JAMES L. ANGTUACO, M.D., DPPS,DPSPC, FPCC U.P. College of Medicine Intarmed Class 1992 Pediatric Residency, UP-PGH 1993-95 Fellowship, Pediatric Cardiology, UP-PGH 1996-99 Fellowship, Pediatric Cardiology, New Children’s Hospital of Westmead, Sydney Australia, 1999-2000 Positions: Chair, CME Programs, Chinese General Hospital, 2010-present Head, OPD Section of Pediatric Cardiology, SLMC 2009-present Member, Committee on Research Philippine Pediatric Society, 2012- Chair, Research Committee, Chinese General Hospital, 2004 – 2010 Member, Residency Training Committee, Chinese General Hospital, 2004- present Faculty, San Beda College of Medicine (2006-present) Vice President RF/ RHD Foundation of the Philippines (2012- ) Affiliations: Metropolitan Medical Center Chinese General Hospital St. Luke’s Medical Center Manila Adventist Medical Center Our Lady of Lourdes Hospital Manila Doctor’s Hospital
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JAMES L. ANGTUACO, M.D., DPPS,DPSPC, FPCC U.P. College of Medicine Intarmed Class 1992 Pediatric Residency, UP-PGH 1993-95 Fellowship, Pediatric Cardiology,
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JAMES L. ANGTUACO, M.D., DPPS,DPSPC, FPCC
U.P. College of Medicine Intarmed Class 1992Pediatric Residency, UP-PGH 1993-95Fellowship, Pediatric Cardiology, UP-PGH 1996-99
Fellowship, Pediatric Cardiology, New Children’s Hospital of Westmead, Sydney Australia, 1999-
2000
Positions:Chair, CME Programs, Chinese General Hospital, 2010-presentHead, OPD Section of Pediatric Cardiology, SLMC 2009-presentMember, Committee on Research Philippine Pediatric Society, 2012-Chair, Research Committee, Chinese General Hospital, 2004 – 2010Member, Residency Training Committee, Chinese General Hospital, 2004-presentFaculty, San Beda College of Medicine (2006-present)Vice President RF/ RHD Foundation of the Philippines (2012- )
Affiliations:Metropolitan Medical Center Chinese General HospitalSt. Luke’s Medical Center Manila Adventist Medical CenterOur Lady of Lourdes Hospital Manila Doctor’s Hospital
Pulmonary Hypertension:Guidelines in the Diagnosis and
Treatment
James L. Angtuaco, M.D., DPPS, DPSPC, FPCCPediatric Cardiologist
DISCLAIMER
OBJECTIVES:
1. To discuss the definition of Pulmonary arterial hypertension2. To discuss the different pathology / pathobiology of
Pulmonary arterial hypertension3. To describe the classifications of Pulmonary arterial
hypertension4. To discuss the clinical presentations of Pulmonary arterial
hypertension5. To discuss the different diagnostic modalities for Pulmonary
arterial hypertension6. To discuss the different treatment modalities for Pulmonary
arterial hypertension
Pulmonary Hypertension
• Definition:– increase in mean pulmonary arterial pressure > 25
mmHg at rest as assessed by right heart catheterization
– normal mean pulmonary arterial pressure is 14+3 mmHg. with an upper limit of ~20 mmHg.
– gray zone : 21-24 mmHg.
