1
|
Niznik S, Rapoport MJ, Avnery O, Kidon M, Shavit R, Ellis MH, Agmon-Levin N. Heart valve disease in primary antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:1397-1402. [PMID: 37572296 DOI: 10.1093/rheumatology/kead399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/17/2023] [Accepted: 07/16/2023] [Indexed: 08/14/2023] Open
Abstract
OBJECTIVES APS-associated heart valve disease (HVD) is well described. Nonetheless, limited data exist on clinical parameters associated with the course of primary APS (pAPS) patients with HVD. The goal of this study was to assess clinical features and related outcomes in patients with APS-associated HVD. METHODS In this multicentre retrospective study, we identified 33 pAPS patients with HVD (pAPS-HVD group) and compared their clinical course with 128 pAPS patients with normal heart valves on echocardiography (pAPS-control group). RESULTS pAPS-HVD patients had more cerebrovascular events (56.3% vs 25%, P = 0.005) and livedo reticularis (24.2% vs 7.8%, P = 0.013) than pAPS-controls. Furthermore, catastrophic-APS (CAPS) (12.1% vs 2.4%, P = 0.034), recurrent thrombosis (33.3% vs 4.7%, P < 0.001) and need for advanced therapy (i.e. IVIG, plasmapheresis or rituximab) were more frequent in pAPS-HVD patients. Anti-β2-glycoprotein 1 IgG (84.8% vs 63.2%, P = 0.034), anti-cardiolipin IgG (90.9% vs 64.8%, P = 0.005) and triple positive aPL (75.8% vs 56.5%, P = 0.047) were commoner in pAPS-HVD patients vs pAPS-controls. Ten of the 33 patients with pAPS-HVD underwent valve surgery, which was associated with male gender, smoking, arterial limb ischaemia and livedo reticularis. CONCLUSION pAPS-HVD patients had a more severe APS clinical course including CAPS and thrombotic events as well as a specific serology, namely IgG isotype aPL antibodies and triple positivity. Our data suggest that pAPS-HVD represents a high-risk subgroup of APS patients.
Collapse
Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Micha J Rapoport
- Department of Internal Medicine 'C', Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Mona Kidon
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
2
|
Pons I, Louro J, Sitges M, Vidal B, Cervera R, Espinosa G. Heart Valve Involvement in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Study of a Single Centre. J Clin Med 2023; 12:jcm12082996. [PMID: 37109332 PMCID: PMC10145646 DOI: 10.3390/jcm12082996] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Valve involvement is the most common cardiac manifestation in antiphospholipid syndrome (APS). The objective of the study was to describe the prevalence, clinical and laboratory features, and evolution of APS patients with heart valve involvement. METHODS A retrospective longitudinal and observational study of all APS patients followed by a single centre with at least one transthoracic echocardiographic study. RESULTS 144 APS patients, 72 (50%) of them with valvular involvement. Forty-eight (67%) had primary APS, and 22 (30%) were associated with systemic lupus erythematosus (SLE). Mitral valve thickening was the most frequent valve involvement present in 52 (72%) patients, followed by mitral regurgitation in 49 (68%), and tricuspid regurgitation in 29 (40%) patients. Female sex (83% vs. 64%; p = 0.013), arterial hypertension (47% vs. 29%; p = 0.025), arterial thrombosis at APS diagnosis (53% vs. 33%; p = 0.028), stroke (38% vs. 21%; p = 0.043), livedo reticularis (15% vs. 3%; p = 0.017), and lupus anticoagulant (83% vs. 65%; p = 0.021) were more prevalent in those with valvular involvement. Venous thrombosis was less frequent (32% vs. 50%; p = 0.042). The valve involvement group suffered from higher mortality (12% vs. 1%; p = 0.017). Most of these differences were maintained when we compared patients with moderate-to-severe valve involvement (n = 36) and those with no or mild involvement (n = 108). CONCLUSIONS Heart valve disease is a frequent manifestation in our cohort of APS patients and is associated with demographic, clinical and laboratory features, and increased mortality. More studies are needed, but our results suggest that there may be a subgroup of APS patients with moderate-to-severe valve involvement with its own characteristics that differs from the rest of the patients with mild valve involvement or without valve involvement.
Collapse
Affiliation(s)
- Isaac Pons
- Department of Autoimmune Diseases, Reference Centre (UEC/CSUR) for Systemic Autoimmune Diseases of the Catalan and Spanish Health Systems, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Internal Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (UVic-UCC), 08240 Manresa, Spain
| | - Joana Louro
- Department of Autoimmune Diseases, Reference Centre (UEC/CSUR) for Systemic Autoimmune Diseases of the Catalan and Spanish Health Systems, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Marta Sitges
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Bàrbara Vidal
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre (UEC/CSUR) for Systemic Autoimmune Diseases of the Catalan and Spanish Health Systems, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre (UEC/CSUR) for Systemic Autoimmune Diseases of the Catalan and Spanish Health Systems, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| |
Collapse
|
3
|
Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Shavit R, Ellis MH, Agmon-Levin N. Long Term Follow up of Patients With Primary Obstetric Antiphospholipid Syndrome. Front Pharmacol 2022; 13:824775. [PMID: 35529433 PMCID: PMC9068935 DOI: 10.3389/fphar.2022.824775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Primary obstetric antiphospholipid syndrome (OAPS) is defined by specific morbidities and/or losses of pregnancy in the presence of persistent antiphospholipid antibodies (aPL). This variant of APS is usually treated during pregnancy and the post-partum period. Data on occurrence of thrombotic event during long term follow-up of OAPS patients is limited. Methods: A multi-centre retrospectively cohort of female patients with primary APS (pAPS) was assembled during 2004-2019. Patients were grouped according to disease presentation as pure OAPS or thrombotic APS (tAPS) for those presenting with thrombosis. Clinical and serological data were compared between groups. Results: Of 219 pAPS female patients 67 (30.6%) were diagnosed with OAPS and 152 (69.4%) with tAPS. During >10 years of follow-up 24/67 (35.8%) OAPS and 71/152 (50%) tAPS suffered a new thrombotic event (p = 0.06), while obstetric morbidity was more likely in the OAPS group (31.3 vs. 10.5%, p < 0.001) respectively. Among patients with OAPS at presentation heart valve disease and the presence of ANA were related to thrombosis following diagnosis (25 vs. 4.7%, p = 0.02; and 45.8 vs. 20.8%, p = 0.04 respectively). Conclusion: Thrombotic event following diagnosis were common among female patients with pAPS regardless of disease presentation. Heart valve disease and ANA positivity may be risk factors for thrombosis during follow-up of patients presenting with pure OAPS.
Collapse
Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Micha J. Rapoport
- Department of Internal Medicine “C”, Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Martin H. Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
4
|
Hussain K, Gauto-Mariotti E, Cattoni HM, Arif AW, Richardson C, Manadan A, Yadav N. A Meta-analysis and Systematic Review of Valvular Heart Disease in Systemic Lupus Erythematosus and Its Association With Antiphospholipid Antibodies. J Clin Rheumatol 2021; 27:e525-e532. [PMID: 32558678 DOI: 10.1097/rhu.0000000000001464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Valvular heart disease (VHD) is a known cardiac manifestation of systematic lupus erythematosus (SLE). This systematic review aims to pool data from studies to estimate the frequency of valvular lesions in SLE patients. It also aims to demonstrate the association between VHD in SLE and antiphospholipid antibodies positivity. METHODS We included 27 studies after identifying relevant abstracts from PubMed, Scopus, and Google Scholar from the time of inception of database to 2019. Inclusion criteria consisted of English-language case-control and cohort studies. Three reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale for assessing risk for bias. RESULTS For VHD in SLE patients, the most commonly involved valve was the mitral valve, with 19.7% lesions being mitral regurgitation. In terms of morphological lesions, valve thickening (11.06%) and vegetations (11.76%) were among the most prevalent. Other commonly encountered lesions were mitral valve prolapse and tricuspid regurgitation in 9.25% and 10.86% of patients, respectively. A meta-analysis of 21 studies with 2163 SLE patients, of which 23.3% had valvular lesions, showed a significant association of anticardiolipin antibodies positivity with VHD (relative risk, 1.55; confidence interval, 1.10-2.18). CONCLUSIONS Systemic lupus erythematosus is associated with VHD, and it should be considered a clinical manifestation of SLE in the absence of other valvular pathologies. There is a clear association between VHD in SLE and immunoglobulin G anticardiolipin antibodies positivity. This association suggests that this subgroup of SLE patients might benefit from a screening echocardiogram.
