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Bendstrup E, Lynn E, Troldborg A. Systemic Lupus Erythematosus-related Lung Disease. Semin Respir Crit Care Med 2024; 45:386-396. [PMID: 38547915 DOI: 10.1055/s-0044-1782653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Systemic Lupus Erythematosus (SLE) is a multifaceted, multisystem autoimmune disorder with diverse clinical expressions. While prevalence reports vary widely, pulmonary involvement accounts for significant morbidity and mortality in SLE. This comprehensive review explores the spectrum of pulmonary disease in SLE, including upper airway manifestations (e.g., laryngeal affection), lower airway conditions (e.g., bronchitis, bronchiolitis, bronchiectasis), parenchymal diseases (e.g., interstitial lung disease, acute lupus pneumonitis, diffuse alveolar hemorrhage), pleural diseases (e.g., serositis, shrinking lung syndrome), and vascular diseases (e.g., pulmonary arterial hypertension, pulmonary embolism, acute reversible hypoxemia syndrome). We discuss diagnostic modalities, treatment strategies, and prognosis for each pulmonary manifestation. With diagnostics remaining a challenge and with the absence of standardized treatment guidelines, we emphasize the need for evidence-based guidelines to optimize patient care and improve outcomes in this complex disease.
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Affiliation(s)
- Elisabeth Bendstrup
- Center for Rare Lung Disease, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Evelyn Lynn
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Anne Troldborg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Biomedicine, Aarhus University, Aarhus, Denmark
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2
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Di Bartolomeo S, Alunno A, Carubbi F. Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
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Affiliation(s)
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, 06123 Perugia, Italy;
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L’Aquila and Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, 67100 L’Aquila, Italy
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3
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Amarnani R, Yeoh SA, Denneny EK, Wincup C. Lupus and the Lungs: The Assessment and Management of Pulmonary Manifestations of Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 7:610257. [PMID: 33537331 PMCID: PMC7847931 DOI: 10.3389/fmed.2020.610257] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022] Open
Abstract
Pulmonary manifestations of systemic lupus erythematosus (SLE) are wide-ranging and debilitating in nature. Previous studies suggest that anywhere between 20 and 90% of patients with SLE will be troubled by some form of respiratory involvement throughout the course of their disease. This can include disorders of the lung parenchyma (such as interstitial lung disease and acute pneumonitis), pleura (resulting in pleurisy and pleural effusion), and pulmonary vasculature [including pulmonary arterial hypertension (PAH), pulmonary embolic disease, and pulmonary vasculitis], whilst shrinking lung syndrome is a rare complication of the disease. Furthermore, the risks of respiratory infection (which often mimic acute pulmonary manifestations of SLE) are increased by the immunosuppressive treatment that is routinely used in the management of lupus. Although these conditions commonly present with a combination of dyspnea, cough and chest pain, it is important to consider that some patients may be asymptomatic with the only suggestion of the respiratory disorder being found incidentally on thoracic imaging or pulmonary function tests. Treatment decisions are often based upon evidence from case reports or small cases series given the paucity of clinical trial data specifically focused on pulmonary manifestations of SLE. Many therapeutic options are often initiated based on studies in severe manifestations of SLE affecting other organ systems or from experience drawn from the use of these therapeutics in the pulmonary manifestations of other systemic autoimmune rheumatic diseases. In this review, we describe the key features of the pulmonary manifestations of SLE and approaches to investigation and management in clinical practice.