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 1: PULMONARY ARTERIAL HYPERTENSION– idiopathic– Heritable• BMPR2 (bone morphogenesis protein receptor 2 gene)• ALK1 (activin receptor like kinase type 1 gene), endoglin
(with or without hereditary hemorrhagic telangiectasia)• Unknown
– Drugs and toxins induced (weight loss drugs)
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
– Persistent pulmonary hypertension of the newborn
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 1’ : PULMONARY VENO-OCCLUSIVE DISEASE WITH PULMONARY CAPILLARY HEMANGIOMATOSIS
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 2: PULMONARY HYPERTENSION DUE TO LEFT HEART DISEASE– systolic dysfunction– diastolic dysfunction– valvular disease
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 3: PULMONARY HYPERTENSION DUE TO LUNG DISEASE AND/ OR HYPOXIA– chronic obstructive pulmonary disease– interstitial lung disease– other pulmonary diseases with mixed restrictive and
obstructive pattern– sleep-disordered breathing– alveolar hypoventilation disorders– chronic exposure to high altitude– developmental abnormalities
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 4: CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION (CTEPH)
CLINICAL CLASSIFICATION OF PULMONARY ARTERIAL HYPERTENSION
(The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology and the European Respiratory Society, endorsed by the International Society of Heart & Lung
Transplantation 2009)European Heart Journal 2009
• GROUP 5 : PULMONARY HYPERTENSION WITH UNCLEAR AND/OR MULTIFACTORIAL MECHANISMS– hematologic disorders : myeloproliferative disorders,
• Group 1: PAH– affects the distal pulmonary arteries (<500 um in diameter)– medial hypertrophy– intimal proliferation and fibrotic changes (concentric and
eccentric)– adventitial thickening with moderate perivascular
• Group 1: PAH– vasoconstriction, proliferative, and obstructive remodelling
of pulmonary vessel wall– inflammation and thrombosis– abnormal function or expression of potassium channels in
smooth muscle cells– endothelial dysfunction– impaired production of vasodilator and anti-proliferative
agents (e.g. NO and prostacyclin)– overexpression of vasoconstrictor & proliferative substances
(e.g.. thromboxane A2 and endothelin-1)Humbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
PATHOBIOLOGY OF PULMONARY HYPERTENSION
• Group 1: PAH– elevated vascular tone– promote vascular remodelling by proliferative
changes (includes endothelial, smooth muscle cells, and fibroblasts)
– increased production of extracellular matrix including: collagen, elastin, fibronectin, and tenascin
– prothrombotic activityHumbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
PATHOBIOLOGY OF PULMONARY HYPERTENSION
• Group 2: PAH due to left heart disease– vasoconstrictive reflexes from stretch receptors in
the left atrium and pulmonary veins– endothelial dysfunction of pulmonary arteries
favour vasoconstriction and proliferation of vessel wall cells
Humbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
PATHOBIOLOGY OF PULMONARY HYPERTENSION
• Group 3: PAH due to lung disease– hypoxic vasoconstriction– mechanical stress of hyperinflated lungs– loss of capillaries– inflammation and toxic effects of cigarette smoke– endothelin derived vasoconstrictor – vasodilator
imbalance
Humbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
PATHOBIOLOGY OF PULMONARY HYPERTENSION
• Group 4: CTEPH– abnormalities in the clotting cascade, endothelial
cells, and platelets– shear, stress, pressure, inflammation, and release of
cytokines and vasculotropic substances
Humbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
PATHOBIOLOGY OF PULMONARY HYPERTENSION
• Group 5: – unknown
Humbert M. et. al. JACC 2004Hassoun PM et. al. JACC 2009Morrell N. et. al JACC 2009
DIAGNOSIS
• CLINICAL PRESENTATION– NON-SPECIFIC SYMPTOMS:• breathlessness• fatigue• weakness• angina• syncope• abdominal distension• symptoms at rest only in very advanced cases
Rich S et. al Ann Intern Med 1987
DIAGNOSIS
• CLINICAL PRESENTATION– SIGNS:• left parasternal lift
• accentuated P2
• holosystolic murmur of tricuspid regurgitation• diastolic murmur of pulmonary regurgitation
Rich S et. al Ann Intern Med 1987
DIAGNOSIS
• CLINICAL PRESENTATION– SIGNS in more advanced cases:• S3 gallop
• ELECTROCARDIOGRAM:– suggestive or supportive evidence• RV hypertrophy (87%) and strain• Right axis deviation (79%)• RA dilatation• atrial flutter and atrial fibrillation (ADVANCED STAGES)
– absence does NOT rule out disease– insufficient sensitivity (55%) and specificity (70%)
Rich S et. al Ann Intern Med 1987
DIAGNOSIS
• CHEST RADIOGRAPH:– central pulmonary arterial dilatation– pruning (loss of) distal pulmonary vessels– RA and RV enlargement (ADVANCED STAGES)– can be used to exclude moderate to severe lung
diseases or pulmonary venous hypertension due to left heart disease
– cannot assess the degree of PAH
Rich S et. al Ann Intern Med 1987
DIAGNOSIS
• PULMONARY FUNCTION TESTS and ABG– decreased lung diffusion capacity of carbon monoxide
(40-80% of predicted)– mild to moderate reduction of lung volume
• may indicate interstitial lung disease if coupled with above
– arterial oxygen tension is normal or slightly lower at rest– arterial carbon dioxide tension is decreased– irreversible airflow obstruction– increased residual volumes– overnight oximetry or polysomnography is with OSA
DIAGNOSIS
• ECHOCARDIOGRAPHY– transthoracic echocardiography– estimation of PAP:
• peak pressure gradient of TR = 4x(TR velocity)2
• PAP = PG TR jet + estimated RA Pressure – RA Pressure is estimated at 5-10 mmHg.
