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Оптимизация специфической терапии легочной гипертензии: возможности риоцигуата
Оптимизация специфической терапии легочной гипертензии: возможности риоцигуата
Мартынюк Т.В., Шмальц А.А., Горбачевский С.В., Чазова И.Е. Оптимизация специфической терапии легочной гипертензии: возможности риоцигуата. Терапевтический архив. 2021; 93 (9): 1117–1124. DOI: 10.26442/00403660.2021.09.201014
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Аннотация
Легочная гипертензия (ЛГ) – тяжелое и часто быстро прогрессирующее заболевание с фатальным исходом. Эндотелиальная дисфункция при ЛГ сопровождается снижением продукции оксида азота. После рассмотрения механизмов действия и доказательной базы специфической терапии ингибиторами фосфодиэстеразы 5 (иФДЭ-5) и стимуляторами растворимой гуанилатциклазы проводится обзор исследований по переключению с иФДЭ-5 на риоцигуат. Потенциальным преимуществом риоцигуата является независимость от эндогенного оксида азота и других (помимо ФДЭ-5) изоферментов фосфодиэстераз. Благоприятный профиль эффективности силденафила доказан для основных форм легочной артериальной гипертензии, риоцигуата – для основных форм легочной артериальной гипертензии и хронической тромбоэмболической ЛГ. Клиническая эффективность замены иФДЭ-5 на риоцигуат показана в неконтролируемых исследованиях и рандомизированном контролируемом исследовании REPLACE. Возможность оптимизации терапии за счет переключения с иФДЭ-5 на риоцигуат закреплена в российских (класс и уровень доказательности B-3) и евразийских (класс и уровень доказательности IIb-B) клинических рекомендациях, а также в материалах Кельнского консенсуса экспертов. Дополнительным аргументом за переключение в условиях Российской Федерации служит меньшая стоимость по сравнению с комбинированной терапией. Согласно российским и евразийским рекомендациям по ЛГ и российской инструкции по применению риоцигуата его прием следует начинать не ранее чем через 24 ч после отмены силденафила.
Ключевые слова: легочная гипертензия, специфическая терапия, силденафил, риоцигуат, оптимизация терапии
Keywords: pulmonary hypertension, specific therapy, sildenafil, riociguat, therapy optimization
Ключевые слова: легочная гипертензия, специфическая терапия, силденафил, риоцигуат, оптимизация терапии
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Keywords: pulmonary hypertension, specific therapy, sildenafil, riociguat, therapy optimization
Полный текст
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3. Pulmonary hypertension, including chronic thromboembolic pulmonary hypertension. Russian clinical guidelines. 2020. Available at: https://cr.minzdrav.gov.ru/recomend/159_1. Accessed: 18.08.2021 (in Russian).
4. Chazova IE, Martyniuk TV, Valieva ZS, et al. Eurasian clinical guidelines for the diagnosis and treatment of pulmonary hypertension (2019). Eurasian Journal of Cardiology. 2020;1:78-124 (in Russian). DOI:10.24411/2076-4766-2020-10002
5. Chazova IE, Martyniuk TV, Valieva ZS, et al. Eurasian guidelines for the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (2020). Eurasian Journal of Cardiology. 2021;1:6-43 (in Russian). DOI:10.38109/2225-1685-2021-1-6-43
6. Galié N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119. DOI:10.1093/eurheartj/ehv317
7. Stasch JP, Pacher P, Evgenov OV. Soluble guanylate cyclase as an emerging therapeutic target in cardiopulmonary disease. Circulation. 2011;123:2263-73.
8. Schlossmann J, Schinner E. cGMP becomes a drug target. Naunyn Schmiedebergs Arch Pharmacol. 2012;385(3):243-52. DOI:10.1007/s00210-012-0730-6
9. Evgenov OV, Pacher P, Schmidt PM, et al. NO-independent stimulators and activators of soluble guanylate cyclase: discovery and therapeutic potential. Nat Rev Drug Discov. 2006;5(9):755-68. DOI:10.1038/nrd2038
10. Giaid A, Saleh D. Reduced expression of endothelial nitric oxide synthase in the lungs of patients with pulmonary hypertension. N Engl J Med. 1995;333(4):214-21. DOI:10.1056/NEJM199507273330403
11. Ignarro LJ. NO More Heart Disease: How Nitric Oxide Can Prevent – Even Reverse – Heart Disease and Strokes. New York: St. Martin's Press, 2005.