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Affiliation(s)
- Raj Amarnani
- Department of Rheumatology, University College London Hospital, London, United Kingdom
| | - Su-Ann Yeoh
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
| | - Emma K. Denneny
- Department of Respiratory Medicine, University College London Hospital, London, United Kingdom
- Leukocyte Trafficking Laboratory, Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, United Kingdom
| | - Chris Wincup
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
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4
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Management of Severe Refractory Systemic Lupus Erythematosus: Real-World Experience and Literature Review. Clin Rev Allergy Immunol 2020; 60:17-30. [PMID: 33159635 DOI: 10.1007/s12016-020-08817-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 12/11/2022]
Abstract
Systemic lupus erythematosus (SLE) is a highly heterogeneous disease affecting multiple organs and is characterized by an aberrant immune response. Although the mortality of SLE has decreased significantly since the application of glucocorticoids, severe or refractory SLE can potentially cause irreversible organ damage and contribute to the disease morbidity and mortality. Early recognition of severe SLE or life-threatening conditions is of great challenge to clinicians since the onset symptoms can be rapid and aggressive, involving the visceral organs of the neuropsychiatric, gastrointestinal, hematologic, renal, pulmonary, and cardiovascular systems, etc. Additionally, SLE patients with specific comorbidities and detrimental complications could lead to a clinical dilemma and contribute to poor prognosis. Prompt and adequate treatment for severe refractory SLE is crucial for a better prognosis. However, as evidence from well-designed randomized controlled trials is limited, this review aims to provide real-world evidence based on cohort studies from Peking Union Medical College Hospital, the national tertiary referral center in China, together with the literature, on clinical characteristics, risks and prognostic factors, and treatment strategies for severe and/or refractory SLE.
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5
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Severe Pulmonary Hypertension as Initial Presentation of SLE: A Case Report and Literature Review. Case Rep Rheumatol 2020; 2020:6014572. [PMID: 32509370 PMCID: PMC7245690 DOI: 10.1155/2020/6014572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/01/2020] [Indexed: 11/25/2022] Open
Abstract
Severe pulmonary artery hypertension (PAH) is a rare initial presentation of systemic lupus erythematosus (SLE). SLE associated with PAH carries worse prognosis that isolated SLE. However, there has been improvement in mortality of the patients in the recent years owing to newer treatment options available. Early recognition remains of prime importance. We present here a case of young female who presented with severe pulmonary hypertension with right heart failure leading to cardiogenic shock and was found to have SLE. She was started on appropriate treatment; however, given the severity of her illness, the patient did not survive. This case highlights the importance of early recognition and prompt treatment of SLE-associated PAH, which might improve the survival rate in the patients.
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Yang GL, Guo J, Pudasaini B, Yuan P, Gong SG, Wang L, Zhao QH, Yang WL, Jiang R, Zhou C, Liu JM. Value of heart rate recovery in female patients with pulmonary arterial hypertension due to systemic lupus erythematosus. CLINICAL RESPIRATORY JOURNAL 2019; 13:545-554. [PMID: 31295761 DOI: 10.1111/crj.13056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 05/19/2019] [Accepted: 07/01/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study intended to explore the relation between heart rate recovery at 1 minutes (HRR1) during the recovery phase of cardiopulmonary exercise test (CPET) and exercise capacity in female systemic lupus erythematosus associated pulmonary arterial hypertension (SLE-PAH) patients. METHODS Twenty-one female SLE-PAH patients underwent right heart catheterization (RHC), pulmonary function test (PFT) and CPET. Forty-two healthy subjects matched with SLE-PAH patients in age, sex and BMI were recruited as a control group. The correlations between HRR1 with clinical and CPET parameters were performed. RESULTS Peak HR, ΔHR, HRR1, Peak HR-warm HR1min , Peak HR-warm HR2min and CR were significantly lower in SLE-PAH than in controls (P < .01). Increased incidence of CRI was seen in SLE-PAH. Except for the Peak PET O2 , which was higher in controls, all other CPET parameters were lower in SLE-PAH. SLE-PAH patients with HRR1 ≥ 16 had longer 6MWD, lower NT-proBNP, better percent of predicted gas transfer index or diffusing capacity for carbon monoxide (DLco% pred) as well as better CO and CI. Peak HR, ΔHR, HRR1, Peak HR-warm HR1min , Peak HR-warm HR2min , CR, Peak Load, Peak VO2 , Peak PET CO2 , OUEP and OUES were lower and duration of exercise was shorter in patients with HRR1 < 16. HRR1 had positive correlation with 6MWD, DLco% pred, CO, CI and some key CPET parameters. CONCLUSIONS HRR1 is an easily obtained auxiliary parameter in SLE-PAH patients to reflect an altered autonomic tone. SLE-PAH patients with HRR1 < 16 have more severe hemodynamics, worse clinical findings and marked oxygen uptake inefficiency than those with HRR1 ≥ 16.
