Associate editor: E.D. MichelakisRole of apoptosis in pulmonary hypertension: From experimental models to clinical trials
Introduction
Pulmonary arterial hypertension (PAH) is a disease characterized by elevated pulmonary artery pressures and is associated with significant morbidity and mortality; there is no known cure (Gaine, 2000). Elevated pulmonary vascular resistance results in high right ventricular systolic pressures causing right ventricular remodeling, ultimately progressing to heart failure. On autopsy, the characteristic pathological findings include medial and adventitial remodeling and excessive arterial muscularization (Tuder et al., 2007), as well as the presence of thrombotic lesions (Johnson et al., 2006). In addition, pulmonary arterioles demonstrate intimal lesions, thickening, and fibrosis that is responsible for a decrease in the luminal caliber of these vessels. The most dramatic pathological findings are perhaps the plexiform lesions which often occur distally to an occluded arteriole, usually at branch points and appear to represent an “angioproliferative” process (Archer & Michelakis, 2006). Many investigators believe that these imtimal lesions are the critical pathogical determinants of the severity and progression of this disease, and the overview will focus on the etiology and consequences of endothelial damage in the pathogenesis of PAH.
Pulmonary hypertension can occur in an idiopathic form (IPAH) which was previously known as primary pulmonary hypertension. PAH occasionally occurs in familial form (FPAH). As well, a variety of secondary forms of the disease can be associated (APAH) with other medical conditions such as congenital heart disease with significant left to right shunting (Eisenmenger syndrome) or collagen vascular disorders such as scleroderma. PAH can also arise as a result of HIV infection or the use of anorexigens such as fenfluramine. Although the etiology is likely quite different in these different forms of PAH, they share a nearly identical pathological picture including the presence of the characteristic intimal and plexiform lesions.
Section snippets
Historical perspective
Traditionally, PAH has been characterized as a disease of endothelial dysfunction (Budhiraja et al., 2004) with an imbalance between vasoconstrictors and vasodilators. In the late 1970s, it was found that the infusion of PGE1 to pulmonary hypertensive patients resulted in a reduction of pulmonary arterial pressures and right ventricular end diastolic pressure (Szczeklik et al., 1978). Moreover, an imbalance between thromboxane (TXA2) and prostacyclin (PGI2) had been reported in IPAH patients in
Lessons from the “PAH gene”
Arguably, one of the most important advances in the elucidation of the pathogenesis of IPAH has been the discovery of the association between mutations of the bone morphogenetic protein receptor 2 (Bmpr2) gene and FPAH by two groups working independently (Lane et al., 2000, Thomson et al., 2000). Over 100 different loss-of-function mutations have been identified and haploinsufficiency of this member of the TGF-β receptor superfamily has been reported in up to 60% of patients with FPAH and 25%
Endothelial apoptosis — The triggering event for PAH?
Several lines of experimental evidence using different PAH models have provided support for the role of endothelial cell apoptosis in PAH. Both the MCT and chronic hypoxia models of pulmonary hypertension have been shown to be associated with reduced levels of VEGF transcripts (Arcot et al., 1993, Partovian et al., 1998). VEGF is not only a potent EC trophic and pro-angiogenic factor, but also a potent survival factor protecting ECs from apoptosis mediated through the extrinsic pathway (Alavi
Link between EC apoptosis and angioproliferative lesions in PAH
In vitro studies using human pulmonary microvascular endothelial cells in an artificial capillary system have shown that after initial apoptosis of endothelial cells induced by VEGFR blockade there is an increased proliferation of apoptosis-resistant ECs (Sakao et al., 2005). Similarly, in a small study (3 controls and 5 IPAH subjects), cultured endothelial cells isolated from the pulmonary arteries of patients with IPAH showed increased proliferation based on the BrdU incorporation and
EC apoptosis hypothesis of PAH
In this review, we suggest a “unifying” hypothesis that can bring together many of the seemingly divergent ideas surrounding the role of EC apoptosis and proliferation in the pathogenesis of this disease (Fig. 3). The lung is the most vascular organ in the body and the massive pulmonary endothelial surface area is exposed nearly directly to the environment through the air we breathe. Thus, it is very likely that even in healthy individuals, there are episodes of EC injury induced by
Vascular repair and therapy for pulmonary hypertension
Current treatments for pulmonary hypertension include bosentan, an endothelin receptor antagonist, sildenafil, a phosphodiesterase inhibitor, calcium channel blockers, and prostacyclin analogues. In addition to affecting hemodynamics, some of the agents mentioned above may perhaps affect cellular proliferation and survival. Endothelin can induce the proliferation of endothelial (Morbidelli et al., 1996a) and smooth muscle cells (Janakidevi et al., 1992). Hence, if endothelial apoptosis leads to
Future directions
The advances in our understanding of PAH pathophysiology made over the past two decades has dramatically changed the current approach to experimental therapies for PAH. We have seen a shift in emphasis from therapies strictly focusing on pulmonary hemodynamics to those also affecting endothelial survival and proliferation. Indeed, based on experimental models that suggest endothelial cell apoptosis as a trigger for PAH, current therapies center on utilizing the potential of EPCs in hopes of
References (74)
- et al.
Alterations of growth factor transcripts in rat lungs during development of monocrotaline-induced pulmonary hypertension
Biochem Pharma
(1993) - et al.
Increased plasma serotonin in primary pulmonary hypertension
Am J Med
(1995) - et al.
Thrombotic arteriopathy and anticoagulation in pulmonary hypertension
Chest
(2006) - et al.
Impaired apoptosis of pulmonary endothelial cells is associated with intimal proliferation and irreversibility of pulmonary hypertension in congenital heart disease
J Am Coll Cardiol
(2007) - et al.
BMPR2 Haploinsufficiency as the inherited molecular mechanism for primary pulmonary hypertension
Am J Hum Genet
(2001) - et al.
Monocrotaline pyrrole induces apoptosis in pulmonary artery endothelial cells
Toxicol Appl Pharmacol
(1998) - et al.
Pathology of pulmonary hypertension
Clin Chest Med
(2007) - et al.
Transplantation of autologous endothelial progenitor cells may be beneficial in patients with idiopathic pulmonary arterial hypertension: a pilot randomized controlled trial
J Am Coll Cardio
(2007) - et al.
DNA damage cell checkpoint activities are altered in monocrotaline pyrrole-induced cell cycle arrest in human pulmonary artery endothelial cells
Toxicol Appl Pharmacol
(2000) - et al.
A novel anti-apoptosis gene, survivin, expressed in cancer and lymphoma
Nat Med
(1997)