Collapse
Affiliation(s)
- Kifah Hussain
- From the John H. Stroger Hospital of Cook County, Chicago
| | | | | | | | | | | | - Neha Yadav
- From the John H. Stroger Hospital of Cook County, Chicago
| |
Collapse
|
5
|
Slivka AP, Agriesti JE, Orsinelli DA. Natural history of nonbacterial thrombotic endocarditis treated with warfarin. Int J Stroke 2020; 16:519-525. [PMID: 33040698 DOI: 10.1177/1747493020961744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report on the natural history of a cohort of patients presenting with transient ischemic attack or stroke and nonbacterial thrombotic endocarditis treated with warfarin.Patients with valvular vegetations on echocardiography, stroke, or transient ischemic attack presenting to a single neurologist were included. All patients were treated with warfarin until the vegetation resolved or for two years, then were switched to aspirin and had at least one clinical and echocardiographic follow-up.Twenty-nine patients were included and followed for a median of 27 months. Average age was 42 years and 72% were female. Two patients had vegetations on two valves. Five patients (17%) had recurrent strokes, three had systemic lupus erythematosus and antiphospholipid antibodies, one had antiphospholipid antibodies alone and one had neither condition. Three of the five patients did not have resolution of the vegetation at the time of the event. The valvular vegetations resolved in 23 of the 31 affected valves (74%) after a median of 11 months (range 4.5-157.5). Eleven patients had at least one follow-up echocardiogram after resolution of the vegetation and none had recurrent vegetations after warfarin was stopped.This study should serve to provide general recommendations regarding treatment of patients with TIA/stroke with nonbacterial thrombotic endocarditis. Valvular vegetations resolve in most patients and the risk of recurrent stroke is low. Warfarin can safely be switched to aspirin in most patients when the vegetation resolves or after two years if it does not resolve. Prolonged warfarin may be warranted in patients with systemic lupus erythematosus, positive antiphospholipid antibodies, and a persistent vegetation.
Collapse
Affiliation(s)
- Andrew P Slivka
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Julie E Agriesti
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - David A Orsinelli
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
6
|
Piranavan P, Perl A. Management of cardiovascular disease in patients with systemic lupus erythematosus. Expert Opin Pharmacother 2020; 21:1617-1628. [PMID: 32511034 PMCID: PMC7451028 DOI: 10.1080/14656566.2020.1770227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION SLE is increasingly recognized as an important risk factor for cardiovascular disease. Premature CAD and several other cardiac manifestations are resulting in significant morbidity and premature death among young and older adults. There is a considerable unmet need for developing specific guidelines toward the primary and secondary prevention of cardiovascular disease in SLE patients. AREAS COVERED The authors describe the prevalence of various cardiovascular manifestations, associated with traditional and lupus-specific risk factors. They summarize the evidence behind various nonpharmacological and pharmacological options such as cardiac medications, antimalarials, anti-inflammatory, and immunosuppressant medications. EXPERT OPINION There is considerable literature claiming that the traditional Framingham score used to calculate the risk in the general population would not clearly predict the 10-year risk among SLE patients as they do not include lupus-specific risk factors such as accelerated inflammation, immunometabolic changes, thrombosis, vasospasm, vasculitis, and endothelial dysfunction into account. Identifying potential risk factors among SLE patients and treating hyperlipidemia regardless of their risk scores may be the first step in reducing mortality. Blocking lupus-specific inflammatory pathways by targeting validated biomarkers of pathogenesis has great future potential and more studies are needed on their cardiovascular benefits.
Collapse
Affiliation(s)
- Paramarjan Piranavan
- Department of Medicine, State University of New York, College of Medicine, Syracuse, New York 13210, USA
| | - Andras Perl
- Department of Medicine, State University of New York, College of Medicine, Syracuse, New York 13210, USA
- Department of Microbiology and Immunology, State University of New York, College of Medicine, Syracuse, New York 13210, USA
- Department of Biochemistry and Molecular Biology, State University of New York, College of Medicine, Syracuse, New York 13210, USA
| |
Collapse
|
7
|
Kazzaz NM, Wilson AM, Kado R, Barnes GD, Knight JS. A 37-Year-Old Man With Primary Antiphospholipid Syndrome Presenting With Respiratory Distress and Worsening Toe Ischemia. Arthritis Care Res (Hoboken) 2019; 69:1253-1259. [PMID: 27992694 DOI: 10.1002/acr.23168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Ruba Kado
- University of Michigan Medical School, Ann Arbor
| | | | | |
Collapse
|
8
|
Higuera-Ortiz V, Mora-Arias T, Castillo-Martinez D, Amezcua-Guerra LM. Anti-Ro/SSA antibodies are associated with severe mitral valve regurgitation in patients with systemic lupus erythematosus. Mod Rheumatol 2016; 27:476-480. [DOI: 10.1080/14397595.2016.1208136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Violeta Higuera-Ortiz
- Department of Rheumatology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Tania Mora-Arias
- Department of Rheumatology, Hospital Ángeles del Pedregal, Mexico City, Mexico
| | - Diana Castillo-Martinez
- Department of Dermatology, Hospital General de Zona 32 Villa Coapa, Instituto Mexicano del Seguro Social, Mexico City, Mexico
- School of Medicine, Universidad Anahuac, Mexico City, Mexico
| | - Luis M. Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
- Department of Health Care, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
- School of Medicine, LaSalle University at Mexico City, Mexico
| |
Collapse
|
9
|
Morelli S, Bernardo ML, Viganego F, Sgreccia A, De Marzio P, Conti F, Priori R, Valesini G. Left-sided heart valve abnormalities and risk of ischemic cerebrovascular accidents in patients with systemic lupus erythematosus. Lupus 2016; 12:805-12. [PMID: 14667095 DOI: 10.1191/0961203303lu468oa] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the study was to assess the relationship between ischemic cerebrovascular accidents (ICVAs), that is, transient ischemic attack (TIA) or stroke, and left-sided heart valve abnormalities (LHVAs) in patients with systemic lupus erythematosus (SLE). In total, 71 consecutive SLE patients were studied.At baseline, history, clinical and laboratoryevaluations, as well as trans-thoracic echocardiography (TTE) were performed. From the original population, so patients were followed up for a mean time of 5.80 + 1.53 years. After a mean period of 5.39 + 1.42 years; 40 patients underwent a repeat TTE. Previous ICVA history was present at baseline in 16 patients (22.5%). Of these, 13 (81.2%) had evidence of LHVAs on TTE. Previous ICVAs were significantly associated to diagnosis of secondary anti-phospholipid syndrome (SAPS), positivity for anti-cardiolipin antibodies (aCl), and LHVAs. Multivariate analysis confirmed the correlation between previous ICVAs and LHVAs. LHVAs were not more commonly observed in patients with SAPS compared to patients without SAPS. At the end of follow-up, irrespective of any differences in antithrombotic treatment, ICVAs had occurred in 13 patients.During follow-up, ICVAs had recurredin seven patients, while a first eventTIA occurredin one patient. Multivariate analysis confirmed the relationship between ICVAs and LHVAs, and a trend towards a positive correlation of the former with SAPS. This study demonstratesthat LHVAs represent a compelling risk factor for the development of ICVAs in SLE patients. Conversely, SAPS and aCl positivity, although associated with ICVAs, did not clearly correlate with LHVAs in our study. These results provide insight on the pathogenesis of ICVAs and may give clues on the potential efficacy of preventive/therapeutic strategies in different SLE subpopulations.