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Affiliation(s)
- Guo-Ling Yang
- Medical College, Soochow University, Suzhou, China.,Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Guo
- Medical College, Soochow University, Suzhou, China.,Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Lan Yang
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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7
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Zhang N, Li M, Qian J, Wang Q, Zhao J, Yang Z, Tian Z, Zhang X, Zuo X, Zhang M, Zhu P, Ye S, Zhang W, Zheng Y, Qi W, Li Y, Zhang Z, Ding F, Gu J, Liu Y, Wei W, Zeng X. Pulmonary arterial hypertension in systemic lupus erythematosus based on a CSTAR-PAH study: Baseline characteristics and risk factors. Int J Rheum Dis 2019; 22:921-928. [PMID: 30746850 DOI: 10.1111/1756-185x.13478] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/09/2018] [Accepted: 12/17/2018] [Indexed: 02/05/2023]
Abstract
AIM Pulmonary arterial hypertension (PAH) is a complex and devastating complication of systemic lupus erythematosus (SLE). We sought to describe the baseline characteristics of right heart catheterization (RHC)-confirmed SLE-associated PAH and identify risk factors for PAH in SLE patients. METHODS A multicenter, cross-sectional study was conducted using the Chinese SLE Treatment and Research group (CSTAR) registry. Baseline data for patients with SLE-associated PAH and SLE patients without PAH were collected and compared. Risk factors for PAH among patients with SLE were identified. RESULTS A total of 292 patients with SLE-associated PAH were enrolled. RHC was used to reveal hemodynamic features, including mean pulmonary arterial pressure (46.2 ± 12.0 mm Hg), pulmonary arterial wedge pressure (7.84 ± 3.92 mm Hg), pulmonary vascular resistance (10.86 ± 5.57 Wood units), and cardiac index (2.77 ± 0.91 L/min × m2 ). A multivariate logistic regression analysis showed that serositis (odds ratio [OR] = 5.524, 95% CI 3.605-8.465, P < 0.001), anti-ribonucleoprotein (RNP) antibody positivity (OR = 13.332, 95% CI 9.500-18.710, P < 0.001), and diffusion capacity of carbon monoxide in the lung (DLCO)/%Pred <70% (OR = 10.018, 95% CI 6.619-15.162, P < 0.001) were independent predictors of PAH. We recommend using transthoracic echocardiography (TTE) to perform early screening of SLE patients who have serositis, anti-RNP antibody positivity, or DLCO/%Pred <70%. RHC is suggested for patients suspected of having PAH. Once a diagnosis of SLE-PAH is confirmed, evaluation and treatment should immediately begin. CONCLUSION Overall, we recommend performing early screening using TTE in SLE patients with serositis, anti-RNP antibodies, or a DLCO/%Pred <70%, even for patients in a relatively stable condition according to SLE disease activity index.
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Affiliation(s)
- Na Zhang
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Junyan Qian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Zhang
- Department of Rheumatology, Guangdong General Hospital, Guangzhou, China
| | - Xiaoxia Zuo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Miaojia Zhang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ping Zhu
- Department of Clinical Immunology, PLA Specialized Research Institute of Rheumatology & Immunology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital South Campus, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Rheumatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Zheng
- Department of Rheumatology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wufang Qi
- Department of Rheumatology, The First Central Hospital, Tianjin, China
| | - Yang Li
- Department of Rheumatology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Feng Ding
- Department of Rheumatology, Qilu Hospital of Shandong University, Jinan, China
| | - Jieruo Gu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Wei
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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8
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Pulmonary Systemic Lupus Erythematosus Mimicking a Pneumonia in a Postpartum Female. Case Rep Rheumatol 2018; 2018:5379192. [PMID: 30140480 PMCID: PMC6081512 DOI: 10.1155/2018/5379192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/10/2018] [Indexed: 11/18/2022] Open
Abstract
The pulmonary manifestations of systemic lupus erythematosus can range in severity from mild to life threatening and can be particularly marked in women who are recently postpartum. We present below a seventeen-year-old female patient, one month postpartum, who had findings consistent with an acute infectious pneumonia whom upon further query and passage of time was diagnosed with severe pneumonitis due to systemic lupus erythematosus.
