To review the pharmacologic treatment options for pulmonary arterial hypertension in the cardiac intensive care setting and summarize the most-recent literature supporting these therapies.
Literature search for prospective studies, retrospective analyses, and case reports evaluating the safety and efficacy of pulmonary arterial hypertension therapies.
Mechanisms of action and pharmacokinetics, treatment recommendations, safety considerations, and outcomes for specific medical therapies.
Specific targeted therapies developed for the treatment of adult patients with pulmonary arterial hypertension have been applied for the benefit of children with pulmonary arterial hypertension. With the exception of inhaled nitric oxide, there are no pulmonary arterial hypertension medications approved for children in the United States by the Food and Drug Administration. Unfortunately, data on treatment strategies in children with pulmonary arterial hypertension are limited by the small number of randomized controlled clinical trials evaluating the safety and efficacy of specific treatments. The treatment options for pulmonary arterial hypertension in children focus on endothelial-based pathways. Calcium channel blockers are recommended for use in a very small, select group of children who are responsive to vasoreactivity testing at cardiac catheterization. Phosphodiesterase type 5 inhibitor therapy is the most-commonly recommended oral treatment option in children with pulmonary arterial hypertension. Prostacyclins provide adjunctive therapy for the treatment of pulmonary arterial hypertension as infusions (IV and subcutaneous) and inhalation agents. Inhaled nitric oxide is the first-line vasodilator therapy in persistent pulmonary hypertension of the newborn and is commonly used in the treatment of pulmonary arterial hypertension in the ICU. Endothelin receptor antagonists have been shown to improve exercise tolerance and survival in adult patients with pulmonary arterial hypertension. Soluble guanylate cyclase stimulators are the first drug class to be Food and Drug Administration approved for the treatment of chronic thromboembolic pulmonary hypertension.
Literature and data supporting the safe and effective use of pulmonary arterial hypertension therapies in children in the cardiac intensive care are limited. Extrapolation of adult data has afforded safe medical treatment of pulmonary hypertension in children. Large multicenter trials are needed in the search for safe and effective therapy of pulmonary hypertension in children.
1Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO.
2Department of Cardiology, Harvard Medical School, Children’s Hospital Boston, Boston, MA.
3Departments of Pharmacy and Pediatrics (Cardiology), Stanford University, Lucile Packard Children’s Hospital, Palo Alto, CA.
Dr. McSweeney disclosed off-label product use: no pulmonary hypertension (PH) drug is Food and Drug Administration (FDA) approved for pediatric use (this is noted several times throughout the article). Dr. Lee disclosed off-label product use: PH medications in pediatrics (many medications are not FDA approved for pediatrics. This is disclosed in the article). Dr. Ivy has disclosed other support from the University of Colorado contracts with Actelion, Bayer, Gilead, Lilly, and United Therapeutics (Dr. Ivy to be a consultant); served on the steering committee for pediatric PH studies being performed by Actelion, Bayer, Lilly, and United Therapeutics; enrolled patients in research studies sponsored by Actelion, Bayer, Gilead, Lilly, and United Therapeutics; received financial support from the National Institutes of Health (NIH); served as a board member of the Pulmonary Hypertension Association; received restricted financial contributions from the Jayden de Luca Foundation, the Frederick and Margaret Weyerhaeuser Foundation, and the Leah Bult Foundation to perform pediatric PH research; received support for this article research from the NIH, Jayden de Luca Foundation, Frederick and Margaret Weyerhaeuser Foundation, and Leah Bult Foundation; and disclosed off-label product use: ambrisentan, bosentan, macitentan, sildenafil, tadalafil, epoprostenol, treprostinil, and iloprost. His institution received funding from Actelion, Bayer, and Gilead. Dr. Kim disclosed that he does not have any potential conflicts of interest.
For information regarding this article, E-mail: John.Kim@childrenscolorado.org