Collapse
Affiliation(s)
- S Morelli
- Dipartimento di Medicina Intema, Policlinico Umberto I, University of Rome 'La Sapienza', Rome, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Ünlü O, Zuily S, Erkan D. The clinical significance of antiphospholipid antibodies in systemic lupus erythematosus. Eur J Rheumatol 2016; 3:75-84. [PMID: 27708976 PMCID: PMC5042235 DOI: 10.5152/eurjrheum.2015.0085] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/20/2015] [Indexed: 12/22/2022] Open
Abstract
Antiphospholipid syndrome (APS) is the association of thrombosis and/or pregnancy morbidity with antiphospholipid antibodies (aPL). Thirty to forty percent of systemic lupus erythematosus (SLE) patients are tested positive for aPL, which may have an impact on the SLE presentation, management, and prognosis. Compared with SLE patients without aPL, those with aPL have a higher prevalence of thrombosis, pregnancy morbidity, valve disease, pulmonary hypertension, livedo reticularis, thrombocytopenia, hemolytic anemia, acute/chronic renal vascular lesions, and moderate/severe cognitive impairment; worse quality of life; and higher risk of organ damage. The use of low-dose aspirin (LDA) is controversial for primary thrombosis and pregnancy morbidity prevention because of the lack of strong prospective controlled data. Similarly, the use of anticoagulation is controversial for patients with an aPL-related nephropathy. Until further studies are available, physicians should discuss the risk/benefits of LDA or anticoagulation as well as the available literature with patients.
Collapse
Affiliation(s)
- Ozan Ünlü
- Division of Rheumatology, Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Stephane Zuily
- Division of Vascular Medicine, Centre Hospitalier Universitaire de Nancy, Regional Competence Centre For RareVascular and Systemic Autoimmune Diseases, Nancy, France
| | - Doruk Erkan
- Division of Rheumatology, Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| |
Collapse
|
11
|
Kampolis C, Tektonidou M, Moyssakis I, Tzelepis GE, Moutsopoulos H, Vlachoyiannopoulos PG. Evolution of cardiac dysfunction in patients with antiphospholipid antibodies and/or antiphospholipid syndrome: A 10-year follow-up study. Semin Arthritis Rheum 2014; 43:558-65. [DOI: 10.1016/j.semarthrit.2013.07.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 07/30/2013] [Accepted: 07/31/2013] [Indexed: 11/27/2022]
|
12
|
Shahin AA, Shahin HA, Hamid MA, Amin MA. Cardiac involvement in patients with systemic lupus erythematosus and correlation of valvular lesions with anti-Ro/SS-A and anti-La/SS-B antibody levels. Mod Rheumatol 2014. [DOI: 10.3109/s10165-004-0277-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
13
|
The clinical relevance of IgA anticardiolipin and IgA anti-β2 glycoprotein I antiphospholipid antibodies: a systematic review. Autoimmun Rev 2012; 12:421-5. [PMID: 22951216 DOI: 10.1016/j.autrev.2012.08.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/03/2012] [Indexed: 11/20/2022]
Abstract
The antiphospholipid syndrome (APS) is diagnosed in patients with thromboembolic events and/or pregnancy loss in the presence of persistent laboratory evidence for antiphospholipid antibodies (aPL). Diagnostic tests for the detection of antiphospholipid antibodies include laboratory assays that detect anticardiolipin antibodies, lupus anticoagulants, and anti-β(2)-glycoprotein I antibodies. Most studies on aPL have mainly focused on the estimation of the IgG and IgM isotypes, with only a few studies reporting on the pathogenic significance of IgA aPL. In this review we aimed to summarize and analyze the evidence published in the literature on the prevalence and the clinical significance of IgA aPL.
Collapse
|
14
|
Bourré-Tessier J, Huynh T, Clarke AE, Bernatsky S, Joseph L, Belisle P, Pineau CA. Features associated with cardiac abnormalities in systemic lupus erythematosus. Lupus 2011; 20:1518-25. [PMID: 21971202 DOI: 10.1177/0961203311420318] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the prevalence of echocardiographic abnormalities and identify associated clinical and laboratory features in a large systemic lupus erythematosus (SLE) cohort. METHODS Patients fulfilling ACR criteria for SLE underwent a transthoracic echocardiogram (TTE) between January 2005 and June 2006. Variables used as potential correlates included age, sex, ethnicity, lupus duration, lupus disease activity (SLEDAI), cumulative damage (SLICC/ACR damage index (DI)), arterial hypertension, diabetes, current smoking, medication use and laboratory data. Multivariate logistic regression was used to examine the association between TTE abnormalities and potential determinants. RESULTS For the 217 subjects with a TTE performed during the study, the main abnormalities were of the mitral valve (37.3%) and included thickening (25.4%) and insufficiency (25.8%). Other findings included pulmonary artery pressure (PAP) ≥ 30( )mm( )Hg (10.1%), pericardial effusion (4.6%), hypokinesis (2.8%), and aortic insufficiency (3.7%). In multivariate analysis, mitral insufficiency was associated with the use of corticosteroids (OR 2.90; 95%CI 1.42-5.94) and hypokinesis with angiotensin-converting enzyme inhibitors (12.89; 1.06-157.18). Elevated PAP was associated with age (1.04; 1.01-1.07) and with DI (1.20; 1.01-1.42). CONCLUSION Valvular abnormalities are frequent in patients with SLE, with mitral valve lesions occurring in over one third. TTE screening may be indicated in patients with SLE, especially for those with identified risk factors such as corticosteroid use.
Collapse
Affiliation(s)
- J Bourré-Tessier
- Department of Medicine, Division of Rheumatology, McGill University Health Center, Montréal, Québec, Canada
| | | | | | | | | | | | | |
Collapse
|
15
|
Cervera R, Tektonidou MG, Espinosa G, Cabral AR, González EB, Erkan D, Vadya S, Adrogué HE, Solomon M, Zandman-Goddard G, Shoenfeld Y. Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations (I): catastrophic APS, APS nephropathy and heart valve lesions. Lupus 2011; 20:165-73. [PMID: 21303833 DOI: 10.1177/0961203310395051] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objectives of the 'Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations' were to assess the clinical utility of the international consensus statement on classification criteria and treatment guidelines for the catastrophic APS, to identify and grade the studies that analyse the relationship between the antiphospholipid antibodies and the non-criteria APS manifestations and to present the current evidence regarding the accuracy of these non-criteria APS manifestations for the detection of patients with APS. This article summarizes the studies analysed on the catastrophic APS, APS nephropathy and heart valve lesions, and presents the recommendations elaborated by the Task Force after this analysis.
Collapse
Affiliation(s)
- R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Association of antiphospholipid antibodies with valvulopathy in systemic lupus erythematosus: a systematic review. Clin Rheumatol 2011; 30:165-71. [DOI: 10.1007/s10067-010-1662-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 12/11/2010] [Indexed: 10/18/2022]
|
17
|
Bouma W, Klinkenberg TJ, van der Horst ICC, Wijdh-den Hamer IJ, Erasmus ME, Bijl M, Suurmeijer AJH, Zijlstra F, Mariani MA. Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature. J Cardiothorac Surg 2010; 5:13. [PMID: 20331896 PMCID: PMC2859362 DOI: 10.1186/1749-8090-5-13] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 03/23/2010] [Indexed: 11/27/2022] Open
Abstract
Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.
Collapse
Affiliation(s)
- Wobbe Bouma
- Department of Cardiothoracic Surgery, University Medical Center Groningen, the Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Kumar S, Papalardo E, Sunkureddi P, Najam S, González EB, Pierangeli SS. Isolated elevation of IgA anti-beta2glycoprotein I antibodies with manifestations of antiphospholipid syndrome: a case series of five patients. Lupus 2010; 18:1011-4. [PMID: 19762404 DOI: 10.1177/0961203309103048] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current diagnostic classification criteria recommend elevated titres of anti-cardiolipin (aCL) and/or anti-beta(2)GPI antibody by ELISA IgG or IgM and/or lupus anticoagulant (LA) to confirm antiphospholipid syndrome (APS). Although IgA aPL antibodies have been shown to be pathogenic in animal models of APS, their clinical significance has remained elusive. We report four cases of exclusive IgA anti-beta(2)GPI antibody sero-positivity with concomitant clinical manifestations associated with APS. Four of the five patients were LA negative. 1) Thirty-eight-year-old African-American female with SLE presented with resolving digital ulcers. Serum IgA anti-beta(2)GPI antibody titres were 118.5 SAU (normal range: 0-20 SAU). 2) Twenty-seven-year-old African-American woman with SLE was evaluated for recent onset of severe headaches, unresponsive to analgesics and anti-migraine medications. MRI of the brain revealed hyper-intensities in the white matter in the frontal lobes. Serum IgA anti-beta(2)GPI antibody titres were 29.1 Standard A Units (SAU). 3) Thirty-two-year-old Hispanic female with history of two unexplained miscarriages and negative serologies for SLE. Serum IgA anti-beta(2)GPI antibody titres were 102.0 SAU. 4) Twenty-five-year-old white female with history of recent unexplained miscarriage in the 11th week of gestation and associated complaints of numbness and tingling in her hands. Her IgA anti-beta(2)GPI antibody titre was 62.0 SAU. 5) Twenty-five-year-old African-American woman with SLE, positive for anti-Ro antibodies with a history of ischemic fingers, a pregnancy loss and recent pregnancy complicated due to pre-eclampsia. Her LA was positive and her IgA anti-beta(2)GPI antibody titer was 186.0 SAU. This case series supports that elevated IgA anti-beta(2)GPI antibody titres may identify additional patients who have clinical features of APS but who do not meet current diagnostic criteria.