12. Lundberg JO, Gladwin MT, Weitzberg E. Strategies to increase nitric oxide signalling in cardiovascular disease. Nat Rev Drug Discov. 2015;14(9):623-41.
13. cGMP: Generators, Effectors and Therapeutic Implications. Handbook of Experimental Pharmacology 191. Ed. HH Schmidt, F Hofmann, JP Stasch. Springer-Verlag Berlin Heidelberg, 2009.
14. Stasch JP, Evgenov OV. Soluble Guanylate Cyclase Stimulators in Pulmonary Hypertension. Handb Exp Pharmacol. 2013;218:279-313. DOI:10.1007/978-3-642-38664-0_12
15. Cooper CJ, Landzberg MJ, Anderson TJ, et al. Role of nitric oxide in the local regulation of pulmonary vascular resistance in humans. Circulation. 1996;93:266-71.
16. Kielstein JT, Bode-Böger SM, Hesse G, et al. Asymmetrical dimethylarginine in idiopathic pulmonary arterial hypertension. Arterioscler Thromb Vasc Biol. 2005;25(7):1414-8.
17. Hemnes AR, Champion HC. Sildenafil, a PDE5 inhibitor, in the treatment of pulmonary hypertension. Expert Rev Cardiovasc Ther. 2006;4(3):293-300. DOI:10.1586/14779072.4.3.293
18. Galie N, Ghofrani HA, Torbicki A, et al. Sildenafil citrate therapy for pulmonary arterial hypertension. New Engl J Med. 2005;353(20):2148-57. DOI:10.1056/NEJMoa050010
19. Simonneau G, Rubin LJ, Galiè N, et al. Addition of sildenafil to long-term intravenous epoprostenol therapy in patients with pulmonary arterial hypertension: a randomized trial. Ann Intern Med. 2008;149(8):521-30. DOI:10.7326/0003-4819-149-8-200810210-00004
20. Sastry BK, Narasimhan C, Reddy NK, Raju BS. Clinical efficacy of sildenafil in primary pulmonary hypertension: a randomized, placebo-controlled, double-blind, crossover study. J Am Coll Cardiol. 2004;43(7):1149-53. DOI:10.1016/j.jacc.2003.10.056
21. Singh TP, Rohit M, Grover A, et al. A randomized, placebo-controlled, double-blind, crossover study to evaluate the efficacy of oral sildenafil therapy in severe pulmonary artery hypertension. Am Heart J. 2006;151(4):851.e1-5. DOI:10.1016/j.ahj.2005.09.006
22. Guha M. First-in-class guanylate cyclase stimulator approved for PAH. Nat Biotechnol. 2013;31(12):1064. DOI:10.1038/nbt1213-1064b
23. Ghofrani HA, Voswinckel R, Gall H, et al. Riociguat for pulmonary hypertension. Future Cardiol. 2010;6(2):155-66. DOI:10.2217/fca.10.5
24. Schermuly RT, Janssen W, Weissmann N, et al. Riociguat for the treatment of pulmonary hypertension. Expert Opin Investig Drugs. 2011;20(4):567-76. DOI:10.1517/13543784.2011.565048
25. Pulido T, Adzerikho I, Channick RN, et al. Macitentan and morbidity and mortality in pulmonary arterial hypertension. N Engl J Med. 2013;369(9):809-18. DOI:10.1056/NEJMoa1213917
26. Mittendorf J, Weigand S, Alonso-Alija C, et al. Discovery of riociguat (BAY 63-2521): a potent, oral stimulator of soluble guanylate cyclase for the treatment of pulmonary hypertension. Chem Med Chem. 2009;4(5):853-65. DOI:10.1002/cmdc.200900014
27. Ghofrani HA, Galiè N, Grimminger F, et al. Riociguat for the treatment of pulmonary arterial hypertension. N Engl J Med. 2013;369(4):330-40. DOI:10.1056/NEJMoa1209655
28. Rubin LJ, Galiè N, Grimminger F, et al. Riociguat for the treatment of pulmonary arterial hypertension: a long-term extension study (PATENT-2). Eur Respir J. 2015;45(5):1303-13. DOI:10.1183/09031936.00090614
29. Ghofrani HA, D'Armini AM, Grimminger F, et al. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. N Engl J Med. 2013;369:319-29.
