Cardiovascular Complications of Collagen Vascular Disease

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements

Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.

Unexpected post-mortem diagnosis of systemic sclerosis presenting as pneumatosis intestinalis: revised diagnostic criteria and medicolegal implications

Systemic sclerosis is a challenging diagnosis for clinicians and pathologists alike due to its protean manifestations and often insidious onset, particularly in cases without significant titres of auto-antibodies. Herein we present a case of a female in her sixties who died rapidly following a clinical diagnosis of pneumatosis intestinalis and respiratory failure of unclear etiology. Recently revised clinical diagnostic criteria were applied to the clinical history and postmortem findings to reach an unexpected diagnosis of systemic sclerosis. The diagnosis of systemic sclerosis at autopsy has important medicolegal implications largely related to premature death due to delayed treatment or poor post-operative outcome. Moreover, familial clustering of this disease underscores the importance of maintaining a high index of suspicion in the postmortem setting.

Antigen-induced immunomodulation in the pathogenesis of atherosclerosis

Atherosclerosis is a chronic inflammatory disorder characterised by the accumulation of monocytes/macrophages, smooth muscle cells, and lymphocytes within the arterial wall in response to the release of proinflammatory molecules. Such accumulation results in the formation of the atherosclerotic plaque, which would eventually evolve to complications such as total artery occlusion, rupture, calcification, or aneurysm. Although the molecular mechanism responsible for the development of atherosclerosis is not completely understood, it is clear that the immune system plays a key role in the development of the atherosclerotic plaque and in its complications. There are multiple antigenic stimuli that have been associated with the pathogenesis of atherosclerosis. Most of these stimuli come from modified self-molecules such as oxidised low-density lipoproteins (oxLDLs), beta2glycoprotein1 (β2GP1), lipoprotein a (LP(a)), heat shock proteins (HSPs), and protein components of the extracellular matrix such as collagen and fibrinogen in the form of advanced glycation-end (AGE) products. In addition, several foreign antigens including bacteria such as Porphyromonas gingivalis and Chlamydia pneumoniae and viruses such as enterovirus and cytomegalovirus have been associated with atherosclerosis as potentially causative or bystander participants, adding another level of complexity to the analysis of the pathophysiology of atherosclerosis. The present review summarises the most important scientific findings published within the last two decades on the importance of antigens, antigen stimulation, and adaptive immune responses in the development of atherosclerotic plaques.

Cardiac involvement in Crohn's disease: echocardiographic study

BACKGROUND

Crohn's Disease (CD) commonly presents extra-intestinal manifestations, but cardiac involvement is considered rare. The aim of the present study was to assess cardiac involvement in CD and its possible correlation with activity, duration, localization and therapy.

PATIENTS AND METHODS

A group of 68 patients with CD and a control group of 60 healthy subjects were subjected to a transthoracic echocardiogram with Doppler study.

RESULTS

The study found overall morphologic alterations in 47/68 CD patients (69.11%) versus 12/60 controls (20.0%; P < 0.01); mitral valve prolapse in 20/68 CD patients (29.4%) versus 4/60 controls (6.6%; P < 0.01); and pericardial effusion in 13/68 CD patients (19.1%)versus 1/60 controls (1.6%; P < 0.01). The following findings were frequent, but without statistical significance: mitral insufficiency, 9/68 CD (13.2%) versus 3/60 controls (5.0%); tricuspidalic insufficiency, 8/68 CD (11.7%) versus 3/60 controls (5%); aortic insufficiency, 3/68 CD (4.4%) versus none in the control group; and decreased left ventricle ejection fraction, 5/68 CD (7.3%) versus none in the control group. Pericardial effusion was found to be related to CD activity (r = 0.375; P = 0.002) as well as decreased ejection fraction (r = 0.358; P = 0.003). No correlation with age, sex, duration, therapy or localization of disease was found.

CONCLUSIONS

These findings suggest that CD frequently determines cardiac involvement, although it is usually subclinical. The alteration of cytokine network, especially the elevated levels of tumor necrosis factor-alpha, could be implicated in the cardiac alterations because it was observed, as for raised oxidative stress, in other heart diseases.

Comparison of energy expenditure from lifestyle physical activities between patients with rheumatoid arthritis and healthy controls

OBJECTIVE

Low energy expenditure is a risk for cardiovascular morbidity. The goals of this study were to compare energy expenditure between patients with rheumatoid arthritis (RA) and healthy controls.