Collapse
Affiliation(s)
- S Kumar
- Division of Rheumatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-1165, USA
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
Antiphospholipid antibodies (aPL Abs) are associated with thrombosis in patients with the antiphospholipid syndrome (APS). There is strong evidence that aPL Abs are pathogenic in vivo from studies in animal models. Furthermore, there are now convincing data indicating that activation of complement is involved in those processes. This report addresses current modalities of treatment, as well as recent findings with respect to molecular events triggered by aPL Abs on endothelial cells, platelets, monocytes and complement activation. A separate section addresses recent findings with regard to the putative receptor(s) recognized by aPL Abs on target cells. Based on experimental evidence using in vitro and in vivo models, new targeted therapies for treatment and/or prevention of thrombosis in APS are proposed and discussed.
Collapse
Affiliation(s)
- Silvia S Pierangeli
- Division of Rheumatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| |
Collapse
|
20
|
Abstract
Antiphospholipid (aPL) antibodies (Abs) are associated with thrombosis and pregnancy loss in antiphospholipid syndrome (APS), a disorder initially characterised in patients with systemic lupus erythematosus (SLE) but now known to occur in the absence of other autoimmune disease. There is strong evidence that aPL Abs are pathogenic in vivo, from studies of animal models of thrombosis, endothelial cell activation and pregnancy loss. In recent years, progress has been made in characterising the molecular basis of this pathogenicity, which includes direct effects on platelets, endothelial cells and monocytes as well as activation of complement. This review summarises the clinical manifestations of APS and current modalities of treatment, and explains recent advances in understanding the molecular events triggered by aPL Abs on target cells in coagulation pathways as well as effects of aPL Abs on complement activation. Based on this information and on additional scientific evidence using in vitro and in vivo models, new potential targeted therapies for treatment and/or prevention of thrombosis in APS are proposed and discussed.
Collapse
|
21
|
Toubi E, Shoenfeld Y. Livedo Reticularis as a Criterion for Antiphospholipid Syndrome. Clin Rev Allergy Immunol 2007; 32:138-44. [DOI: 10.1007/s12016-007-0004-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 01/13/2023]
|
22
|
Moyssakis I, Tektonidou MG, Vasilliou VA, Samarkos M, Votteas V, Moutsopoulos HM. Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution. Am J Med 2007; 120:636-42. [PMID: 17602939 DOI: 10.1016/j.amjmed.2007.01.024] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 12/21/2006] [Accepted: 01/12/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE We evaluated the prevalence and progression of Libman-Sacks endocarditis in patients with systemic lupus erythematosus and any association between this valvulopathy and their clinical and laboratory characteristics. METHODS Doppler echocardiography was performed in 342 consecutive patients with systemic lupus erythematosus (297 females and 45 males). The clinical and laboratory data were recorded. Patients were reevaluated after a follow-up period of 4 years. RESULTS Libman-Sacks endocarditis was found in 38 patients (11%). In 24 of 38 patients, mitral valve involvement was found, resulting in regurgitation in all (mild in 18, moderate in 4, and severe in 2), whereas stenosis co-occurred with regurgitation in 9 patients (mild in 6 and moderate in 3). Thirteen (34%) of 38 patients had aortic valve involvement; 11 had regurgitation (mild) and 8 had stenosis (mild), coexistent with regurgitation in 6 of them. One patient had mild tricuspid regurgitation. A significant association was found between Libman-Sacks endocarditis and disease duration and activity, thromboses, stroke, thrombocytopenia, anticardiolipin antibodies, and antiphospholipid syndrome. During the follow-up period, 252 of 342 patients were reevaluated echocardiographically. Among the 38 patients with Libman-Sacks vegetations, 5 with mild mitral regurgitation at the beginning developed moderate (n=4) and severe mitral regurgitation (n=1), 2 patients with mitral stenosis (mild in 1 and moderate in 1) developed severe mitral regurgitation, and 2 patients with mild aortic regurgitation developed moderate and severe mitral regurgitation, whereas a significant deterioration of aortic stenosis was found. Two patients who were candidates for surgery died. Among the 213 patients without vegetations at the beginning, 8 developed new Libman-Sacks lesions. CONCLUSIONS Libman-Sacks vegetations can be found in approximately 1 of 10 patients with systemic lupus erythematosus, and they are associated with lupus duration, disease activity, anticardiolipin antibodies, and antiphospholipid syndrome manifestations. A progression of valve lesions may occur during long-term follow-up.
Collapse
|
23
|
Einav E, Gitig A, Marinescu LM, Tanaka KE, Spevack DM. Valvulitis requiring triple valve surgery as an initial presentation of systemic lupus erythematosus. J Am Soc Echocardiogr 2007; 20:1315.e1-3. [PMID: 17600680 DOI: 10.1016/j.echo.2007.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Indexed: 11/24/2022]
Abstract
Cardiac involvement is common in systemic lupus erythematosus. Classically, the term "verrucous endocarditis" was used to describe the noninfective vegetations seen on pathological inspection of heart valves. The wide use of echocardiography has led to increased frequency of detection of valve abnormalities, most commonly leaflet thickening. The vast majority of patients with systemic lupus erythematosus and valvular involvement are asymptomatic, with only a small minority progressing to hemodynamically significant pathology, generally after long disease duration. We report a patient with systemic lupus erythematosus and associated antiphospholipid syndrome, whose first presentation of disease consisted of severe, symptomatic valvular regurgitation of the mitral, aortic, and tricuspid valves requiring triple valve surgery.
Collapse
Affiliation(s)
- Eldad Einav
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA
| | | | | | | | | |
Collapse
|
24
|
Pierangeli SS, Chen PP, González EB. Antiphospholipid antibodies and the antiphospholipid syndrome: an update on treatment and pathogenic mechanisms. Curr Opin Hematol 2007; 13:366-75. [PMID: 16888443 DOI: 10.1097/01.moh.0000239710.47921.d2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The antiphospholipid syndrome is a disorder of recurrent thrombosis, pregnancy loss and thrombocytopenia associated with the presence of antiphospholipid antibodies and persistently positive anticardiolipin or lupus anticoagulant positive tests. Since its recognition in the 1980s, growing interest in the field, not only with respect to diagnosis and treatment, but also regarding the pathogenesis of antiphospholipid antibodies, has emerged. RECENT FINDINGS First, this review addresses the recently updated classification criteria for diagnosis and treatment of the antiphospholipid syndrome. A discussion on the newly described potential beneficial roles of hydroxychloroquine and the statins for the treatment of antiphospholipid syndrome-associated clinical manifestations is included. Importantly, this article analyzes recent data that examine the molecular and intracellular events that antiphospholipid antibodies trigger in target cells, as well as new findings in the identification of the receptors for these antibodies on the membrane of those cells. A separate section discusses novel pathogenic mechanisms of antiphospholipid antibodies, including the activation of complement and their interaction with homologous catalytic domains of several serine proteases of the coagulation system. SUMMARY Understanding the molecular interactions and the intracellular signaling that antiphospholipid antibodies trigger, new therapeutic and targeted strategies to ameliorate clinical manifestations in patients with antiphospholipid syndrome may be established.