30. Galie N, Muller K, Scalise AV, Grunig E. PATENT PLUS: a blinded, randomised and extension study of riociguat plus sildenafil in PAH. Eur Respir J. 2015;45(5):1314-22. DOI:10.1183/09031936.00105914
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32. Shmalts AA, Gorbachevsky SV. Advantages and limitations of initial combination therapy in pulmonary arterial hypertensionpatients in Russia. Terapevticheskii Arkhiv (Ter. Arkh.). 2020;92(12):80-5 (in Russian). DOI:10.26442/00403660.2020.12.000840
33. Shmalts AA, Gorbachevsky SV. A systematic review as a method of gathering scientific evidence into clinical guidelines: CHEST-2019 guideline for the therapy pulmonary arterial hypertension in adults. Terapevticheskii Arkhiv (Ter. Arkh.). 2019;91(12):105-14 (in Russian). DOI:10.26442/00403660.2019.12.000468
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19. Simonneau G, Rubin LJ, Galiè N, et al. Addition of sildenafil to long-term intravenous epoprostenol therapy in patients with pulmonary arterial hypertension: a randomized trial. Ann Intern Med. 2008;149(8):521-30. DOI:10.7326/0003-4819-149-8-200810210-00004
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23. Ghofrani HA, Voswinckel R, Gall H, et al. Riociguat for pulmonary hypertension. Future Cardiol. 2010;6(2):155-66. DOI:10.2217/fca.10.5
24. Schermuly RT, Janssen W, Weissmann N, et al. Riociguat for the treatment of pulmonary hypertension. Expert Opin Investig Drugs. 2011;20(4):567-76. DOI:10.1517/13543784.2011.565048
25. Pulido T, Adzerikho I, Channick RN, et al. Macitentan and morbidity and mortality in pulmonary arterial hypertension. N Engl J Med. 2013;369(9):809-18. DOI:10.1056/NEJMoa1213917
26. Mittendorf J, Weigand S, Alonso-Alija C, et al. Discovery of riociguat (BAY 63-2521): a potent, oral stimulator of soluble guanylate cyclase for the treatment of pulmonary hypertension. Chem Med Chem. 2009;4(5):853-65. DOI:10.1002/cmdc.200900014
27. Ghofrani HA, Galiè N, Grimminger F, et al. Riociguat for the treatment of pulmonary arterial hypertension. N Engl J Med. 2013;369(4):330-40. DOI:10.1056/NEJMoa1209655
28. Rubin LJ, Galiè N, Grimminger F, et al. Riociguat for the treatment of pulmonary arterial hypertension: a long-term extension study (PATENT-2). Eur Respir J. 2015;45(5):1303-13. DOI:10.1183/09031936.00090614
29. Ghofrani HA, D'Armini AM, Grimminger F, et al. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. N Engl J Med. 2013;369:319-29.
30. Galie N, Muller K, Scalise AV, Grunig E. PATENT PLUS: a blinded, randomised and extension study of riociguat plus sildenafil in PAH. Eur Respir J. 2015;45(5):1314-22. DOI:10.1183/09031936.00105914
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36. Валиева З.С., Таран И.Н., Мартынюк Т.В., Чазова И.Е. Современный взгляд на место риоцигуата в лечении легочной гипертензии. Терапевтический архив. 2018;90(4):55-9 [Valieva ZS, Taran IN, Martynyuk TV, Chazova IE. Modern view on the place of riociguat in the treatment of pulmonary hypertension. Terapevticheskii Arkhiv (Ter. Arkh.). 2018;90(4):55-9 (in Russian)]. DOI:10.26442/terarkh201890455-59
37. Шмальц А.А., Горбачевский С.В. Риоцигуат и силденафил в лечении легочной гипертензии: сходства и различия. Пульмонология. 2016;26(1):85-91 [Shmal'ts AA, Gorbachevskii SV. Riotsiguat i sildenafil v lechenii legochnoi gipertenzii: skhodstva i razlichiia. Pul'monologiia. 2016;26(1):85-91 (in Russian)]. DOI:10.18093/0869-0189-2016-26-1-85-91
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39. Taichman DB, Ornelas J, Chung L, et al. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest. 2014;146(2):449-75.