METHODS

A total of 121 RA patients and 120 healthy controls in New York City completed the Paffenbarger Physical Activity and Exercise Index at time of enrollment (1999-2000) and 1 year later to measure energy expenditure from walking, climbing stairs, and exercise/sports. Analyses were adjusted for age, sex, education, pain, social support, and depressive symptoms and were compared with recommended thresholds of energy expenditure.

RESULTS

Participants' mean age was 49 years, and 87% were women. Patients with RA expended fewer kilocalories per week than controls (mean +/- SD 1,474 +/- 1,198 versus 1,958 +/- 1,940, P = 0.003), with most of this difference from less walking as opposed to high-intensity activities. Although similar percents of RA patients and controls met national recommendations for total weekly energy expenditure (56% versus 64% for the lower [> or =1,000 kilocalories per week] threshold; P = 0.14, and 41% versus 48% for the higher [> or =1,400 kilocalories per week] threshold; P = 0.17), fewer RA patients met the recommendations (> or =700 kilocalories per week) for walking (32% versus 48%; P = 0.01). The strongest predictor of more energy expenditure at 1 year for both groups was more energy expenditure at enrollment.

CONCLUSION

Most of the difference in energy expenditure between RA patients and healthy controls was due to less walking. Given that walking is an effective and relatively safe lifestyle activity, increasing walking should be a priority to improve cardiovascular risk in RA.

Renal transplantation in lupus nephritis

Most patients with systemic lupus erythematosus (SLE) are suitable candidates for renal transplantation. However, a number of them may present some disease-related problems. As cardiovascular disease is a leading cause of morbidity and mortality in SLE patients, a careful pretransplant cardiovascular screening is recommended. A search for antiphospholipid antibodies is also useful as the presence of these antibodies can cause an early graft thrombosis. The risk of recurrence of SLE nephritis after transplantation may range between 2 and 30%. In most cases recurrence is characterized by mild histologic lesions. Only rarely does it lead to graft failure. Postransplant immunosuppression does not differ from that used routinely. Whenever possible, a steroid-free immunosuppression should be scheduled to prevent iatrogenic toxicity in patients who have already received long-term steroid treatment. The results of kidney transplantation largely depend on the clinical conditions at transplantation. In patients with poor clinical status or receiving an aggressive immunosuppression it is advisable to postpone the transplant. When some selection criteria are respected, the results of renal trasplantation in SLE patients are at least as good as in other transplant recipients.

Systemic lupus erythematosus in a multiethnic US cohort (LUMINA): XXI. Disease activity, damage accrual, and vascular events in pre- and postmenopausal women

OBJECTIVE

To determine the differences in clinical manifestations, disease activity, damage accrual, and medication use in systemic lupus erythematosus (SLE) patients as a function of menopausal status at disease onset.

METHODS

Women with SLE as per the criteria of the American College of Rheumatology, with disease duration of </=5 years and of Hispanic (Texas and Puerto Rico ancestries), African American, and Caucasian ethnicity, from LUMINA (LUpus in MInorities, NAture versus nurture), a multiethnic, longitudinal cohort, were studied. Menopause at the time of disease onset was defined as self-report of climacteric symptoms, and/or amenorrhea lasting >6 months, and/or oophorectomy, and/or increased follicle-stimulating hormone values for reproductive-age women, and/or treatment with hormone replacement therapy. Patients were divided into premenopausal and postmenopausal categories. Socioeconomic status, cumulative clinical manifestations, disease activity (at study entry or time 0, last visit, and over time), as measured by the Systemic Lupus Activity Measure, and damage accrual, as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (at time 0 and at last visit) were compared between the 2 groups of women. Multivariable models were then examined making adjustments for all possible known confounders. Dependent variables in the models were renal involvement, damage accrual, arterial vascular events, and venous thrombosis.

RESULTS

Five hundred eighteen women from the LUMINA cohort were included; 436 (84.2%) were premenopausal and 82 (15.8%) were postmenopausal. Disease onset after menopause was more common among Caucasians. Renal involvement was more common in premenopausal women, whereas vascular arterial events were more frequent in postmenopausal women. All other disease manifestations, as well as disease activity, were comparable between both groups. The presence of damage accrual at time 0 and study end was more frequent in postmenopausal women. Age, rather than menopausal status, independently contributed to damage accrual, renal involvement, and vascular arterial events in these women.

CONCLUSION

A hypoestrogenemic state secondary to menopause appears not to be protective against disease activity and damage accrual. Age rather than menopausal status is a strong independent predictor of damage accrual and of vascular events in women with lupus.