Collapse
Affiliation(s)
- Silvia S Pierangeli
- Department of Microbiology, Biochemistry and Immunology. Morehouse School of Medicine, Atlanta, GA 30310 1459, USA.
| | | | | |
Collapse
|
25
|
Schotte H, Becker H, Domschke W, Gaubitz M. [Cardiovascular monitoring of patients with systemic lupus erythematosus]. Z Rheumatol 2005; 64:564-75. [PMID: 16328762 DOI: 10.1007/s00393-005-0668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Accepted: 10/05/2004] [Indexed: 11/28/2022]
Abstract
Accelerated atherosclerotic cardiovascular disease is increasingly recognized as a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac manifestations of SLE are frequent and can involve almost all components of the heart. Pulmonary hypertension often develops during the course of SLE. The high incidence of cardiovascular complications may justify a screening of SLE patients in order to ensure early diagnosis and therapy. Results of diagnostic procedures that detect coronary insufficiency, surrogates of atherosclerotic burden and echocardiographic findings are often abnormal in SLE. However, evidence to support a routine screening for cardiovascular disease is currently not available. Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest assessment of risk factors and the performance of echocardiography at least annually in asymptomatic SLE patients. If two or more risk factors are present, an exercise ECG is recommended. The benefit, however, of screening SLE patients for cardiovascular disease has to be confirmed in prospective studies.
Collapse
Affiliation(s)
- H Schotte
- Medizinische Klinik und Poliklinik B, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
| | | | | | | |
Collapse
|
26
|
Turiel M, Sarzi-Puttini P, Peretti R, Bonizzato S, Muzzupappa S, Atzeni F, Rossi E, Doria A. Five-year follow-up by transesophageal echocardiographic studies in primary antiphospholipid syndrome. Am J Cardiol 2005; 96:574-9. [PMID: 16098314 DOI: 10.1016/j.amjcard.2005.04.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2004] [Revised: 04/06/2005] [Accepted: 04/05/2005] [Indexed: 10/25/2022]
Abstract
This prospective study describes valvular abnormalities assessed by transesophageal echocardiography (TEE) in patients with primary antiphospholipid syndrome (APLS) over a 5-year follow-up. Of the 56 patients with APLS evaluated at baseline, 47 (84%) had repeat TEE examinations, including 3 patients who died before the end of the follow-up. The first TEE study showed cardiac involvement (thickening or vegetations and embolic sources) in 34 subjects (61%), with mitral valve thickening, the most common abnormality, present in 30 patients (54%). Embolic sources were found in 14 patients (25%; 9 severe spontaneous echocardiographic contrast, 5 Libman-Sacks endocarditis), associated with mitral valve thickening or stenosis in 10 patients. Over the 5-year follow-up, cardiac involvement was unchanged in 30 subjects (64%). New cardiac abnormalities were observed in 17 patients (36%), 15 (88%) with high immunoglobulin-G (IgG) anticardiolipin antibody (aCL) titers and 2 (12%) with low IgG aCL titers. In conclusion, this study showed that mitral valve thickening and embolic sources are frequently observed in patients with APLS. Anticoagulant and/or antiplatelet treatment was ineffective in terms of valvular lesion regression. New appearances of cardiac involvement are significantly related to high IgG aCL titers.
Collapse
Affiliation(s)
- Maurizio Turiel
- Department of Cardiology, Istituto Ortopedico Galeazzi, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Letranchant L, Ruivard M, Dauphin C, Chanet V, Philippe P. [Non infectious endocarditis: retrospective study (6 cases)]. Rev Med Interne 2005; 26:189-95. [PMID: 15777581 DOI: 10.1016/j.revmed.2004.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 11/29/2004] [Indexed: 11/25/2022]
Abstract
PURPOSE If there is cardiac valve vegetation and the blood cultures are negatives we need to look for slow growing bacteria, fungi, Legionella pneumophilia, Bartonella henselae and quintana, Brucella melitensis and abortus, Coxiella burneti, Chlamydiae pneumoniae by serologic tests. The diagnosis of non- infectious endocarditis could be considered only if these results were negative. The main purpose of this study was to describe the clinical and echocardiographic signs of non-infectious endocarditis cases observed in two different wards. METHODS This study was done retrospectively during a five-year period in a cardiology and an internal medicine wards. The selection criteria are: the proof of at least one cardiac valve vegetation, observed on echocardiography, negative blood cultures and negative serologic tests as described above. RESULTS Six non-bacterial endocarditis were described. Four Libman-Sacks endocarditis, two associated with a primary antiphospholipid syndrome revealed by an acute ischemia of leg for one patient and by an eclampsia for another and the other two associated with a systemic lupus erythematous revealed by fever for one patient and by neurologic symptoms for the other. One fibroblastic endocarditis associated to an essential hypereosinophilia and one marastic endocarditis associated to a metastatic mucin-producing cancer. CONCLUSIONS For these six cases, a complete physical examination, a CBC for hypereosinophylia, a dosage of antiphospholipid antibodies and a thoraco-abdominal CT-scan allowed the etiologic diagnosis of non infectious endocarditis. Libman Sacks endocarditis associated with an antiphospholipid syndrome is the main etiology for which a long-term anticoagulation treatment was not followed.
Collapse
Affiliation(s)
- L Letranchant
- Service de médecine interne et hématologie, Hôtel-Dieu, CHU de Clermont-Ferrand, boulevard Malfrey, 63038 Clermont-Ferrand cedex 01, France.
| | | | | | | | | |
Collapse
|
28
|
Qaddoura F, Connolly H, Grogan M, Orszulak TA, Schaff HV, Chandrasekaran K, Click RL. Valve Morphology in Antiphospholipid Antibody Syndrome: Echocardiographic Features. Echocardiography 2005; 22:255-9. [PMID: 15725161 DOI: 10.1111/j.0742-2822.2005.04021.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Primary antiphospholipid antibody (PAP) syndrome can present with a variety of clinical manifestations including cardiac valvular lesions. Prior reports of the valvular lesions associated with PAP have been nonspecific. The purpose of this paper is to present four cases of patients with documented PAP and demonstrate the characteristic transesophageal echocardiographic features. The primary feature is focal, symmetrical, nodular thickening at the leaflet's coaptation points.
Collapse
|
29
|
Perez-Villa F, Font J, Azqueta M, Espinosa G, Pare C, Cervera R, Reverter JC, Ingelmo M, Sanz G. Severe valvular regurgitation and antiphospholipid antibodies in systemic lupus erythematosus: A prospective, long-term, followup study. ACTA ACUST UNITED AC 2005; 53:460-7. [PMID: 15934103 DOI: 10.1002/art.21162] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess whether the presence of antiphospholipid antibodies is related to the incidence and progression of severe valvular dysfunction and the need for valve replacement in patients with systemic lupus erythematosus (SLE). METHODS In this prospective, long-term followup study, the initial echocardiographic findings in a cohort of 61 consecutive SLE patients were compared with those of 40 matched controls. All patients were serially evaluated for 14 +/- 3 years and had a followup echocardiogram 8 +/- 3 years after the initial evaluation. Serial determinations of anticardiolipin antibodies and lupus anticoagulant were performed in all cases. RESULTS The number of SLE patients with valvular abnormalities increased from 39% to 73% between the initial and the followup echocardiography, but only 7 patients (12%) developed severe valvular regurgitation. Severe valvular regurgitation was significantly associated with the presence of high levels of IgG anticardiolipin antibodies (P = 0.001). The combined incidence of stroke, peripheral embolism, need for valve surgery, and death was 86% in patients with severe valvular regurgitation, compared with 25% in those without (P = 0.003). CONCLUSION In SLE patients, the presence of high levels of IgG anticardiolipin antibodies is associated with the development of severe valvular regurgitation and with a high incidence of thromboembolic events and the need for valvular surgery.
Collapse
|
30
|
Harris EN, Pierangeli SS. Primary, Secondary, Catastrophic Antiphospholipid Syndrome: is there a difference? Thromb Res 2004; 114:357-61. [PMID: 15507265 DOI: 10.1016/j.thromres.2004.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Revised: 08/02/2004] [Accepted: 08/04/2004] [Indexed: 11/21/2022]
Abstract
Following broad recognition of the disorder called Antiphospholipid Syndrome (APS), it has come to be subcategorized into Primary (PAPS), Secondary (SAPS), and Catastrophic Antiphospholipid Syndrome (CAPS). Primary utilized when there is no associated disorder, secondary with an associated autoimmune disorder such as systemic lupus erythematosus (SLE), and "catastrophic" when thrombosis occurs at multiple sites in a short space of time. Are these entities different? Such differences should be demonstrated in terms of their clinical presentation, disease course, pathogenesis, or management. If no differences exist, is there a basis for continued use of these terms? This manuscript will attempt to explore distinctions between subgroups of the APS and reasons for or against perpetuation of these classifications in the literature.