40. Liu HL, Chen XY, Li JR, et al. Efficacy and Safety of Pulmonary Arterial Hypertension-specific Therapy in Pulmonary Arterial Hypertension: A Meta-analysis of Randomized Controlled Trials. Chest. 2016;150(2):353-66. DOI:10.1016/j.chest.2016.03.031
41. Fox BD, Shtraichman O, Langleben D, et al. Combination Therapy for Pulmonary Arterial Hypertension: A Systematic Review and Meta-analysis. Can J Cardiol. 2016;32(12):1520-30. DOI:10.1016/j.cjca.2016.03.004
42. Lajoie AC, Lauzière G, Lega J-C, et al. Combination therapy versus monotherapy for pulmonary arterial hypertension: a meta-analysis. Lancet Respir Med. 2016;4(4):291-305. DOI:10.1016/S2213-2600(16)00027-8
43. Sofer A, Ryan MJ, Tedford RJ, et al. A systematic review of transition studies of pulmonary arterial hypertension specific medications. Pulm Circ. 2017;7(2):326-38. DOI:10.1177/2045893217706357
44. Dos Santos Fernandes CJC, Humbert M, Souza R. Challenging the concept of adding more drugs in pulmonary arterial hypertension. Eur Respir J. 2017;50:1701527. DOI:10.1183/13993003.01527-2017
45. Hoeper MM, Simonneau G, Corris PA, et al. RESPITE: switching to riociguat in pulmonary arterial hypertension patients with inadequate response to phosphodiesterase-5 inhibitors. Eur Respir J. 2017;50(3):1602425. DOI:10.1183/13993003.02425-2016
46. Taran IN, Belevskaya AA, Saidova MA, et al. Initial Riociguat Monotherapy and Transition from Sildenafil to Riociguat in Patients with Idiopathic Pulmonary Arterial Hypertension: Influence on Right Heart Remodeling and Right Ventricular-Pulmonary Arterial Coupling. Lung. 2018;196(6):745-53. DOI:10.1007/s00408-018-0160-4
47. McLaughlin VV, Jansa P, Nielsen-Kudsk JE, et al. Riociguat in patients with chronic thromboembolic pulmonary hypertension: results from an early access study. BMC Pulm Med. 2017;17(1):216. DOI:10.1186/s12890-017-0563-7
48. Davey R, Benza RL, Murali S, Raina A. Phosphodiesterase type 5 inhibitor to riociguat transition is associated with hemodynamic and symptomatic improvement in pulmonary hypertension. Pulm Circ. 2017;7(2):539-42. DOI:10.1177/2045893217708566
49. Andersen A, Korsholm K, Mellemkjær S, Nielsen-Kudsk JE. Switching from sildenafil to riociguat for the treatment of PAH and inoperable CTEPH: Real-life experiences. Respir Med Case Rep. 2017;22:39-43. DOI:10.1016/j.rmcr.2017.06.005
50. Raina A, Benza RL, Farber HW. Replacing a phosphodiesterase-5 inhibitor with riociguat in patients with connective tissue disease-associated pulmonary arterial hypertension: a case series. Pulm Circ. 2017;7(3):741-6. DOI:10.1177/2045893217721694
51. Yamamoto K, Tanabe N, Suda R, et al. Riociguat for patients with chronic thromboembolic pulmonary hypertension: Usefulness of transitioning from phosphodiesterase type 5 inhibitor. Respiratory Investigation. 2017;55(4):270-5. DOI:10.1016/j.resinv.2017.04.004
52. Darocha S, Banaszkiewicz M, Pietrasik A, et al. Sequential treatment with sildenafil and riociguat in patients with persistent or inoperable chronic thromboembolic pulmonary hypertension improves functional class and pulmonary hemodynamics. Int J Cardiol. 2018;269:283-8. DOI:10.1016/j.ijcard.2018.07.015
53. Kuroda K, Akagi S, Nakamura K, et al. Successful Transition From Phosphodiesterase-5 Inhibitors to Riociguat Without a Washout Period in Patients With Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: A Pilot Cohort Study. Heart Lung Circ. 2020;29(3):331-6. DOI:10.1016/j.hlc.2019.01.013
54. Gall H, Vachiéry JL, Tanabe N, et al. Real-World Switching to Riociguat: Management and Practicalities in Patients with PAH and CTEPH. Lung. 2018;196(3):305-12. DOI:10.1007/s00408-018-0100-3
55. Grunig E, Gall H, Ghofrani HA, et al. Safety of switching to riociguat for the treatment of pulmonary hypertension: data from the EXPERT registry. World Symposium on Pulmonary Hypertension. Nice. 2018.
