, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
c INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
d Department of Medicine, Division of Respirology, University of Calgary, Calgary, Canada
e Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary arterial hypertension &#40;PAH&#41; and chronic thromboembolic pulmonary hypertension &#40;CTEPH&#41; are progressive diseases of the pulmonary circulation that lead to right heart failure&#46; Exciting recent advances have improved prognosis&#44; however PAH and CTEPH remain disabling and life limiting conditions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Currently approved medical therapies improve functional capacity&#44; hemodynamics and delay clinical worsening by targeting the 3 main pathobiologic pathways&#58; prostacyclin&#44; endothelin&#44; and nitric oxide&#46; Recently&#44; several new agents targeting the classic PAH pathways have been developed for the treatment of pulmonary hypertension&#46; However&#44; a targeted treatment that delays or reverses vascular remodeling remains elusive&#46; Recent attempts to specifically inhibit or reverse vascular proliferation in PAH with imatinib&#44; a tyrosine kinase inhibitor&#44; were disappointing because of the high dropout rate due to adverse events &#40;over 30&#37;&#41; and the high incidence of subdural hematoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Selexipag is a new oral selective PGI2 receptor agonist that targets the prostacyclin pathway&#46; In the placebo-controlled GRIPHON study of 1156 patients with PAH&#44; selexipag reduced the risk of death or PAH-related complications by 40&#37;&#44; an effect that was primarily driven by a reduction in disease progression and hospitalization for PAH&#59; mortality was similar in both study groups&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Importantly though&#44; the treatment effect was consistent across treatment na&#239;ve patients and those receiving background phosphodiesterase type 5 &#40;PDE5&#41; inhibitors and&#47;or endothelin receptor antagonists&#46; Unlike PDE5 inhibitors&#44; riociguat acts by directly stimulating soluble guanylate cyclase&#44; independent of nitric oxide availability&#46; In recently published long-term extension studies of randomized controlled trials of PAH patients &#40;PATENT-2&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and CTEPH patients &#40;CHEST-2&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> riociguat was well tolerated with sustained improvements in functional capacity and 6-minute walk distance in both patient populations&#46; Riociguat is also the only targeted medication currently approved for treating CTEPH&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Combination therapy in PAH has gained momentum&#44; however there remains some debate on the optimal strategy&#58; upfront versus sequential addition of therapies&#46; The COMPASS-2 study evaluated a strategy of sequentially adding bosentan to patients on background sildenafil for at least 12 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> This was a negative study with regards to the primary endpoint&#59; however&#44; a long recruitment period and high dropout rate resulted in the study being underpowered&#46; In contrast&#44; the AMBITION trial evaluated an upfront combination approach using ambrisentan and tadalafil versus monotherapy in treatment na&#239;ve patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> There was a 50&#37; reduction in the primary endpoint with initial combination therapy&#44; driven by a reduction in hospitalization for PAH&#46; Based on the results of AMBITION&#44; initial combination therapy with ambrisentan and tadalafil was given a class IB recommendation in the recent European guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This recommendation is supported by a recent analysis from the French registry showing a 3-year survival of 84&#37; in patients treated with initial dual oral combination therapy compared to an expected historical 3-year survival of 66&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although pulmonary endarterectomy remains the gold standard treatment for eligible CTEPH patients&#44; many are not eligible for surgery due to inaccessible distal thromboembolic disease or comorbidities&#46; Balloon pulmonary angioplasty &#40;BPA&#41;&#44; an endovascular procedure to widen narrowed or obstructed pulmonary arteries&#44; has emerged as an exciting alternative treatment option for patients with non-operable CTEPH or patients with persistent pulmonary hypertension after endarterectomy&#46; The first series published in 2001 demonstrated a reduction in mean pulmonary artery pressure &#40;mPAP&#41; of 9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; but reported a 5&#46;6&#37; rate of in-hospital death&#46; Following refinements in the technique&#44; several reports&#44; mainly from Japan&#44; now support the efficacy and safety of BPA&#46; The hemodynamic benefits were summarized in a recent review article&#44; which reported an overall reduction in mPAP of 12&#8211;21<span class="elsevierStyleHsp" style=""></span>mmHg from baseline&#44; and a mortality rate of 0&#46;0&#8211;3&#46;4&#37; after 2&#8211;5 angioplasty sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A recent Japanese study reported the results of 170 patients who underwent BPA over a 7 year period&#46; They found sustained hemodynamic improvements&#44; almost to within the normal range&#44; in mPAP and pulmonary vascular resistance up to 3&#46;5 years after BPA&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In this series&#44; the 1&#44; 3&#44; and 5-year survival rates were 98&#46;7&#37;&#44; 98&#46;0&#37;&#44; and 95&#46;5&#37;&#44; however 1 death was attributed to multi-organ failure secondary to pulmonary artery injury&#44; a known complication of BPA&#46; Severe and fatal complications&#44; including reperfusion edema or pulmonary artery perforation&#44; may be minimized as the learning curve progresses&#46; Although the indications and limitations have not been fully established&#44; BPA has the potential to become a key treatment strategy for patients with non-operable CTEPH&#46; An open-label&#44; randomized controlled trial comparing BPA to riociguat in non-operable CTEPH patients is currently underway in France&#44; with a primary endpoint of change in pulmonary vascular resistance at 26 weeks &#40;RACE trial&#44; <a href="ctgov:NCT02634203">NCT02634203</a>&#41;&#46; This trial may help clarify the relative place of BPA and riociguat in a CTEPH treatment algorithm&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; there have been important advances in the treatment of PAH and CTEPH over the past few years&#46; However&#44; PAH remains a progressive and fatal disease in most cases&#46; Until the development of effective therapies that can slow or reverse vascular proliferation&#44; inflammation and remodeling&#44; parenteral prostanoids&#44; combination therapy and lung transplantation are the only life-prolonging therapies&#46; Patients with CTEPH now benefit from several therapeutic options including possible combinations of surgery&#44; medical therapy and BPA&#46; Riociguat and balloon pulmonary angioplasty are new effective options for CTEPH that result in significant clinical improvements for non-operable patients and those with persistent pulmonary hypertension after endarterectomy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dr&#46; Humbert reports personal fees from Actelion Pharmaceuticals Ltd&#46;&#44; grants and personal fees from Bayer&#44; grants and personal fees from GSK&#44; personal fees from Pfizer&#59; and personal fees from Novartis&#44; outside the submitted work&#46; Dr&#46; Weatherald has received grants from the European Respiratory Society and Canadian Thoracic Society&#59; personal fees and non-financial support from Actelion and Bayer&#44; outside the submitted work&#46; Dr&#46; Taniguchi has no conflict of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 03002896
Original language: English
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