Collapse
Affiliation(s)
- E Nigel Harris
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310-1495, USA.
| | | |
Collapse
|
31
|
Abstract
Valvular involvement is the most encountered form of heart disease in systemic lupus erythematosus (SLE). Immunoglobulin and complement deposition in the valvular structure will subsequently lead to Libman-Sacks vegetations, valve thickening, and valve regurgitation. Valvular stenosis is rarely seen. Involvement of the mitral valve is most frequently encountered. Valve disease for most patients is mild and asymptomatic, but patients in whom severe mitral regurgitation develops will present with symptoms of congestive heart failure. A heart murmur will be heard in almost all patients with moderate or severe regurgitation. Transesophageal echocardiography is the most sensitive method to detect the valvular involvement. The valvular changes, the hemodynamic status, or the symptomatology have been shown to progress, remain stable, or sometimes improve. Severe regurgitation, infective endocarditis, and thromboembolic events (mostly stroke or transitory ischemic attacks) are complications of valvular involvement in SLE. In treatment of these patients, prophylaxis of infectious endocarditis, selective antiaggregant and anticoagulant medication, and valve replacement are currently offered. The role of corticosteroid treatment is still unclear in the outcome of SLE valvulopathy.
Collapse
Affiliation(s)
- Adrian Fluture
- Department of Medicine/Internal Medicine, New York Medical College/Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, USA
| | | | | |
Collapse
|
32
|
Evangelopoulos ME, Alevizaki M, Toumanidis S, Sotou D, Evangelopoulos CD, Koutras DA, Stamatelopoulos SF, Mavrikakis M. Mitral valve prolapse in systemic lupus erythematosus patients: clinical and immunological aspects. Lupus 2003; 12:308-11. [PMID: 12729055 DOI: 10.1191/0961203303lu314oa] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mitral valve prolapse (MVP) has been reported to be associated with systemic lupus erythematosus (SLE). The aim of the present study was to determine the prevalence of MVP in SLE patients, assess its clinical significance and examine the possible association of this entity with other autoimmune indices. Eighty-seven consecutive SLE patients attending the rheumatology clinic and 73 normal control subjects were examined by M-mode, two-dimensional color-Doppler echocardiography. Serum samples were examined for various organ and non-organ specific autoantibodies. MVP was detected in 19/87 patients with SLE and in four of the healthy controls(P = 0.0057). SLE patients with MVP were younger (33.6 +/- 12.4 years) than those without MVP (41. +/- 12.9, P = 0.04) and with shorter duration of the disease (P = 0.03). We found a statistically higher prevalence of anticardiolipin antibodies (aCL) in SLE patients with prolapse (11/19) compared with SLE patients without prolapse (15/68, P = 0.04). This association was independent of age. The aCL-lgG levels were significantly higher in SLE patients with MVP (32.37 +/- 43.26) compared with SLE patients without MVP (22.24 +/- 29.95, P = 0.04). Thyroid autoantibodies tended to be more common in S LE patients with MVP. Th e prevalence of MVP is increased in SLE patients. The presence of aCL and of organ-specific autoantibodies in SLE patients with MVP might indicate the autoimmune origin of MVP. The possibility that SLE patients with MVP may be predisposed to further autoimmune diseases should be considered.
Collapse
|
33
|
Bulckaen HG, Puisieux FL, Bulckaen ED, Di Pompeo C, Bouillanne OM, Watel AA, Fauchais ALM, De Groote P, Millaire A. Antiphospholipid antibodies and the risk of thromboembolic events in valvular heart disease. Mayo Clin Proc 2003; 78:294-8. [PMID: 12630582 DOI: 10.4065/78.3.294] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the role of antiphospholipid antibodies (aPLs) in subsequent thromboembolic events and mortality in a prospective follow-up of 89 patients with severe, nonspecific valvular heart disease. PATIENTS AND METHODS Between November 1, 1993, and March 31, 1994, 89 patients with valvular heart disease were assessed for the presence of anticardiolipin antibodies and lupus anticoagulant. The primary end point was thromboembolic events, and the secondary end points were cardiovascular mortality and overall mortality. RESULTS All patients were followed up for a mean of 59 months; 1 patient (without aPLs) was lost to follow-up. Nineteen patients had increased titers of aPLs. Thromboembolic events were significantly more frequent in the aPL-positive group than in the aPL-negative group (7/19 [37%] vs 8/70 [11%]; P=.01). Cardiovascular mortality tended to be higher in the aPL-positive group than in the aPL-negative group (3 [16%] vs 6 [9%]; P = .40). However, in multivariate Cox analysis, presence of aPLs was not an independent risk factor for thromboembolic events. CONCLUSION Our results suggest that patients with severe valvular heart disease and aPLs have an increased risk for developing thromboembolic events.
Collapse
Affiliation(s)
- Hélène G Bulckaen
- Service de Médecine Interne et Gériatrie, Hôpital Gériatrique les Bateliers, Centre Hospitalier Régional et Universitaire de Lille, 59037 Lille, France
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Ilarraza H, Márquez MF, Alcocer A, Bañales JL, Nava AH, Reyes PA. Anticardiolipin antibodies are not associated with rheumatic heart disease. Lupus 2002; 10:873-5. [PMID: 11787877 DOI: 10.1191/096120301701548526] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to examine the prevalence of anticardiolipin antibodies in rheumatic valve heart disease. Serum samples of 31 consecutive patients with rheumatic heart disease and documented valve involvement, as well as six patients with acute rheumatic fever were tested for IgG anticardiolipin antibodies by a validated ELISA. No anticardiolipin antibodies were found when a cut-off point set at mean +/- 5 s.d. was applied. We can conclude that anticardiolipin antibodies are not present in rheumatic heart disease patients and, as suggested by several observations, these antibodies do not appear to have a pathogenic role in this particular disease.
Collapse
Affiliation(s)
- H Ilarraza
- Department of Cardiology, Instituto Nacional de Cardiologiá Ignacio Chávez, México City, Mexico
| | | | | | | | | | | |
Collapse
|
35
|
Sander GE, Giles TD. Cardiovascular Complications of Collagen Vascular Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2002; 4:151-159. [PMID: 11858777 DOI: 10.1007/s11936-002-0035-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Collagen vascular diseases commonly affect the heart; cardiovascular events are the major cause of mortality in people with these diseases. A striking feature of the cardiac involvement in individuals with systemic lupus erythematosus (SLE) and rheumatoid arthritis is aggressive and accelerated atherosclerosis; women with SLE in the 35- to 44-year-old age group are more than 50 times more likely to suffer myocardial infarction than are matched controls. Traditional risk factors contribute to the accelerated atherosclerosis, but cannot explain the extent of risk. It is possible that the inflammatory process, which is similar to the inflammatory process in atherosclerosis, pays a critical pathophysiologic role. It is critically important to identify the presence of traditional cardiovascular risk factors (eg, tobacco usage, hypertension, hypercholesterolemia, diabetes, homocysteinemia), and to modify these to secondary prevention targets. Cardiac valvular disease is common in individuals with SLE and rheumatoid arthritis; its presence should be anticipated and subacute bacterial endocarditis prophylaxis precautions initiated. Cardiac autonomic neuropathy and conduction disturbances are common in people with heart disease related to systemic sclerosis and human leukocyte antigen B27; these patients should be monitored carefully for evidence of dysrhythmias.
Collapse
Affiliation(s)
- Gary E. Sander
- Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | | |
Collapse
|
36
|
Abstract
Systemic lupus erythematosus (SLE) is a connective tissue disease characterized by the formation of autoantibodies and immune complexes. The heart and lungs are among the organ systems commonly affected in SLE. Pericarditis, premature coronary atherosclerosis, pleuritis and pulmonary infections are the most prevalent cardiopulmonary manifestations. Other rare associations include myocarditis, coronary arteritis, acute lupus pneumonitis/pulmonary haemorrhage, acute reversible hypoxaemia and 'shrinking lung' syndrome. Current imaging modalities may provide earlier detection of subclinical disease, which may aid in preventing these potentially fatal complications. The response to treatment varies, depending on the presentation of disease. In this chapter we address the frequency, diagnosis and monitoring, and treatment regimens of cardiac and pulmonary involvement in patients with SLE.
Collapse
Affiliation(s)
- Amy H Kao
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, PA 15261, USA
| | | |
Collapse
|
37
|
Nagappan R, Lodge RS. Acute autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome. Anaesth Intensive Care 2002; 30:226-9. [PMID: 12002935 DOI: 10.1177/0310057x0203000219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.
