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From ABCD to E for endothelin

in resistant hypertension
George R. Abraham1,2 and Anthony P. Davenport2,*
1Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
2Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
*Correspondence: apd10@medschl.cam.ac.uk
https://doi.org/10.1016/j.cell.2022.12.014

The potent vasoconstrictor peptide endothelin-1 has long been recognized as a physiological regulator of
vascular tone. However, pharmacological blockade of the endothelin-1 pathway has few proven indications
thus far. A recent clinical trial for resistant hypertension published in The Lancet may yet herald a new era for
endothelin receptor antagonists into the clinical mainstream.

Hypertension represents a major global
public health priority with an estimated
population prevalence amongst adults of
46%.1 The condition is highly pathologi-
cally significant for atherosclerosis alth-
ough has an indolent course, often left
undiagnosed until late in its natural his-
tory. Consequently, hypertension confers
an elevated risk of life-threatening car-
diovascular events such as myocardial
infarction and stroke. Additionally, hy-
pertensive injurious forces transmitted to
the brain, heart, and kidney accumulate
over time, resulting in chronic organ
dysfunction.
In 1988, Yanagisawa and colleagues
ignited the field of biomedical sciences
by reporting the discovery of endothe-
lin-1, the elusive ‘‘endothelium-derived
vasoconstricting factor.’’ They demon-
strated a 21-amino-acid peptide with an
unusual structure, stabilized by two di-
sulphide bridges.2 This peptide had
remarkable pharmacological properties:
a long-lasting vasoconstrictor effect on
the smooth muscle of coronary arteries
at an order of magnitude more potent
than angiotensin II or other vasoactive
agents. Endothelin-1 is expressed in
endothelial cells of all human vascular
beds examined and is equally potent in
constricting the small resistance vessels
(100 mm) that contribute to blood pres-
sure.3 A pivotal discovery using an ETA
receptor-selective antagonist in a first-
in-human study was that endothelin-1
contributed to the maintenance of
normal vascular tone via ETA receptors
expressed on smooth muscle4 (Figure 1).
In contrast, ETB receptors, expressed by
endothelial cells, act in an autocrine
manner to release endothelin’s nemesis,
nitric oxide, to relax the underlying
smooth muscle.5 Despite compelling ev-
idence from pre-clinical studies, clinical
benefit of ET receptor antagonists has
not been established in hypertension.
To date, only three ET receptor antago-
nists are approved for clinical use (ambri-
sentan, bosentan, and macitentan) for
the treatment of pulmonary arterial
hypertension, a rare but devastating dis-
ease.5 High blood pressure can be miti-
gated by current standard of care. How-
ever, in 15% of hypertensive patients,
blood pressure remains above recom-
mended targets for cardiovascular risk
modification even after treatment with a
combination of drugs targeting several
pathways. The American Heart Associa-
tion defines resistant hypertension (RH)
as blood pressure above the desired
target (130/80 mmHg for most individ-
uals) despite treatment with at least three
antihypertensive drugs of different clas-
ses. As a subgroup of hypertensive pa-
tients, RH patients have significantly
higher rates of adverse cardiovascular
events and progression to severe chronic
kidney disease.6 Current RH guidelines
recommend add-on medication including
the mineralocorticoid antagonist spirono-
lactone. Spironolactone has prognostic
benefit in heart failure but is limited by
dangerous adverse effects including hy-
perkalemia and contra-indicated in
advanced chronic kidney disease. New
therapies for RH are therefore urgently
required.
Recently published in The Lancet, the
Parallel-Group, Phase 3 Study in Subjects
with Resistant Hypertension (PRECISION)
trial, testing aprocitentan (ACT-132577),
the pharmacologically active metabolite

240 Cell 186, January 19, 2023 ª 2022 Elsevier Inc.

 ll
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Figure 1. Proposed pathways contributing to hypertension in the human vasculature and kidney and related therapeutic strategies
Endothelial cells lining all blood vessels continuously synthesize and release endothelin-1 from the secretory vesicles of the constitutive pathway. Endothelin-1 is
also released intermittently from Weibel-Palade bodies of the regulated pathway in response to external stimuli. Endotelin-1 released abluminally causes the
underlying smooth muscle to contract, by interacting mainly with the ETA receptors before undergoing internalization to the endosome and recycling of the
receptor to the cell surface. Low densities of ETB receptors may also be expressed by smooth muscle cells from specific vascular beds. Some of the released
endothelin-1 also feeds back in an autocrine or paracrine manner, by binding to endothelial ETB receptors to release nitric oxide (NO) to cause vasodilatation of
the smooth muscle, limiting vasoconstrictor activity. Endothelial ETB receptors, mainly in liver, kidney, and lungs, also remove endothelin-1 from the circulation by
internalization to the lysosome and degradation. In the PRECISION trial, three standard-of-care drugs incorporated into a single polypill were used in combi-
nation. In smooth muscle, valsartan blocks angiotensin II binding to AT1 receptors, and amlodipine inhibits transmembrane influx of calcium ions to prevent
vasoconstriction. The diuretic hydrochlorothiazide inhibits the sodium chloride co-transporter in epithelial cells of the distal convoluted tubules system in the
kidney, increasing sodium excretion and leading to water loss and lowering of blood pressure. Under blockade of these three pathways, aprocitentan is able to
lower blood pressure in patients with resistant hypertension. The precise molecular mechanism of this action is not determined, but ETA receptor blockade is
likely to be the major pathway.

