Bosentan

Male ApoE^−/−/C57BL/6J mice or wild type C57BL/6J mice at 10–12 wk of age were obtained from the Jackson Laboratory, Bar Harbor, Maine, and housed at the Stanford Animal Facility, Stanford, CA. Animal care and experimental procedures were conducted in compliance with Stanford Laboratory Animal Care Guidelines. The Administrative Panel on Laboratory Animal Care at Stanford University approved all procedures involving mice.
Two mechanistically distinct, but complementary mouse AAA models were used in this study: subcutaneous Ang II infusion in ApoE^−/− mice (Ang II/ApoE^−/− model) and intra-aortic PPE infusion in C57BL/6J mice (PPE model). In most experiments, ApoE^−/− mice were fed chow supplemented with irbesartan (50 mg/kg), telmisartan (10 mg/kg) or bosentan (100 mg/kg), or were daily given drinking water supplemented with fluvastatin (40 mg/kg) or doxycycline (100 mg/kg). As controls, separate groups of ApoE^−/− mice for individual experiments were given the standard chow and drinking water without drug supplementation. One week later, to induce AAAs, all mice were subcutaneously implanted with osmotic minipumps (Alzet model 2004, Durect Corporation, Cupertino, CA) for continuous infusion of Ang II at 1000 ng/kg/min, and treated continuously with their respective drugs for 28 days [9] (link). In additional experiments, C57BL/6J mice were fed telmisartan-supplemented chow (10 mg/kg) or the standard chow. One week thereafter, AAAs were created by transient intra-aortic infusion of PPE as described previously [93] (link), and these mice were continuously fed with the chow with or without telmisartan supplementation for additional 2 wk. In all experiments, doses for two ARBs and bosentan were selected based on published mouse studies in which each drug lowered blood pressure and/or suppressed cardiovascular pathology [94] (link)–[96] (link).

The validation cohorts were constituted of a cumulative number of 219 patients. All enrolled patients met the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for SSc [2 (link)], and they were also sub-classified as having limited cutaneous systemic sclerosis (lcSSc) or diffuse cutaneous systemic sclerosis (dcSSc) following the LeRoy et al. criteria [10 (link)]. Exclusion criteria were concomitant conditions that may potentially cause additional microvascular changes, such as diabetes, smoking and onychophagic habitus; presence of anti-phospholipid antibodies; and pregnancy. Current treatment with beta-blockers was also an exclusion criterion because it is well known that this drug may cause or exacerbate Raynaud’s phenomenon (RP).
At the time of study enrolment, 52 of the 219 patients were receiving treatment with infusions of intravenous prostanoids (45 with monthly iloprost and 7 with weekly alprostadil), and 16 were taking bosentan. It was decided for ethical reasons to continue the vasodilatory treatments for the prospectively enrolled patients in Milan. Furthermore, all of the patients were receiving stable treatment with low-dose acetylsalicylic acid and calcium channel blockers.
One hundred twenty-two patients with SSc who were referred to the rheumatic disease unit of the Gaetano Pini Institute of Milan formed the prospectively collected internal validation cohort. It was preliminarily established to consecutively include around half the patients with inactive disease (ESSG score <3 and a similar proportion of patients with active disease [ESSG score ≥3]). This cohort did not include any patient who had been recruited for the previous study [7 (link)].
Ninety-seven patients with SSc who were referred to the rheumatology unit of the 2nd University of Naples formed the external validation cohort. These patients and their NVC images were randomly selected from the database on the condition that about one-third of them should have an ESSG score ≥3.

We retrospectively collected and studied adult treatment-naive patients with IPAH or PAH-CHD who were admitted to the Second Xiangya Hospital from November 2011 to June 2020. All recruited patients with IPAH or PAH-CHD met the following diagnostic criteria: mPAP ≥ 25 mmHg, PVR >3 WU and PAWP ≤15 mmHg during resting RHC (Galiè et al., 2016 (link)). Except for IPAH and PAH-CHD, patients with other types of PAH or PH belonging to groups 2–5 were also excluded. All recruited patients were prescribed PAH-specific therapy based on multiparameter risk stratification of contemporaneous guidelines, and cardiac function and haemodynamics parameters were assessed by means of echocardiography. In the 2022 ESC/ERS guideline for pulmonary hypertension, it was recommended to use a three-strata risk-assessment model to classify patients as low, intermediate, or high risk at initial assessment, and to use a four-strata model to classify patients as low, intermediate-low, intermediate-high, or high risk during follow-up (Humbert et al., 2022 (link)). Risk stratification can help guides treatment decisions in patients with PAH. Briefly, initial monotherapy with PDE-5i or ERAs was recommended for patients with PAH and cardiopulmonary comorbidities. In patients with PAH without cardiopulmonary complications, initial dual combination therapy of ERAs and PDE-5i was recommended for patients with low- or intermediate-risk of death, and triple combination therapy of ERAs, PDE-5i, and prostacyclin analogue is recommended for patients with high-risk of death. At follow-up, patients who reach low-risk status continued the initial regimen, and patients with medium-low risk were suggested to add prostacyclin receptor agonist or replace PDE-5i to sGC. In addition, intravenous or subcutaneous prostacyclin or evaluation for lung transplantation was recommended for patients who had insufficient treatment response and were still at intermediate-high or even high risk. PAH-specific medications in this study included PDE-5i (e.g., sildenafifil and tadalafifil), ERAs (e.g., bosentan, ambrisentan, and macitentan), prostacyclin analogues (e.g., intravenous or subcutaneous treprostinil, intravenous epoprostenol, and inhaled iloprost), prostacyclin receptor agonists (slexipag), and sGCs (e.g., riociguat). The study was approved by the Ethics Committee of the Second Xiangya Hospital.

We developed a questionnaire containing questions intended to be answered by the parent of a child living with PH. The survey assessed age at PH diagnosis, congenital heart defects, presence of Down syndrome, maternal age at birth, gestational age, PH therapies utilized, and side effects attributed to PH medications (Treprostinil, Tadalafil, Sildenafil, Ambrisentan, Bosentan, Macitentan, Selexipag, and Riociguat) used during the past 6 months. We also queried participants’ knowledge, attitudes, and perceptions of the Potts Shunt procedure and combined heart/lung transplant. We also assessed specific access to care issues and care provider characteristics such as where PH care is received (local pediatrician’s office, specialty children’s hospital, no specialty PH care available), the type of PH care provider (pediatric cardiologist, pediatric pulmonologist, PH specialist, combination of cardiologist and pulmonologist), distance traveled (miles) to primary PH provider, travel time to PH provider (minutes), need to move residence to receive PH care for child (yes/no), whether genetic testing was offered at diagnosis (yes/no), whether genetic testing was performed (yes/no) and whether a genetic counselor discussed any genetic testing results (yes/no). Finally, we queried family sociodemographics including race (white/other), relationship to child living with PH (father, mother, guardian, primary caregiver), U.S. citizenship (yes/no), respondents’ educational attainment (high school, some college, associate’s degree, bachelor’s degree, graduate or professional degree), employment status (employed, homemaker, unemployed), household income (< $35,000, $35,000–74,999, > $75,000), and health insurance status (yes/no). The average time to complete the survey was 19.5 min (range: 8 to 56 min).