Collapse
Affiliation(s)
- R Nagappan
- Intensive Care Unit, St Vincent's Hospital, Melbourne, Victoria
| | | |
Collapse
|
38
|
Omdal R, Lunde P, Rasmussen K, Mellgren SI, Husby G. Transesophageal and transthoracic echocardiography and Doppler-examinations in systemic lupus erythematosus. Scand J Rheumatol 2002; 30:275-81. [PMID: 11727842 DOI: 10.1080/030097401753180354] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To search for cardiac abnormalities in systemic lupus erythematosus (SLE). METHODS 35 patients examined by 2-D transthoracal Doppler and transesophageal echocardiography. RESULTS Mitral and aortic valve abnormalities were seen in 12 patients (34%) respectively, and occurred altogether in 16 patients (46%). They were in general significantly associated with longer disease duration, but not with anticardiolipin antibodies (aCL), disease activity, or any other variable, except for time on corticosteroids. which was significantly longer in patients with aortic valve calcifications. CONCLUSION Valve masses and valve thickening--often in combination--are the most frequent structural findings in SLE, occurring more often on the aortic than on the mitral valves. Factors other than antiphospholipid antibodies, medication, hypertension, or coronary heart disease seem to be responsible for this phenomenon. Drugs that modulate inflammation in endo- and pericardial tissue may, at least in part, be responsible for the observed mitral valve calcifications and pericardial fibrosis.
Collapse
Affiliation(s)
- R Omdal
- Institute of Clinical Medicine, University of Tromsø, Norway.
| | | | | | | | | |
Collapse
|
39
|
Turiel M, Muzzupappa S, Gottardi B, Crema C, Sarzi-Puttini P, Rossi E. Evaluation of cardiac abnormalities and embolic sources in primary antiphospholipid syndrome by transesophageal echocardiography. Lupus 2001; 9:406-12. [PMID: 10981643 DOI: 10.1191/096120300678828532] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Valvular lesions are frequently present in Primary Antiphospholipid Syndrome (PAPS) patients using transthoracic and/or transesophageal echocardiography. The aim of this study was to describe the prevalence of cardiac abnormalities (valvular thickening and/or regurgitation) or potential embolic sources (spontaneous echocontrast and/or vegetations) in PAPS patients. METHODS Multiplane transesophageal echocardiography was performed consecutively on 40 PAPS PATIENTS: 17 of them with thrombocytopenia, 27 with at least one thromboembolic event (stroke, transient ischaemic attack, arterial and/or venous thrombosis, pulmonary embolism) and 14 with recurrent fetal loss. DESIGN Cardiac involvement (cardiac abnormalities and/or embolic sources) was present in 33/40 (82%) of PAPS patients. According to aCL titer these lesions were revealed in 17/24 (71%) of patients with aCL < or = 40 GPL-U, while these lesions were present in 100% of patients with aCL > 40 GPL-U. Three patients presented mitral stenosis and 3 non-infective valve masses or vegetations. Embolic sources were found in 4/24 (17%) patients with aCL < or = 40 GPL-U, while they were observed in 6/16 (37%) of patients with titer of aCL > 40 GPL-U (chi2 = 10.03, P < 0.01). Regression analysis showed a positive correlation between mitral valve thickening and aCL antibodies titer (r = 0.5; P < 0.001). CONCLUSIONS Valvular lesions are commonly found in PAPS patients. Our data showed a significant correlation among aCL titer, mitral leaflets thickening and thromboembolic events.
Collapse
Affiliation(s)
- M Turiel
- Internal Medicine II, L. Sacco Hospital, University of Milan, Italy.
| | | | | | | | | | | |
Collapse
|
40
|
Tektonidou MG, Ioannidis JP, Moyssakis I, Boki KA, Vassiliou V, Vlachoyiannopoulos PG, Kyriakidis MK, Moutsopoulos HM. Right ventricular diastolic dysfunction in patients with anticardiolipin antibodies and antiphospholipid syndrome. Ann Rheum Dis 2001; 60:43-8. [PMID: 11114281 PMCID: PMC1753369 DOI: 10.1136/ard.60.1.43] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the prevalence of diastolic dysfunction in patients with anticardiolipin antibodies (aCL) and to examine whether the antiphospholipid syndrome (APS) is associated with diastolic dysfunction independently of valvular abnormalities and systolic dysfunction. METHODS Pulsed, continuous, colour Doppler echocardiography was performed in 179 subjects, of whom 15 were excluded from the analysis because of systolic dysfunction or severe valvular disease. The remaining 164 subjects included 29 patients with primary APS, 26 patients with secondary APS (APS in the presence of systemic lupus erythematosus (SLE)), and 30 patients with SLE and aCL but without APS; 43 patients with SLE without aCL and 36 normal volunteers served as control groups. RESULTS The groups compared differed significantly in all measures of right ventricular function. There was a gradation of increasing diastolic function impairment as manifested by prolonged deceleration time (DT) and isovolumic relaxation time (IVRT) across the groups of patients with SLE without aCL, SLE with aCL, secondary APS, and primary APS. Differences in left ventricular diastolic function measures were less prominent. In regression analysis, DT increased by 19.6 ms (p=0.002) in the presence of primary APS and by 20.1 ms (p=0.038) in the presence of pulmonary hypertension. The titre of IgG aCL was the strongest predictor of a prolonged IVRT. CONCLUSION Diastolic dysfunction, in particular of the right ventricle-that is, independent of valvular disease and systolic dysfunction, is a prominent feature of APS and may be related to the pathogenesis of the syndrome.
Collapse
Affiliation(s)
- M G Tektonidou
- Department of Pathophysiology, University of Athens, School of Medicine, Athens, Greece
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Shively BK. Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve. Cardiol Clin 2000; 18:711-29. [PMID: 11236162 DOI: 10.1016/s0733-8651(05)70176-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The most important role of TEE in aortic valve disease is in the diagnosis of endocarditis and its complications. Examination of the annulus and subvalvular region is essential in any patient with possible aortic valve endocarditis. Assessment of the severity of aortic stenosis is a useful application of TEE when other data are either inconsistent or unavailable. TEE can provide a diagnosis of the origin of acute severe aortic insufficiency; this information may play a critical role in surgical planning. The diagnosis of a variety of aortic valve diseases can be made when TEE is performed to find an embolic source or to rule out dissection. In the case of mass lesions, such as papillary fibroelastomas and Libman-Sacks vegetations, the results of TEE carry major therapeutic implications. TEE offers generally excellent quality images of the LVOT and images of the RVOT and pulmonic valve that are superior to transthoracic echocardiography. The major clinical usefulness of TEE stems from its ability to identify pulmonic valve mass lesions and the causes of left and right ventricular outflow obstruction. TEE is also an important adjunct in the surgical management of left ventricular outflow obstruction.
Collapse
Affiliation(s)
- B K Shively
- Adult Echocardiographic Laboratory, Division of Cardiology, Oregon Health Sciences University, Portland, Oregon, USA
| |
Collapse
|
42
|
Affiliation(s)
- E N Harris
- Office of the Dean, Morehouse School of Medicine, Atlanta, GA 30310-1495, USA.
| | | |
Collapse
|
43
|
Abstract
Many patients with systemic lupus erythematosus (SLE) develop cardiac manifestations during the course of their disease. Pericarditis is most commonly seen, with a reported prevalence of 60%. Myocardial involvement is present in only a minority of patients. In recent years, due to better noninvasive diagnostic techniques, valvular abnormalities can be demonstrated in an increasing number of patients. Depending on the technique used, valvulopathy can be demonstrated in up to 77% of SLE patients. Although most of the valvular lesions will be present without any symptoms, valve incompetence can result in congestive heart failure. Valvular lesions are associated with IgG anticardiolipin antibodies (aCL) and disease duration. We present a patient with SLE and secondary antiphospholipid syndrome (APS) who developed acute congestive heart failure due to pancarditis. Endocarditis, together with left ventricular dysfunction and pericardial effusion, were present. The endocarditis caused hemodynamically significant mitral valve insufficiency due to thickening of the mitral cusps. Just two weeks prior to the occurrence of congestive heart failure echocardiography had been normal. Treatment with high dose corticosteroids resulted in a gradual, almost complete recovery. Literature concerning cardiac manifestations in lupus is reviewed.
