Silent cardiovascular involvement in patients with diffuse systemic sclerosis: a controlled cross-sectional study

Arterial Stiffness as a Surrogate Marker of Cardiovascular Disease and Atherosclerosis in Patients with Arthritides and Connective Tissue Diseases: A Literature Review

The increased cardiovascular (CV) risk among patients with autoimmune rheumatic diseases, such as arthritides and connective tissue diseases, has been extensively documented. From a pathophysiological standpoint, systemic inflammation in the context of the disease can lead to endothelial dysfunction, accelerated atherosclerosis, and structural changes in vessel walls, which, in turn, are associated with exaggerated CV morbidity and mortality. In addition to these abnormalities, the increased prevalence of traditional CV risk factors, such as obesity, dyslipidemia, arterial hypertension, and impaired glucose metabolism, can further worsen the status of and overall prognosis for CV in rheumatic patients. However, data on appropriate CV screening methods for patients with systemic autoimmune diseases are scarce, and traditional algorithms may lead to an underestimation of the true CV risk. The reason for this is that these calculations were developed for the general population and thus do not take into account the effect of the inflammatory burden, as well as other chronic-disease-associated CV risk factors. In recent years, different research groups, including ours, have examined the value of different CV surrogate markers, including carotid sonography, carotid-femoral pulse wave velocity, and flow-mediated arterial dilation, in the assessment of CV risk in healthy and rheumatic populations. In particular, arterial stiffness has been thoroughly examined in a number of studies, showing high diagnostic and predictive value for the occurrence of CV events. To this end, the present narrative review showcases a series of studies examining aortic and peripheral arterial stiffness as surrogates of all-cause CV disease and atherosclerosis in patients with rheumatoid and psoriatic arthritis, as well as in systemic lupus erythematosus and systemic sclerosis. Moreover, we discuss the associations of arterial stiffness with clinical, laboratory, and disease-specific parameters.

Is heart-type fatty acid binding protein (H-FABP) a valid marker of arterial stiffness in patients with systemic sclerosis?

Background/Aim: Both micro- and macro-vascular involvement has been researched in systemic sclerosis (SSc) for many years. In this study, the relationship of arterial stiffness with heart-type fatty acid binding protein (h-FABP), which is well-accepted as a cardiac marker, was investigated for the first time. Methods: In this case-control study, 40 patients diagnosed with SSc between the ages of 18 and 65 were included. Thirty healthy individuals of similar age and gender were included as the control group. Patients were excluded from the study if they had cardiovascular risk factors, active infections, and/or malignancies. Along with detecting biochemical markers in the blood, results from methods, such as 24-h blood pressure Holter recordings, pulse-wave velocities (PWV), and echocardiograms (ECHO) were obtained from patients. Results: The homocysteine mean level was higher in the patient group than in the control group (P < 0.001). H-FABP and asymmetric dimethylarginine (ADMA) means were similar between the two groups (P = 0.286 and P = 0.340, respectively). Vascular parameters, including mean arterial pressure (MAP), augmentation index normalized to the 75 /min heart rate (AIx @ 75), and PWV were also similar between the two groups (P = 0.498, P = 0.382 and P = 0.180, respectively). Conclusion: It can be concluded that no ongoing myocardial damage occurs based on normotensive Holter findings, normal h-FABP levels, and ECHO findings in our patients. It is suggested that vasodilatory treatments, such as pentoxifylline and calcium channel blockers, which the patients receive for SSc treatment due to Raynaud Syndrome, may protect them from hypertension and therefore offer protection from myocardial damage.