• mPAP = 0.61 x PA systolic pressure + 2 mmHg
– may use contrast echocardiography if difficult to assess TR
– few studies have been done to find an accurate correlation between these and RHC
Fisher MR et. al. Am J. Resp Crit Care 2009
DIAGNOSIS
• ECHOCARDIOGRAPHY– other findings:• increased velocity of pulmonary valve regurgitation• short acceleration time of RV ejection into the PA• increased dimension of right heart chambers• abnormal shape and function of the interventricular
septum• increased RV wall thickness• dilated main PA
Murkejee D et al. Rheumatology 2004
VENTILATION-PERFUSION SCAN
• useful for potentially treatable CTEPH• higher sensitivity than CT • normal or low-probability VQ scan– excludes CTEPH (sensitivity 90-100% /
specificity 94-100%)
Tunariu N. et. al. J Nucl Med 2007
HIGH-RESOLUTION CT, CONTRAST-ENHANCED CT, AND PULMONARY
ANGIOGRAPHY
• detailed view of lung parenchyma interstitial lung disease and emphysema
• suspected PVOD: interstitial edema with diffuse central central ground-glass opacification and thickening of interlobular septa; lymphadenopathy and pleural effusion
Resten A et. al. Am J Roentgenol 2004
HIGH-RESOLUTION CT, CONTRAST-ENHANCED CT, AND PULMONARY
ANGIOGRAPHY
• contrast CT angiography of the PA– to check for evidence of surgically accessible CTEPH– complete obstruction, bands and webs, and intimal
irregularities (similar to digital subtraction angiography)
• traditional pulmonary angiography– required to identify patients who may benefit from
pulmonary endarterectomy– evaluation for vasculitis or pulmonary AVMs
Dartevelle P et. al. Eur Respir J 2004
CARDIAC MRI
• image RV size, morphology and function• non-invasive assessment of blood flow : including– stroke volume– cardiac output– distensibility of PA– RV mass
• decreased stroke volume, increased RV end-diastolic volume* and decreased LV end-diastolic volume (predictors of poor prognosis)
* most appropriate marker
Torbicki A et. al. Eur Heart J 2007
BLOOD TESTS AND IMMUNOLOGY
• serologic test to identify CTD, HIV and hepatitis• limited scleroderma– anti-centromere antibodies, dsDNA, anti-Ro, U3-RNP, B23, Th/To,
U1-RNP
• diffuse scleroderma– U3-RNP
• SLE– anti-cardiolipin antibodies
• Thrombophilia in CTEPH– anti-phospholipid antibodies, lupus anticoagulant, anti-
• REQUIRED to diagnose PAH– assess severity of hemodynamic impairment– test for vasoreactivity of the pulmonary circulation– PAP (systolic, diastolic, mean), right atrial pressure,
PWP, and RV Pressure– Cardiac output
RIGHT HEART CATHETERIZATION
• REQUIRED to diagnose PAH– to identify who may benefit from long-term therapy
with CCBs.– acute vasodilator challenge with short-acting, safe,
and easy to administer drugs with no or limited systemic effects• nitric oxide• intravenous epoprostenol• intravenous adenosine (risky for systemic vasodilator
effect)
Galie N et. al Am J. Cardiol 1995
RIGHT HEART CATHETERIZATION
• REQUIRED to diagnose PAH– positive acute response:• reduction mean PAP > 10 mmHg. to reach an absolute
value of mean PAP < 40 mmHg. ; with• an increased or unchanged Cardiac Output• long-term responders to CCBs
Sitbon O et. al Circ 2005
exertional dyspneasyncopeangina
progressive limitation of exercise
capacity
Bone Morrphogenetic
Protein Receptor 2, Activin receptor –
Like Kinase type 1, Endoglin
Family History
TREATMENT
• GENERAL MEASURES:– degree of social isolation– encourage patients and family members to join
patient support groups positive effect on coping, confidence, outlook
TREATMENT
• GENERAL MEASURES:– PHYSICAL ACTIVITY and SUPERVISED
REHABILITATION:• active within symptom limits (mild breathlessness is
acceptable; avoid severe breathlessness, exertional dizziness, or chest pain)• training program to improve exercise performance• avoid excessive physical activities• when physically deconditioned supervised exercise
rehabilitation
Mereles D. et. al. Circulation 2006
TREATMENT
• GENERAL MEASURES:– PREGNANCY, BIRTH CONTROL, AND POST-
MENOPAUSAL HORMONAL THERAPY• pregnancy : 30-50% mortality in patients with PAH• barrier method: unpredictable but safe• progesterone only preparations e.g. medroxyprogesterone
acetate and etonogestrel are effective• NOTE: endothelin receptor antagonist bosentan reduces
efficacy of contraceptives• Mirena coil is effective but can cause Vasovagal reaction
The Task Force on the Management of Cardiovascular Disease During Pregnancy Eur Heart J 2003Beclard E. et. al Eur Heart J 2009
TREATMENT
• GENERAL MEASURES:– TRAVEL• may need in –flight O2 if WHO-FC III/IV and arterial blood
O2 <60 mmHg.