Collapse
Affiliation(s)
- M Bijl
- Department of Internal Medicine, University Hospital, Groningen, The Netherlands.
| | | | | |
Collapse
|
44
|
Whitelaw DA, Spangenberg JJ, Rickman R, Hugo FH, Roberts M. The association between the antiphospholipid antibody syndrome and neuropsychological impairment in SLE. Lupus 1999; 8:444-8. [PMID: 10483012 DOI: 10.1177/096120339900800606] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the relationship between neuropsychological impairment and antiphospholipid antibody syndrome (aPL syndrome) in patients with systemic lupus erythermatosus (SLE). PATIENTS Sixty-nine patients satisfying ACR criteria were studied. Sixteen patients with the aPL syndrome and 53 patients without the syndrome were subjected to eight neuropsychological tests, a physical examination and serological investigations. No patients with other pathology, known to cause acute or chronic impairment of neuropsychological function, were included. Sixty-five underwent MRI scans. RESULTS There were no significant differences in age, level of education, incidence of hypertension or disease activity in the two groups. Pearson's correlation coefficients revealed a significant negative correlation with duration of disease in six out of eight tests in the aPL positive group and one out of eight in the aPL negative group. This suggests that aPL syndrome may be involved in the psychological impairment in SLE patients. A larger cohort needs to be studied to confirm this observation.
Collapse
Affiliation(s)
- D A Whitelaw
- Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | | | | | | | | |
Collapse
|
45
|
Abstract
Systemic lupus erythematosus (SLE), a connective tissue disease characterized by the production of autoantibodies, can affect all organ systems. Cardiac involvement in patients with SLE has been described since the early 20th century. The manifestations are numerous and can involve all components of the heart, including the pericardium, conduction system, myocardium, valves, and coronary arteries. In recent years, echocardiography has yielded additional information about the heart in patients who have SLE with and without clinical cardiac involvement. Moreover, antiphospholipid antibodies have been linked to several cardiac manifestations in patients with SLE, including valvular abnormalities and possibly coronary artery disease. This updated, comprehensive review summarizes the new literature on SLE and the heart.
Collapse
Affiliation(s)
- K G Moder
- Division of Rheumatology and Internal Medicine, Mayo Clinic Rochester, MN 55905, USA
| | | | | |
Collapse
|
46
|
Miller CS, Egan RM, Falace DA, Rayens MK, Moore CR. Prevalence of infective endocarditis in patients with systemic lupus erythematosus. J Am Dent Assoc 1999; 130:387-92. [PMID: 10085662 DOI: 10.14219/jada.archive.1999.0209] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions. These lesions may place patients with SLE at risk of developing infective endocarditis, or IE. METHODS The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE. They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE. RESULTS Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed. Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made. CONCLUSIONS The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance. Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures. However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE. CLINICAL IMPLICATIONS Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown. Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.
Collapse
Affiliation(s)
- C S Miller
- Department of Oral Health Science, University of Kentucky College of Dentistry, Lexington 40536-0084, USA
| | | | | | | | | |
Collapse
|
47
|
Walz ET, Slivka AP, Tice FD, Gray PC, Orsinelli DA, Pearson AC. Noninfective mitral valve vegetations identified by transesophageal echocardiography as a cause of stroke. J Stroke Cerebrovasc Dis 1998; 7:310-4. [PMID: 17895106 DOI: 10.1016/s1052-3057(98)80048-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/20/1997] [Accepted: 03/12/1998] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is a useful procedure to evaluate selected stroke patients for cardiac sources of embolism. To date, noninfective valvular vegetations have not been described in large studies using transesophageal echocardiography to detect cardiac sources of embolism. We sought to investigate the frequency of noninfective valvular vegetations in patients with unexplained stroke referred for TEE and to determine the relationship of these vegetations to unrecognized thrombophilic disorders. METHODS We evaluated 641 consecutive patients referred for TEE as a result of unexplained stroke or transient ischemic attack for the presence of valvular vegetations. Of those with vegetations identified, serial blood cultures were obtained to evaluate for an infectious etiology. Patients also had serum testing for thrombophilic disorders and selected patients underwent cerebral angiography. RESULTS Thirteen patients (2%) who underwent TEE evaluation for unexplained stroke or transient ischemic attack were found to have noninfective valvular vegetations, all involving the mitral valve; none were identified by transthoracic echocardiography. Antiphospholipid antibodies were identified in 8 of these 13 patients (62%) and a protein C deficiency in 1 patient (8%). CONCLUSIONS Noninfective valvular vegetations are a potential cardiac source of embolism in patients with unexplained stroke that can be better identified using transesophageal echocardiography. A large percentage of these individuals have a previously unrecognized thrombophilic disorder.
Collapse
Affiliation(s)
- E T Walz
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | | | | | | | | | | |
Collapse
|
48
|
Abstract
The connective tissue diseases are immune-mediated inflammatory diseases that manifest predominantly with symptoms and signs of musculoskeletal and mucocutaneous inflammation. They frequently affect the heart valves, pericardium, and myocardium. In patients with AKS, the aortic root and conduction system are also frequently involved. Echocardiographic series in these patients have demonstrated that valvular disease is highly prevalent and associated with substantial morbidity and mortality (Table 1). The prevalence rates of clinically detected valvular disease, however, are either unknown or low. This discrepancy is related to lack of awareness, overshadowing of the cardiovascular manifestations by the inflammatory symptoms and signs of the musculoskeletal system, lack of systematic application of the history and cardiovascular physical examination, and high sensitivity of echocardiography for detecting subclinical abnormalities. Several valvular abnormalities have been identified as unique to a specific disease. Libman-Sacks vegetations, valve nodules, and subaortic bump are characteristic of SLE, RA, and AKS (see Table 1). The valvular complications and respective therapy are similar to those of other causes of valvular disease; however, the associated morbidity and mortality of these complications in these patients are high. The worse prognosis of valvular disease in these patients is related to the chronicity and debilitating nature of their illness, their high prevalence of multisystem disease, and immunosuppression. These factors underscore the importance of early recognition, prevention of complications, and proper clinical or echocardiographic follow-up. The distinctive echocardiographic characteristics of the valve abnormalities associated with the connective tissue diseases may allow their differentiation from other common valvulopathies, such as infective endocarditis, rheumatic valvular disease, and degenerative valvular disease (Table 2). Despite the clinical and prognostic implications of valvular disease associated with the connective tissue diseases, incomplete data are available about pathogenesis, relation to clinical features of the primary disease, evolution, and effect of steroid or cytotoxic therapy. Echocardiography, especially TEE, has the potential to redefine the prevalence rates and to characterize better the valve abnormalities associated with these conditions. Finally, future large cross-sectional and longitudinal studies using clinical and echocardiographic data may help to define better the presence, evolution, and therapy of the valvular disease associated with the connective tissue diseases.
Collapse
Affiliation(s)
- C A Roldan
- Echocardiography Laboratory, Veterans Affairs Medical Center, Albuquerque, New Mexico, USA
| |
Collapse
|
49
|
Nesher G, Ilany J, Rosenmann D, Abraham AS. Valvular dysfunction in antiphospholipid syndrome: prevalence, clinical features, and treatment. Semin Arthritis Rheum 1997; 27:27-35. [PMID: 9287387 DOI: 10.1016/s0049-0172(97)80034-0] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Valvular abnormalities develop in 36% and 35% of patients with primary antiphospholipid syndrome (PAPS) and with systemic lupus erythematosus (SLE) respectively, and in 48% of patients with SLE and antiphospholipid antibodies (aPL). Valvulopathy includes leaflet thickening, vegetations, regurgitation, and stenosis. A literature survey shows that significant morbidity from valvular dysfunction, mostly mitral regurgitation leading to congestive heart failure, occurs in 4% and 6% of SLE and PAPS patients, respectively. The pathogenesis of valvulopathy may involve interaction of aPL with antigens on the valve surface, resulting in valvulitis. Current therapy includes symptomatic measures and valve replacement. A novel approach for symptomatic antiphospholipid syndrome (APS) related valvulopathy involves treatment with systemic corticosteroid. We describe four such patients and their dramatic clinical and hemodynamic response to treatment with prednisone when symptomatic measures failed.
Collapse
Affiliation(s)
- G Nesher
- Internal Medicine-Rheumatology Service, Shaare-Zedek Medical Center, Jerusalem, Israel
| | | | | | | |
Collapse
|
50
|
|