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9
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Kim JS, Kim D, Joo YB, Won S, Lee J, Shin J, Bae SC. Factors associated with development and mortality of pulmonary hypertension in systemic lupus erythematosus patients. Lupus 2018; 27:1769-1777. [DOI: 10.1177/0961203318788163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives This study aims to identify the factors associated with the development and mortality of pulmonary hypertension (PH) in systemic lupus erythematosus (SLE) patients. Methods We conducted a prospective study of SLE patients in a single tertiary center. PH was defined as a systolic pulmonary arterial pressure ≥30 mmHg on transthoracic echocardiography. We assessed potential associated factors contributing to the development and mortality of PH in SLE patients. Results Of 1110 patients with SLE, 48 patients were identified to have PH. Multivariable analysis indicated that pleuritis or pericarditis (odds ratio (OR) = 4.62), anti-RNP antibody (OR = 2.42), interstitial lung disease (ILD) (OR = 8.34) and cerebro-cardiovascular disease (OR = 13.37) were independently associated with the development of PH in SLE. Subgroup analysis among patients with PH demonstrated that there were no statistically significant factors associated with PH mortality in SLE. Conclusions The prevalence of PH was 4.3% in our cohort. There were significant associations with pleuritis or pericarditis, anti-RNP antibody, ILD, and cerebro-cardiovascular disease in SLE, which may contribute to the development of PH. However, there were no statistically significant factors associated with PH mortality in SLE.
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Affiliation(s)
- J S Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - D Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - Y B Joo
- Department of Rheumatology, St Vincent's Hospital, Catholic University of Korea, Suwon, Republic of Korea
| | - S Won
- Clinical Research Center for Rheumatoid Arthritis, Seoul, Republic of Korea
| | - J Lee
- Clinical Research Center for Rheumatoid Arthritis, Seoul, Republic of Korea
| | - J Shin
- Department of Cardiology, Hanyang University Hospital, Seoul, Republic of Korea
| | - S-C Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
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10
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Huang D, Cheng YY, Chan PH, Hai J, Yiu KH, Tse HF, Wong KL, Fan K, Li YW, Ng WL, Yim CW, Wong CHJ, Tam LS, Wong PCH, Wong CY, Ho CH, Leung AMH, Mok CC, Lam H, Lau CS, Cheung T, Ho C, Law SWY, Chan EW, Yin LX, Yue WS, Mok TM, Evora MA, Siu CW. Rationale and design of the screening of pulmonary hypertension in systemic lupus erythematosus (SOPHIE) study. ERJ Open Res 2018. [PMID: 29531959 PMCID: PMC5839606 DOI: 10.1183/23120541.00135-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Current guideline-recommended screening for pulmonary hypertension in patients with systemic sclerosis has not been evaluated in systemic lupus erythematosus (SLE), which is disproportionately prevalent in Asians. This multicentre, cross-sectional screening study aims to study the prevalence of pulmonary hypertension among SLE patients using these guidelines, and identify independent predictors and develop a prediction model for pulmonary hypertension in SLE patients. SLE patients from participating centres will undergo an echocardiography- and biomarker-based pulmonary hypertension screening procedure as in the DETECT study. Standard right heart catheterisation will be provided to patients with intermediate or high echocardiographic probability of pulmonary hypertension. Those with low echocardiographic probability will rescreen within 1 year. The primary measure will be the diagnosis and types of pulmonary hypertension and prevalence of pulmonary hypertension in SLE patients. The secondary measures will be the predictors and prediction models for pulmonary hypertension in SLE patients. The estimated sample size is approximately 895 participants. The results of the SOPHIE study will be an important contribution to the literature of SLE-related pulmonary hypertension and may be immediately translatable to real clinical practice. Ultimately, this study will provide the necessary evidence for establishing universal guidelines for screening of pulmonary hypertension in SLE patients.