• 2L / min. sufficient• avoid going to altitudes above 1500-2000 m without
supplemental O2
• travel with a written information about the PAH
TREATMENT
• GENERAL MEASURES:– PSYCHOSOCIAL SUPPORT• REFER for Psychiatric evaluation if with severe anxiety
and depression• Patient Support Groups
– INFECTION PREVENTION• influenza and pneumococcal vaccine
– ELECTIVE SURGERY• suggest epidural vs. general anesthesia• shift to i.v. or nebulized meds then shift back to oral
Rich S. eta. al Ann Intern Med 1998
TREATMENT
• SUPPORTIVE THERAPY– Oral Anticoagulation• its use is based on the non-specific risk for venous
thromboembolism (e.g. heart failure and immobility) versus the risk of bleeding (e.g. portopulmonary hypertension)• useful in patients with IPAH, heritable PAH, and PAH due
to anorexigens
Fuster V et. al Circ 1984
TREATMENT
• SUPPORTIVE THERAPY– Diuretics• no RCTs on its use• benefit in fluid overloaded patients with raised CVP,
hepatic congestion, ascites, and peripheral edema• monitor renal function and blood biochemistry• avoid hypokalemia and decreased intravascular volume
TREATMENT
• SUPPORTIVE THERAPY– Oxygen• no RCTs on its use on a long-term basis
• advise to maintain an O2 arterial blood pressure of > 60 mmHg. at least 15h/day
– Digoxin• improves cardiac output acutely in IPAH• efficacy is unknown when taken chronically• slow ventricular rate in atrial tachyarrhythmia
Weitzenblum E. et. al. Am Rev Respir Dis 1985Rich S. Chest 1998
TREATMENT
• SPECIFIC DRUG THERAPY– CALCIUM CHANNEL BLOCKERS (CCBs)• choice depends on baseline heart rate• relative bradycardia favouring NIFEDIPINE and
AMLODIPINE; relative tachycardia favouring DILTIAZEM• daily doses in IPAH : 120-240 mg. for NIFEDIPINE; or 240-
720 mg. in DILTIAZEM, or 20 mg. in AMLODIPINE• low initial doses: 30 mg. Nifedipine slow release BID, or
60 mg. Diltiazem TID, or 2.5 mg. Amlodipine OD– cautiously increase to maximum tolerated dose– care for systemic hypotension and peripheral edema
Sitbon O et. al. Circ 2005
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• Prostacyclin produced in endothelial cells inducing
potent vasodilation of all vascular beds• most potent endogenous inhibitor of platelet aggregation• potent cytoprotective and antiproliferative activities
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• EPOPROSTENOL
– freeze dried preparation dissolved in alkaline buffer for IV infusion
– short half-life (3-5 mins.)– stable at room temperature for only 8 hours– administered continuously via infusion pump and a permanent
tunnelled catheter– improves symptoms, exercise capacity and hemodynamics– only treatment showing improvement in survival in IPAH
Barst J et. al. NEJM 1996
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• EPOPROSTENOL
– initial dose: 2-4 ng/kg/min.– doses increasing at a rate limited by the side effects (flushing,
headache, diarrhea, leg pain)– optimal dose : 20-40 ng/kg/min.– serious adverse events: pump malfunction, local site infection,
catheter obstruction, sepsis– avoid abrupt interruption of infusion rebound PH with
symptomatic deterioration and even death
McLaughlin V et al. Circ 2002
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• ILOPROST
– STABLE prostacyclin analogue (i.v., oral, and aerosol)– inhaled route advantageous selective for pulmonary
dose 30 ug/day– increase in exercise capacity and improvement of symptoms,
PVR, and clinical events– iv as effective as Epoprostenol, but oral form has not been
assessed AIR Olschewski H et al NEJM 2002
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• TREPROSTINIL
– tricyclic benzidine analogue of epoprostenol– stable at ambient temperature; iv. and subQ routes– initial dose: 1-2 ng/kg/min. SQ increasing dose limited by side
effects (local site pain, flushing, headache); optimal dose 20-80 ng/kg/min