56. Benza R, Corris P, Ghofrani A, et al. EXPRESS: Switching to riociguat: A potential treatment strategy for the management of CTEPH and PAH. Pulm Circ. 2019;10(1):2045894019837849. DOI:10.1177/2045894019837849
57. Hoeper MM, Al-Hiti H, Benza RL, et al. Switching to riociguat versus maintenance therapy with phosphodiesterase-5 inhibitors in patients with pulmonary arterial hypertension (REPLACE): a multicentre, open-label, randomised controlled trial. Lancet Respir Med. 2021;9(6):573-84. DOI:10.1016/S2213-2600(20)30532-4
58. Hansson L, Hedner T, Dahlöf B. Prospective randomized open blinded end-point (PROBE) study. A novel design for intervention trials. Prospective Randomized Open Blinded End-Point. Blood Press. 1992;1(2):113-9. DOI:10.3109/08037059209077502
59. Sitbon O, Gomberg-Maitland M, Granton J, et al. Clinical trial design and new therapies for pulmonary arterial hypertension. Eur Respir J. 2019;53(1):1801908. DOI:10.1183/13993003.01908-2018
60. Olschewski H, Simonneau G, Galiè N, et al. Aerosolized Iloprost Randomized Study Group. Inhaled iloprost for severe pulmonary hypertension. N Engl J Med. 2002;347(5):322-9. DOI:10.1056/NEJMoa020204
61. Simonneau G, Ghofrani HA, Corris PA, et al. Assessment of the REPLACE study composite endpoint in riociguat-treated patients in the PATENT study. Pulm Circ. 2020;10(4):2045894020973124. DOI:10.1177/2045894020973124
62. Hoeper MM, Apitz C, Grünig E, et al. Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol. 2018;272S:37-45. DOI:10.1016/j.ijcard.2018.08.082
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43. Sofer A, Ryan MJ, Tedford RJ, et al. A systematic review of transition studies of pulmonary arterial hypertension specific medications. Pulm Circ. 2017;7(2):326-38. DOI:10.1177/2045893217706357
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46. Taran IN, Belevskaya AA, Saidova MA, et al. Initial Riociguat Monotherapy and Transition from Sildenafil to Riociguat in Patients with Idiopathic Pulmonary Arterial Hypertension: Influence on Right Heart Remodeling and Right Ventricular-Pulmonary Arterial Coupling. Lung. 2018;196(6):745-53. DOI:10.1007/s00408-018-0160-4
47. McLaughlin VV, Jansa P, Nielsen-Kudsk JE, et al. Riociguat in patients with chronic thromboembolic pulmonary hypertension: results from an early access study. BMC Pulm Med. 2017;17(1):216. DOI:10.1186/s12890-017-0563-7
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49. Andersen A, Korsholm K, Mellemkjær S, Nielsen-Kudsk JE. Switching from sildenafil to riociguat for the treatment of PAH and inoperable CTEPH: Real-life experiences. Respir Med Case Rep. 2017;22:39-43. DOI:10.1016/j.rmcr.2017.06.005
50. Raina A, Benza RL, Farber HW. Replacing a phosphodiesterase-5 inhibitor with riociguat in patients with connective tissue disease-associated pulmonary arterial hypertension: a case series. Pulm Circ. 2017;7(3):741-6. DOI:10.1177/2045893217721694
51. Yamamoto K, Tanabe N, Suda R, et al. Riociguat for patients with chronic thromboembolic pulmonary hypertension: Usefulness of transitioning from phosphodiesterase type 5 inhibitor. Respiratory Investigation. 2017;55(4):270-5. DOI:10.1016/j.resinv.2017.04.004
52. Darocha S, Banaszkiewicz M, Pietrasik A, et al. Sequential treatment with sildenafil and riociguat in patients with persistent or inoperable chronic thromboembolic pulmonary hypertension improves functional class and pulmonary hemodynamics. Int J Cardiol. 2018;269:283-8. DOI:10.1016/j.ijcard.2018.07.015