The Impaired Elasticity of Large Arteries in Systemic Sclerosis Patients

(1) Background: Systemic sclerosis (SSc) is an autoimmune disease characterized by endothelial dysfunction and fibrosis of skin and visceral organs. In the last decade, attention has been focused on the macrovascular involvement of the disease. In particular, the observation of increased arterial stiffness represented an interesting aspect of the disease, as predictor of cardiovascular risk. (2) Methods: We recruited 60 SSc patients (52 ± 12 years old, 90% females) and 150 age/sex-matched healthy controls in order to evaluate both intima-media thickness of the right common carotid artery and arterial stiffness using the B-mode echography and the SphygmoCor system® tonometer. (3) Results: The carotid-femoral pulse wave velocity (PWV) was higher in SSc patients than in controls (8.6 ± 1.7 vs. 7.8 ± 1.5 m/s; p < 0.001), as was the carotid-radial PWV (7.8 ± 1.1 vs. 6.7 ± 1.4 m/s; p < 0.001). The intima-media thickness was higher in SSc than in controls (654 ± 108 vs. 602 ± 118 µm; p = 0.004). The other parameters measured at carotid (radial strain, Young’s modulus, compliance and distensibility) all indicated that arterial stiffness in tension was more pronounced in SSc. Of interest, the direct correlation between PWV and age corresponded closely in SSc. Moreover, a significant difference between SSc and controls as regards the carotid parameters was evident in younger subjects. (4) Conclusions: SSc patients showed an increased arterial stiffness compared to healthy controls. In particular, an SSc-related pathologic effect was suggested by the more pronounced increase in PWV with age and lower values of carotid elasticity in younger SSc patients than in age-matched controls.

[Systemic sclerosis and macrovascular involvement: Status of the issue in 2019]

Systemic sclerosis (SSc) is a rare immune disease leading to fibrosis of the skin and internal organs. Microvasculopathy is a hallmark of SSc. However, some patients have severe macrovascular complications as affecting cerebral, cardiac or peripheral vessels. To date, macrovascular involvement in SSc remains a matter of debate. Many studies have shown an increased prevalence of macrovascular involvement in SSc in comparison with controlled subjects with similar cardiovascular risk factors. Various methods were used: ankle brachial pressure index, intima media thickness, imagery, coronary calcium score, pulse wave velocity, or flow mediated dilation. The pathophysiology of macrovascular involvement remains unknown and is probably multifactorial: accelerated atherosclerosis, endothelial dysfunction, or reflected wave of microvessel obliteration. The aim of this study was to perform a comprehensible review of the literature, through the study of different types of involved vessels. Results of the main studies are summarized in tables according to the method of investigation used.

Meta-Analysis of Asymmetric Dimethylarginine Concentrations in Rheumatic Diseases

Raised circulating concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), have been reported in several rheumatic diseases (RDs). However, the strength of this relationship is unclear. Therefore, the aim of this systematic review and meta-analysis was to evaluate the magnitude and the robustness of the association between ADMA concentrations and RDs. We calculated standardized mean differences (SMD, with 95% confidence intervals, CI). Study heterogeneity was evaluated by meta-regressions and sensitivity analyses according to type of RDs, conventional cardiovascular risk factors, inflammatory markers, and type of ADMA assessment methodology. Thirty-seven studies with a total of 2,982 subjects (1,860 RDs patients and 1,122 healthy controls) were included in our meta-analysis. Pooled results showed that ADMA concentrations were significantly higher in patients with RDs than in healthy controls (SMD = 1.27 µmol/L, 95% CI 0.94–1.60 µmol/L; p < 0.001). However, the between-studies heterogeneity was high. Differences in ADMA concentrations between controls and RDs patients were not significantly associated with inflammatory markers, increasing age, lipid concentrations, body mass index, blood pressure, or methodology used to assess ADMA. Furthermore, subgroup analysis showed no difference across RDs. This meta-analysis showed that, in the context of significant between-study heterogeneity, circulating concentrations of ADMA are positively related to RDs.

Systemic sclerosis and the risk of perioperative major adverse cardiovascular events for inpatient non-cardiac surgery

AIM

We investigated the association between systemic sclerosis (SSc) and perioperative cardiovascular risk for inpatient non-cardiac surgical procedures.

METHODS

We used data from the National Inpatient Sample (NIS) for the year 2014 to identify patients undergoing inpatient non-cardiac surgery. SSc and major adverse cardiovascular events (MACE) were defined by International Classification of Diseases 9th Revision diagnosis codes. Univariate and multivariate analyses were performed. We adjusted for demographic information, socioeconomic status, cardiac comorbidities, cardiovascular risk factors and procedural category. Two models were used with different categorization strategies for surgical procedures.

RESULTS

A total of 8 156 379 hospitalizations for non-cardiac surgeries were included, 4385 of which had a diagnosis of SSc. Patients with SSc were older, more likely to be female and Caucasian and with higher cardiac and systemic comorbidity burden. In univariate analysis, SSc was associated with higher risk of perioperative MACE (odds ratio [OR] = 2.9; P < 0.001) and all-cause death (P = 3.07; P < 0.001). Multivariate analysis yielded conflicting results regarding the association between SSc and perioperative MACE (Model 1: OR = 1.42; P = 0.146; Model 2: OR = 1.59; P = 0.048). Subsequent analysis showed that only perioperative myocardial infarction (Model 1 OR = 1.85; P = 0.048; Model 2 OR = 1.94; P = 0.031) was independently associated with SSc.