– more convenient as reservoir is changed every 48 hours– inhaled treprostinil improved exercise capacity with bosentan or
sildenafil– improves exercise capacity and hemodynamics
Simmoneau G et al. Am J Respir Crit Care Med 2002Barst RJ et. al. Eur Respir J 2006
TREATMENT
• SPECIFIC DRUG THERAPY– PROSTANOIDS• BERAPROST
– improvement in exercise capacity– persists only for 3-6 months– no hemodynamic benefits– headache, flushing, jaw pain, diarrhea
Galie N et al. JACC 2002
TREATMENT
• SPECIFIC DRUG THERAPY– ENDOTHELIN RECEPTOR ANTAGONIST• Endothelin-1 exerts vasoconstrictor and mitogenic
effects by binding to distinct receptors (endothelin-A and B) in the pulmonary vascular smooth muscle cells• activation of Endothelin B receptors in endothelial cells
result in release of vasodilators and antiproliferative substances (e.g. NO and prostacyclin)
TREATMENT
• SPECIFIC DRUG THERAPY– ENDOTHELIN RECEPTOR ANTAGONIST• BOSENTAN
– oral active dual (ETa and ETb) receptor antagonist for PAH (IPAH, CTD associated PAH, Eisenmenger’s syndrome)
– start at 62.5 mg. twice daily and uptitrated to 125 mg. bid after 4 weeks
– improvement in exercise capacity, functional class, hemodynamics, echocardiographic and doppler variables, and time to clinical worsening
– increases in hepatic transaminases, reduction in hemoglobin, and impaired spermatogenesis
Galie N et. al. Circ 2006
TREATMENT
• SPECIFIC DRUG THERAPY– ENDOTHELIN RECEPTOR ANTAGONIST• SITAXENTAN
– selective orally active ETa receptor antagonist for PAD (IPAH, PAH associated with CTD or CHD)
– 100 mg once daily– improvement in exercise capacity and hemodynamics– 3-5% abnormal liver function– interacts with warfarin need to reduce warfarin dose
Benza RL et. al. Chest 2008
TREATMENT
• SPECIFIC DRUG THERAPY– ENDOTHELIN RECEPTOR ANTAGONIST• AMBRISENTAN
– non-sulfonamide, propanoic acid-class selective ETa
– improves symptoms, exercise capacity, hemodynamics, and time to clinical worsening
– 5 mg. once daily to 10 mg. once daily if tolerated at the initial dose
– 0.8 – 3% with abnormal liver function test– increased episode of peripheral edema
McGoon M et. al. Chest 2009
TREATMENT
• SPECIFIC DRUG THERAPY– PHOSPHODIESTERASE TYPE 5 INHIBITORS• inhibition of cGMP-degrading enzyme phosphodiesterase
type 5 vasodilation thru NO/cGMP pathway• exerts antiproliferative effects• significant pulmonary vasodilation occurs after 60
(Sildenafil), 75-90 (Tadalafil), and 40-45 (Vardenafil) minutes
TREATMENT
• SPECIFIC DRUG THERAPY– PHOSPHODIESTERASE TYPE 5 INHIBITORS
• SILDENAFIL– orally active potent selective inhibitor– 20 mg. tid with up titration to 40-80 mg. tid (where durability of
effects up to a year is seen) (Pediatric : 0.35 mg/kg/dose q 4H)/ (0.25 -1 mg/kg QID)
– improvement in exercise capacity, symptoms, and hemodynamics– headache, flushing, epistaxis– 5-year survival rate 81%; more than 75% did not reach the
composite end-point of hospitalization for RV Failure and death for a 5-year period Palma G. et. al. Tex Heart Inst J 2011
Tilman H. et. al. Circ 2005SUPER-2 Rubin L et. al. Chest 2012Yanagisawa R et. al Circulation J 2012
TREATMENT
• SPECIFIC DRUG THERAPY– PHOSPHODIESTERASE TYPE 5 INHIBITORS• TADALAFIL
– once daily dispensed selective phosphodiesterase type 5 inhibitor
– 5, 10, 20, or 40 mg. OD (in Pediatrics: 1 mg/kg/day)– favourable result in exercise capacity, symptoms,
hemodynamics, and time to clinical worsening– side effects: headache, nausea, myalgia, nasal congestion,
flushing
Galie N. et. al. Circulation 2009Takatsuki S. et. al. Pediatr Cardiol 2012
TREATMENT
• EXPERIMENTAL COMPOUNDS–PHASE II and III studies:• NO-independent stimulators• cGMP activators• inhaled vasoactive intestinal peptide• non-prostanoid prostacyclin receptor agonists• tissular dual ERA• tyrosine kinase inhibitors• serotonin antagonists