Dual ET A /ET B blockade with macitentan improves both vascular remodeling and angiogenesis in pulmonary arterial hypertension

Dysregulated metabolism and rarefaction of the capillary network play a critical role in pulmonary arterial hypertension (PAH) etiology. They are associated with a decrease in perfusion of the lungs, skeletal muscles, and right ventricle (RV). Previous studies suggested that endothelin‐1 (ET‐1) modulates both metabolism and angiogenesis. We hypothesized that dual ET A /ET B receptors blockade improves PAH by improving cell metabolism and promoting angiogenesis. Five weeks after disease induction, Sugen/hypoxic rats presented severe PAH with pulmonary artery (PA) remodeling, RV hypertrophy and capillary rarefaction in the lungs, RV, and skeletal muscles (microCT angiogram, lectin perfusion, CD31 staining). Two‐week treatment with dual ET A /ET B receptors antagonist macitentan (30 mg/kg/d) significantly improved pulmonary hemodynamics, PA vascular remodeling, and RV function and hypertrophy compared to vehicle‐treated animals (all P  = 0.05). Moreover, macitentan markedly increased lung, RV and quadriceps perfusion, and microvascular density (all P  = 0.05). In vitro, these effects were associated with increases in oxidative phosphorylation (oxPhox) and markedly reduced cell proliferation of PAH‐PA smooth muscle cells (PASMCs) treated with macitentan without affecting apoptosis. While macitentan did not affect oxPhox, proliferation, and apoptosis of PAH–PA endothelial cells (PAECs), it significantly improved their angiogenic capacity (tube formation assay). Exposure of control PASMC and PAEC to ET‐1 fully mimicked the PAH cells phenotype, thus confirming that ET‐1 is implicated in both metabolism and angiogenesis abnormalities in PAH. Dual ET A /ET B receptor blockade improved the metabolic changes involved in PAH‐PASMCs’ proliferation and the angiogenic capacity of PAH‐PAEC leading to an increased capillary density in lungs, RV, and skeletal muscles.