title: Asymmetric dimethylarginine is increased in chronic thromboembolic pulmonary hypertension.
abstract: BACKGROUND
  Asymmetric dimethylarginine (ADMA), a potent endogenous nitric oxide synthase (NOS) inhibitor, is increased in idiopathic pulmonary arterial hypertension and associated with unfavorable outcome.
  
  
  OBJECTIVE
  Chronic thromboembolic pulmonary hypertension (CTEPH), although principally amenable to surgical removal of major pulmonary arterial obstructions by pulmonary endarterectomy, may show a small-vessel pulmonary arteriopathy similar to idiopathic pulmonary arterial hypertension. We hypothesized that ADMA plasma levels are increased in patients with CTEPH.
  
  
  METHODS
  We measured ADMA by high-performance liquid chromatography at the time of diagnosis in 135 patients with CTEPH. Inoperability in 66 patients was based on an imbalance between severity of pulmonary hypertension and morphologic lesions.
  
  
  RESULTS
  ADMA plasma levels were significantly elevated in patients, compared with 40 matched control subjects (0.62 [0.51-0.73] vs. 0.51 [0.45-0.6] micromol/L, P = 0.0002). At baseline, ADMA plasma concentrations correlated with mixed venous saturation (r = -0.25, P = 0.005), right atrial pressure (r = 0.35, P < 0.0001), and cardiac index (r = -0.21, P = 0.01). Patients who underwent surgery demonstrated lower ADMA levels at baseline than inoperable patients (0.60 [0.5-0.68] vs. 0.63 [0.53-0.85] micromol/L, P = 0.02), with a further decrease 12 +/- 1 months after pulmonary endarterectomy (P = 0.02). Endothelial NOS expression in endothelial cells was low in patients with elevated ADMA plasma levels. Survival of patients with ADMA plasma levels >/= 0.64 micromol/L was worse than in patients with ADMA plasma levels < 0.64 micromol/L.
  
  
  CONCLUSIONS
  ADMA plasma levels correlate with the severity of pulmonary vascular disease and predict outcome in patients with CTEPH. Measurement of ADMA plasma levels may be useful for estimating the degree of small-vessel arteriopathy in CTEPH.
authors.affiliation: Professor of Vascular Biology, Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria. irene.lang@meduniwien.ac.at
authors.forename: Nika
authors.initials: N
authors.lastname: Skoro-Sajer
authors.forename: Friedrich
authors.initials: F
authors.lastname: Mittermayer
authors.forename: Adelheid
authors.initials: A
authors.lastname: Panzenboeck
authors.forename: Diana
authors.initials: D
authors.lastname: Bonderman
authors.forename: Roela
authors.initials: R
authors.lastname: Sadushi
authors.forename: Robert
authors.initials: R
authors.lastname: Hitsch
authors.forename: Johannes
authors.initials: J
authors.lastname: Jakowitsch
authors.forename: Walter
authors.initials: W
authors.lastname: Klepetko
authors.forename: Meinhard P
authors.initials: MP
authors.lastname: Kneussl
authors.forename: Michael
authors.initials: M
authors.lastname: Wolzt
authors.forename: Irene M
authors.initials: IM
authors.lastname: Lang
mesh_terms: D000368:Aged; D001120:Arginine / Q000031:analogs & derivatives* / Q000097:blood; D002908:Chronic Disease; D042783:Endothelial Cells / Q000201:enzymology; D004791:Enzyme Inhibitors / Q000097:blood*; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary / Q000097:blood* / Q000209:etiology* / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D019001:Nitric Oxide Synthase / Q000037:antagonists & inhibitors / Q000378:metabolism; D009994:Osmolar Concentration; D011379:Prognosis; D011651:Pulmonary Artery / Q000201:enzymology; D012720:Severity of Illness Index; D013923:Thromboembolism / Q000150:complications*
chemical_list: D004791:Enzyme Inhibitors; C018524:N,N-dimethylarginine; D001120:Arginine; D019001:Nitric Oxide Synthase