53. Kuroda K, Akagi S, Nakamura K, et al. Successful Transition From Phosphodiesterase-5 Inhibitors to Riociguat Without a Washout Period in Patients With Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: A Pilot Cohort Study. Heart Lung Circ. 2020;29(3):331-6. DOI:10.1016/j.hlc.2019.01.013
54. Gall H, Vachiéry JL, Tanabe N, et al. Real-World Switching to Riociguat: Management and Practicalities in Patients with PAH and CTEPH. Lung. 2018;196(3):305-12. DOI:10.1007/s00408-018-0100-3
55. Grunig E, Gall H, Ghofrani HA, et al. Safety of switching to riociguat for the treatment of pulmonary hypertension: data from the EXPERT registry. World Symposium on Pulmonary Hypertension. Nice. 2018.
56. Benza R, Corris P, Ghofrani A, et al. EXPRESS: Switching to riociguat: A potential treatment strategy for the management of CTEPH and PAH. Pulm Circ. 2019;10(1):2045894019837849. DOI:10.1177/2045894019837849
57. Hoeper MM, Al-Hiti H, Benza RL, et al. Switching to riociguat versus maintenance therapy with phosphodiesterase-5 inhibitors in patients with pulmonary arterial hypertension (REPLACE): a multicentre, open-label, randomised controlled trial. Lancet Respir Med. 2021;9(6):573-84. DOI:10.1016/S2213-2600(20)30532-4
58. Hansson L, Hedner T, Dahlöf B. Prospective randomized open blinded end-point (PROBE) study. A novel design for intervention trials. Prospective Randomized Open Blinded End-Point. Blood Press. 1992;1(2):113-9. DOI:10.3109/08037059209077502
59. Sitbon O, Gomberg-Maitland M, Granton J, et al. Clinical trial design and new therapies for pulmonary arterial hypertension. Eur Respir J. 2019;53(1):1801908. DOI:10.1183/13993003.01908-2018
60. Olschewski H, Simonneau G, Galiè N, et al. Aerosolized Iloprost Randomized Study Group. Inhaled iloprost for severe pulmonary hypertension. N Engl J Med. 2002;347(5):322-9. DOI:10.1056/NEJMoa020204
61. Simonneau G, Ghofrani HA, Corris PA, et al. Assessment of the REPLACE study composite endpoint in riociguat-treated patients in the PATENT study. Pulm Circ. 2020;10(4):2045894020973124. DOI:10.1177/2045894020973124
62. Hoeper MM, Apitz C, Grünig E, et al. Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol. 2018;272S:37-45. DOI:10.1016/j.ijcard.2018.08.082
Авторы
Т.В. Мартынюк*1,2, А.А. Шмальц3,4, С.В. Горбачевский3,4, И.Е. Чазова1
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия;
3 ФГБУ «Национальный медицинский исследовательский центр сердечно-сосудистой хирургии им. А.Н. Бакулева» Минздрава России, Москва, Россия;
4 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*trukhiniv@mail.ru
1 National Medical Research Center of Cardiology, Moscow, Russia;
2 Pirogov Russian National Research Medical University, Moscow, Russia;
3 Bakoulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia;
4 Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*trukhiniv@mail.ru
1 ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия;
3 ФГБУ «Национальный медицинский исследовательский центр сердечно-сосудистой хирургии им. А.Н. Бакулева» Минздрава России, Москва, Россия;
4 ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*trukhiniv@mail.ru
________________________________________________
1 National Medical Research Center of Cardiology, Moscow, Russia;
2 Pirogov Russian National Research Medical University, Moscow, Russia;
3 Bakoulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia;
4 Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*trukhiniv@mail.ru
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