of macitentan,7 may represent a para-
digm shift for the mainstream use of ET
receptor antagonists.
During a 12-weeks screening phase
prior to randomization, patients had
been established on a maximally tolerated
polypill comprising valsartan, (‘‘A’’ for
angiotensin II type 1 [AT1] receptor antag-
onist), amlodipine (‘‘C’’ for calcium chan-
nel antagonist, inhibiting transmembrane
influx of calcium ions into vascular
smooth muscle), and hydrochlorothiazide
(‘‘D’’ for diuretic, inhibiting sodium chlo-
ride transport in the kidney, therefore
increasing sodium and water excretion.
The use of beta-blockers ‘‘B’’ in the histor-
ical ABCD algorithm for hypertension has
been superseded). The trial then random-
ized 730 patients to placebo versus apro-
citentan 12.5 mg and aprocitentan 25 mg
(to target ‘‘E’’ for the ETA pathway). The
key findings were that systolic blood pres-
sure was reduced in the treatment arm
compared with placebo after a 4-weeks
double-blind phase. This was sustained
during a 32-weeks non-placebo contr-
olled phase using aprocitentan 25 mg
and reversed after a 12-weeks withdrawal
phase, where patients were re-random-
ized to aprocitentan 25 mg or placebo.
Whether the level of BP reduction ob-
served translates to clinical relevance
should be the focus of long-term follow-
up studies recording clinically relevant
endpoints such as death or non-fatal
myocardial infarction. Medication non-
adherence is a key issue identified in up
to 50%–80% of patients treated for hy-
pertension.6 In the PRECISION trial,
adherence to prescribed therapy was
carefully monitored and patients without
true RH were excluded by detailed

Cell 186, January 19, 2023 241

 ll
assessments prior to randomization. Im-
portantly, further clinical evaluation of
aprocitentan will require minimizing non-
adherence to combination therapy,
especially given the high adverse event
rate (most commonly related to symptom-
atic fluid retention) of 9%–18% re-
ported here.
Several unanswered questions remain
about the pharmacological mechanism
of aprocitentan at the doses used in this
trial. In particular, as a mixed receptor
antagonist, the relative contribution of
ETA to ETB blockade is incompletely
defined. ETB receptors function to clear
circulating endothelin-1; therefore, signif-
icantly increased plasma endothelin-1
levels during treatment is a surrogate for
ETB blockade and could be used to
confirm engagement of this receptor sub-
type.5 In healthy volunteers, plasma em-
dothelin-1 concentrations significantly
increased following treatment with apro-
citentan at doses R 25 mg,8 indicating
ETB receptor blockade. However, it is
not clear whether this occurs at the lower
doses used in PRECISION. In previous
functional assays comparing macitentan
with its metabolite aprocitentan, aproci-
tentan demonstrated less potent antago-
nism (pA2 for ETA = 6.7 vs. 7.6)9; however,
the benefit of aprocitentan over the other
clinically approved ET receptor antago-
nists may be underpinned by a roughly 3
times longer terminal plasma half-life
(45 h).5
Finally, we suggest further analysis
of this clinical trial population using
proteomics in order to identify novel com-
panion diagnostic biomarkers for specific
groups of patients likely to benefit from a
precision medicine approach. In this
spirit, there is also likely to be mileage in
identifying genetic variations that will pre-
dict response to ETA receptor antago-
nists, especially given that a functional
SNP upregulating the endothelin-1 sys-
tem has already been discovered to be
significantly associated with multiple
242 Cell 186, January 19, 2023
disorders including coronary artery
disease.10
The critical discovery is that despite
pharmacological blockade of three dis-
tinct pathways, the untreated endothe-
lin-1 pathway persists to raise blood pres-
sure. These results will catalyze further
clinical trials in resistant hypertension
and other conditions where the endothe-
lin-1 pathway is not currently targeted.
ACKNOWLEDGMENTS
G.R.A. is supported by The Jon Moulton Char-
ity Trust.
DECLARATION OF INTERESTS
A.P.D. is a co-investigator for the Medical
Research Council Precision Medicine with Zibo-
tentan in Microvascular Angina (PRIZE) Trial.
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