CONCLUSION

We did not find consistent association between SSc and perioperative MACE in non-cardiac surgical procedures. SSc may be associated with perioperative myocardial infarction.

Impact of Pulmonary Arterial Hypertension on Left Ventricular Function – a Comparative Study between Scleroderma and Coronary Artery Disease

Background: The impact of pulmonary arterial hypertension (PAH) on left ventricular performance in patients with scleroderma is still unknown. This study aims to perform a comparative echocardiographic analysis of left ventricular function between two different etiological varieties of PAH, namely PAH caused by systemic sclerosis as a representative of systemic inflammatory diseases and PAH caused by myocardial ischemia.

Material and method: We conducted a prospective observational study on 82 patients, of which 36 were with documented PAH, with the systolic pressure in the pulmonary artery above 35 mmHg, and 46 were patients with normal pulmonary artery pressure. The study population was divided into two groups, based on the etiology of PAH: group 1 included patients diagnosed with scleroderma (n = 48); group 2 included patients with coronary artery disease (n = 35). Patients from each group were divided into two subgroups based on the diagnosis of PAH: subgroup 1A – subjects with scleroderma and associated PAH (n = 20); subgroup 1B – subjects with scleroderma without PAH (n = 28); subgroup 2A – ischemic patients with associated PAH (n = 16); and subgroup 2B – patients with ischemic disease without PAH (n = 19).

Results: A significant difference between LVEF values in patients with PAH versus those without PAH in the ischemic group (p = 0.023) was recorded. Compared to scleroderma subjects, ischemic patients presented significantly lower values of LVEF in both PAH and non-PAH subgroups (p <0.0001 and p <0.0001, respectively). Linear regression analysis between sPAP and LVEF revealed a significant negative correlation only for the ischemia group (r = −0.52, p = 0.001) and the scleroderma 2B subgroup (r = −0.51, p = 0.04). Tissue Doppler analysis of left ventricular function revealed a significant impact of PAH on left ventricular diastolic performance in the ischemic group.

Conclusions: Compared to patients with coronary artery disease, those with scleroderma present a less pronounced deterioration of LVEF in response to pulmonary arterial hypertension.

The clinical effects of l-arginine and asymmetric dimethylarginine: implications for treatment in secondary Raynaud's phenomenon

Secondary Raynaud's phenomenon (RP) is often the sentinel clinical finding in systemic sclerosis and may precede systemic disease by several years. Altered nitric oxide metabolism plays a critical role in both fibrosis and severe secondary RP phenotypes in these patients. Increased flux through inducible nitric oxide synthase (iNOS) drives cutaneous fibrosis. Failure of flux through endothelial nitric oxide synthase (eNOS) contributes to increased vasoconstriction and decreased vasorelaxation. The underproduction of nitric oxide by eNOS is in part due to increased levels of asymmetric dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase. The inhibitory effects of increased ADMA levels may be counteracted increasing serum l‐arginine, which is often an effective treatment strategy in these patients. As such, l‐arginine‐based therapies should be considered in managing secondary RP, particularly given their favourable safety and tolerability profile. While there is no established dosing regimen, studies of oral l‐arginine in secondary RP suggest that divided dosing may begin at 1–2 g/day and may be titrated up to 10 g/day. Conversely, primary RP is not associated with increased ADMA production which likely accounts for the failure of l‐arginine trials to show benefit in primary RP.

Cardiovascular Imaging Techniques in Systemic Rheumatic Diseases

The risk of cardiovascular (CV) events and mortality is significantly higher in patients with systemic rheumatic diseases than in the general population. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. Various types of assessments are employed for the evaluation of CV risk such as transthoracic or transesophageal echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. The diameter of coronary arteries can be assessed using invasive quantitative coronarography or intravascular ultrasound, and coronary flow reserve can be assessed using non-invasive transesophageal or transthoracic ultrasonography (US), MRI, CT, or positron emission tomography (PET) after endothelium-dependent vasodilation. Finally, peripheral circulation can be measured invasively using strain-gauge plethysmography in an arm after the arterial infusion of an endothelium-dependent vasodilator or non-invasively by means of US or MRI measurements of flow-mediated vasodilation of the brachial artery. All of the above are reliable methods of investigating CV involvement, but more recently, introduced use of speckle tracking echocardiography and 3-dimensional US are diagnostically more accurate.

