Treating pulmonary hypertension in COPD: where do we start?

Abstract

Endothelin receptor antagonists, phosphodiesterase (PDE)-5 inhibitors and prostanoids are effective treatments for pulmonary arterial hypertension (PAH), a severe but relatively rare form of pulmonary hypertension 1–3. Other forms of pulmonary hypertension as seen, for instance, in chronic lung disease are much more common than PAH and although usually less severe, they are clinically meaningful as they are associated with aggravated symptoms and shorter survival 4, 5]. Thus, it comes as no surprise that physicians are tempted to use so-called PAH drugs in other forms of pulmonary hypertension, even though there is limited evidence supporting this approach. In this issue of the European Respiratory Journal ( ERJ ), Stolz et al. 6, from the University Hospital Basel (Basel, Switzerland), report on the results of a small randomised placebo-controlled study they conducted to assess the safety and efficacy of the endothelin receptor antagonist bosentan in patients with chronic obstructive pulmonary disease (COPD). The study included 30 patients with advanced COPD at Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV. It is noteworthy that the presence of pulmonary hypertension at rest was not an inclusion criterion as the authors reasoned that pulmonary hypertension during exercise was to be expected in the majority of their patients 7. In fact, echocardiography at baseline showed no evidence for pulmonary hypertension at rest in 24 out of the 30 patients. The rationale of the study of Stolz et al. 6 was that by lowering pulmonary artery …