Role of NO-cGMP-PKG axis in pulmonary arterial hypertension

The nitric oxide (NO) - cyclic guanosine monophosphate (cGMP) - protein kinase G (PKG) axis is a critical signaling cascade in the development of pulmonary arterial hypertension (PAH). Dysregulation of the NO-cGMP-PKG axis results in pulmonary vascular inflammation, thrombosis and constriction, and ultimately leads to PAH. The PDE5 inhibitors such as sildenafil and tadalafil block the breakdown of cGMP. The resultant increase in cGMP concentration leads to relaxation of the smooth muscle and vasodilation. These effects are dependent on NO availability and sGC activity. The sGC stimulator riociguat has a dual mode of action, sensitizing sGC to endogenous NO by stabilizing NO-sGC binding and directly stimulating sGC via a different binding site. While there are clear pharmacokinetic and pharmacodynamic differences between these agents, it is still difficult to determine which agent is most appropriate for a specific PAH patient. Some patients respond better to sGC stimulator than a PDE5 inhibitor and vice versa. This chapter describes the role of the NO-cGMP-PKG pathway in PAH, potential and established treatment modalities to target this pathway, and their clinical applications.