Unmet Needs in the Pathogenesis and Treatment of Cardiovascular Comorbidities in Chronic Inflammatory Diseases

The developments that have taken place in recent decades in the diagnosis and therapy of a number of diseases have led to improvements in prognosis and life expectancy. As a consequence, there has been an increase in the number of patients affected by chronic diseases and who can face new pathologies during their lifetime. The prevalence of chronic heart failure, for example, is approximately 1-2% of the adult population in developed countries, rising to ≥10% among people >70 years of age; in 2015, more than 85 million people in Europe were living with some sort of cardiovascular disease (CVD) (Lubrano and Balzan World J Exp Med 5:21-32, 5; Takahashi et al. Circ J 72:867-72, 8; Kaptoge et al. Lancet 375:132-40, 9). Chronic disease can become, in turn, a major risk factor for other diseases. Furthermore, several new drugs have entered clinical practice whose adverse effects on multiple organs are still to be evaluated. All this necessarily involves a multidisciplinary vision of medicine, where the physician must view the patient as a whole and where collaboration between the various specialists plays a key role. An example of what has been said so far is the relationship between CVD and chronic inflammatory diseases (CIDs). Patients with chronic CVD may develop a CID within their lifetime, and, vice versa, a CID can be a risk factor for the development of CVD. Moreover, drugs used for the treatment of CIDs may have side effects involving the cardiovascular system and thus may be contraindicated. The purpose of this paper is to investigate the close relationship between these two groups of diseases and to provide recommendations on the diagnostic approach and treatments in light of the most recent scientific data available.

A critical view on cardiovascular risk in systemic sclerosis

Systemic Sclerosis (SSc) is an autoimmune disorder characterized by microvascular injury and diffuse fibrosis of the skin and internal organs. While macrovascular disease and higher risk for cardiovascular events are well documented in other systemic rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, the presence and extent of atherosclerosis among patients with SSc is yet to be established. Primary cardiac involvement, due to impairment of coronary microvascular circulation and myocardial fibrosis, considerably affects prognosis and life expectancy of individuals with SSc, representing one of the leading causes of death in this population. On the other hand the existence and prevalence of atherosclerotic coronary disease remains an issue of debate as studies comparing structural and morphological markers of atherosclerosis and cardiovascular events between SSc patients and the general population have yielded controversial results. The aim of this review is to summarize recent literature about the prevalence of cardiovascular disease in SSc, review the surrogate markers of CVD that have been evaluated and examine whether common pathogenic mechanisms exist between SSc and macrovascular disease.

Pseudo-infarction pattern in diffuse systemic sclerosis. Evaluation using cardiovascular magnetic resonance

BACKGROUND

Diffuse systemic sclerosis (dSSc) is characterized by vascular lesions and fibrosis. Cardiac involvement, although silent, accounts for 36% of deaths. We hypothesized that cardiovascular magnetic resonance (CMR) can clarify the pathophysiology of Q waves in dSSc patients.

PATIENTS-METHODS

105 dSSc, aged 48±2years, with atypical symptoms and normal routine assessment, were evaluated by ECG and CMR using a 1.5 T system. Biventricular function was assessed by steady-state free-precession sequence (SSFP). To identify fibrosis, late gadolinium enhanced areas (LGE) were evaluated 15min after injection of 0.2mmol/kg gadolinium-DTPA and expressed as % of LV mass.

RESULTS

Q waves in V1-V5 (Group A), II, III, AVF (Group B) and I, AVL, II, III, AVF, V1-V5 (Group C) were found in 25/105, 8/105 and 5/105 dSSc, respectively. In 25 dSSc with Q in V1-V6, patchy intramyocardial LGE was detected in 24/25 and involved 8±2% of LV mass. LGE involved the intraventricular septum (IVS) in 11/24 and the lateral wall (LAT) in 5/24 dSSc. Only in 1/25 dSSc, an anterior, transmural LGE, due to LAD occlusion, was identified. In 8 dSSc with Q in II, III, AVF, patchy intramyocardial LGE was detected in the inferior wall and involved 5±2% of LV mass. In 5 dSSc with Q in V1-V5, II, III, AVF, patchy intramyocardial LGE was detected in anterior and inferolateral wall and involved 9±2% of LV mass.

CONCLUSION

CMR unveiled that the pattern of myocardial fibrosis in dSSc with Q waves is due to the systemic disease and not to CAD.

The association between systemic sclerosis, arginine and asymmetric dimethylarginine

Systemic sclerosis (SSc) is a kind of autoimmune disease characterized by inflammatory and endothelial dysfunction. Asymmetric dimethylarginine (ADMA), as an endogenous nitric oxide synthase inhibitor, can cause or contribute to the inflammatory syndrome and endothelial dysfunction. Recently, increased ADMA levels have been demonstrated in SSc, revealing that ADMA might play an important role for the associated manifestations of SSc. Besides, ADMA may play a significant role in the level of NO, which is produced by arginine. In the review, we discuss the role of arginine and ADMA in patients with SSc.

Evaluation of differences in carotid intima-media thickness in patients affected by systemic rheumatic diseases

The objective of this study is to investigate whether rheumatic autoimmune diseases, systemic sclerosis (SSc) in particular, are associated with increased carotid intima-media thickness (C-IMT). A total of 108 clinical outpatients (93 females), mean age 51 ± 14 years suffering from CTD were consecutively enrolled. Patients were subdivided into the following two groups: (1) Systemic Sclerosis (SSc, 60 patients); (2) non-Systemic Sclerosis (NoSSc, 48 patients). No randomization was managed. All patients underwent structured clinical interview, physical examination, laboratory evaluation and two-dimensional echo-color Doppler of the carotid arteries to measure C-IMT and atherosclerotic plaques. Framingham risk score was also calculated. We also enrolled 108 healthy controls (HC), matched by sex and age. The primary outcome was to stratify cardiovascular risk of CTD patients. There were no significant differences between SSc and NoSSc patients regarding any of the demographics and traditional cardiovascular risk factors. Mean C-IMT was not significantly different between the whole CTD patients (0.86 ± 0.13 mm) and HC (0.83 ± 0.13 mm). C-IMT was significantly higher in SSc than in NoSSc group (0.91 ± 0.1 mm vs 0.80 ± 0.14 mm, p < 0.001). Furthermore, C-IMT in SSc group was significantly higher than C-IMT in controls (0.91 ± 0.1 mm vs 0.83 ± 0.13 mm, p < 0.001). C-IMT did correlate neither with disease activity nor with drug intake. SSc patients had a significant increase in C-IMT as compared to NoSSc patients and healthy controls.

Cardiovascular and autoimmune diseases in females: The role of microvasculature and dysfunctional endothelium

Cardiovascular (CV) diseases are becoming increasingly frequent and associated with a high incidence of CV events, disability and death. It is known that there is a relationship between CV burden and systemic autoimmune diseases (SADs) that is mainly due to inflammation and autoimmunity, but the other mechanisms underlying the high CV risk of SAD patients have not yet been fully clarified. The aim of this review article is to discuss some of the specific factors associated with the accelerated atherosclerosis (ATS) characterising SADs (female sex, the microcirculation and the endothelium) in order to highlight the importance of an early diagnosis and the prompt implementation of preventive measures, as well as the possible role of new therapeutic strategies such as vaccine immunomodulation. Finally, as the natural history of ATS begins with endothelial injury (a potentially reversible process that is influenced by various factors) and microvascular damage plays a central role in the etiopathogenesis of SADs, it underlines the crucial need for the development of reliable means of detecting sub-clinical abnormalities in the microcirculation, particularly coronary microcirculation dysfunction.

Cardiovascular disease in systemic sclerosis

Cardiovascular (CV) system involvement is a frequent complication of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). It still remains unclear if a premature atherosclerosis (ATS) occurs even in systemic sclerosis (SSc). Although microvascular disease is a hallmark of SSc, in the last few years a number of studies highlighted a higher prevalence of macrovascular disease in SSc patients in comparison to healthy individuals and these data have been correlated with a poorer prognosis. The mechanisms promoting ATS in SSc are not fully understood, but it is believed to be secondary to multi-system organ inflammation, endothelial wall damage and vasculopathy. Both traditional risk factors and endothelial dysfunction have been proposed to participate to the onset and progression of ATS in such patients. In particular, endothelial cell injury induced by anti-endothelial antibodies, ischemia/reperfusion damage, immune-mediated cytotoxicity represent the main causes of vascular injury together with an impaired vascular repair mechanism that determine a defective vasculogenesis. Aim of this review is to analyse both causes and clinical manifestations of macrovascular involvement and ATS in SSc.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

Atherosclerotic plaques occur in absence of intima-media thickening in both systemic sclerosis and systemic lupus erythematosus: a duplexsonography study of carotid and femoral arteries and follow-up for cardiovascular events

INTRODUCTION

The objective of this cross-sectional and retrospective cohort study was (1) to determine the usefulness of intima-media thickness (IMT) in contrast to plaque assessment, (2) to examine the value of additive femoral artery sonography and (3) to identify potential risk factors for atherosclerosis and incident cardiovascular events in systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) patients.

METHODS

In this study, 90 SSc and 100 SLE patients were examined by duplexsonography. IMT was measured in common carotid and common femoral arteries, plaques were assessed in common, internal and external carotid and common, proximal superficial and deep femoral arteries. Different definitions of pathological IMT (pIMT) were compared with the presence of plaque. Results were evaluated in relation to traditional and non-traditional risk factors for baseline atherosclerosis (logistic regression) and their predictive value for cardiovascular events during follow-up (cox regression).

RESULTS

Definite atherosclerosis occurred frequently without signs of subclinical atherosclerosis in both diseases: pIMT >0.9 mm was present in only 17/59 (28.9%) SSc and 13/49 (26.5%) SLE patients with already present atherosclerotic plaques. Using age-adjusted pIMT definitions, this rate was even lower (5.1-10.3% in SSc, 14.3-26.5% in SLE). Plaques were located only at the carotid or only at the femoral arteries in 26 (13.7%) and 24 (12.6%) patients, respectively. Age and nicotine pack-years were independently associated with atherosclerotic plaques in SLE and SSc patients, as well as the cumulative prednisolone dose in SSc subgroup, and ssDNA positive SLE patients had a lower risk for atherosclerotic plaque. During follow-up (available for 129/190 (67.9%) patients, 650 person-years), cardiovascular events occurred more often in patients with coronary heart disease (adjusted-hazards ratio (HR) 10.19, 95% confidence interval (CI) 3.04 to 34.17, P <0.001), male patients (adjusted-HR 8.78, 95% CI 2.73 to 28.19, P <0.001) and in patients with coexistent carotid and femoral plaques (adjusted-HR 5.92, 95% CI 1.55 to 22.67, P = 0.009). Patients with solely carotid or femoral plaque were not at higher risk.

CONCLUSION

Atherosclerotic plaque lesions can be found frequently in absence of intima-media thickening in both SSc and SLE patients. As well as routine sonography of carotid arteries, the sonography of femoral arteries is recommended to identify additional atherosclerotic lesions and to detect patients at a high risk for cardiovascular events.

My approach to the treatment of scleroderma

Systemic sclerosis (scleroderma) is unique among the rheumatic diseases because it presents the challenge of managing a chronic multisystem autoimmune disease with a widespread obliterative vasculopathy of small arteries that is associated with varying degrees of tissue fibrosis. The hallmark of scleroderma is clinical heterogeneity with subsets that vary in the degree of disease expression, organ involvement, and ultimate prognosis. Thus, the term scleroderma is used to describe patients who have common manifestations that link them together, whereas a highly variable clinical course exists that spans from mild and subtle findings to aggressive, life-threatening multisystem disease. The physician needs to carefully characterize each patient to understand the specific manifestations and level of disease activity to decide appropriate treatment. This is particularly important in treating a patient with scleroderma because there is no treatment that has been proven to modify the overall disease course, although therapy that targets specific organ involvement early before irreversible damage occurs improves both quality of life and survival. This review describes our approach as defined by evidence, expert opinion, and our experience treating patients. Scleroderma is a multisystem disease with variable expression; thus, any treatment plan must be holistic, yet at the same time focus on the dominant organ disease. The goal of therapy is to improve quality of life by minimizing specific organ involvement and subsequent life-threatening disease. At the same time the many factors that alter daily function need to be addressed, including nutrition, pain, deconditioning, musculoskeletal disuse, comorbid conditions, and the emotional aspects of the disease, such as fear, depression, and the social withdrawal caused by disfigurement.