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Affiliation(s)
- Duo Huang
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yang-Yang Cheng
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Pak-Hei Chan
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jojo Hai
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kai-Hang Yiu
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Hung-Fat Tse
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ka-Lam Wong
- Cardiac Medical Unit, The Grantham Hospital, Hong Kong SAR, China
| | - Katherine Fan
- Cardiac Medical Unit, The Grantham Hospital, Hong Kong SAR, China
| | - Ying Wah Li
- Division of Cardiology, Dept of Medicine, The United Christian Hospital, Hong Kong SAR, China
| | - Woon-Leung Ng
- Division of Rheumatology, Dept of Medicine, The United Christian Hospital, Hong Kong SAR, China
| | - Cheuk-Wan Yim
- Rheumatology Division, Dept of Medicine, Tseung Kwan O Hospital, Hong Kong SAR, China
| | - Cheuk-Hon John Wong
- Cardiology Division, Dept of Medicine, Tseung Kwan O Hospital, Hong Kong SAR, China
| | - Lai-Shan Tam
- Division of Rheumatology, Dept of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Priscilla C H Wong
- Division of Rheumatology, Dept of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi-Yuen Wong
- Division of Cardiology, Dept of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Chup-Hei Ho
- Division of Rheumatology, Dept of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Alexander M H Leung
- Division of Rheumatology, Dept of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Chi-Chiu Mok
- Rheumatology Division, Dept of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
| | - Ho Lam
- Cardiology Division, Dept of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
| | - Chak-Sing Lau
- Division of Rheumatology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Tommy Cheung
- Division of Rheumatology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carmen Ho
- Division of Rheumatology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Sharon W Y Law
- Centre for Safe Medication Practice and Research, Dept of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Dept of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Li-Xue Yin
- Dept of Echocardiography and Non-Invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Wen-Sheng Yue
- Affiliated Hospital of North Sichuan Medical College and Medical Imaging Key Laboratory, Nanchong, China
| | - Toi Meng Mok
- Dept of Cardiology, Centro Hospitalar Conde de São Januário, Macau SAR, China
| | - Mario Alberto Evora
- Dept of Cardiology, Centro Hospitalar Conde de São Januário, Macau SAR, China
| | - Chung-Wah Siu
- Division of Cardiology, Dept of Medicine, The University of Hong Kong, Hong Kong SAR, China
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11
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Xu SZ, Yan Liang, Li XP, Li XM, Shuai ZW, Leng RX, Pan HF, Ye DQ. Features associated with pulmonary arterial hypertension in Chinese hospitalized systemic lupus erythematosus patients. Clin Rheumatol 2018. [PMID: 29520672 DOI: 10.1007/s10067-018-4056-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Pulmonary arterial hypertension (PAH) is an increasingly recognized complication of systemic lupus erythematosus (SLE). This study aims to estimate the point prevalence of PAH and identify risk factors for PAH in a large cohort of hospitalized SLE patients. We have collected the medical records of patients hospitalized with SLE at the First Affiliated Hospital of Anhui Medical University and Anhui Provincial Hospital. Resting transthoracic echocardiography (TTE) was used to estimate pulmonary artery pressure (PAP) and PAH was defined as systolic PAP (PASP) > 30 mmHg. Patients with other connective tissue diseases, aPL syndrome, left heart disease, valvular heart disease, congenital heart disease, HIV, and portal hypertension were excluded because of diseases affecting the PAP. We assessed potential risk factors for PAH such as thrombogenic factors, SLE clinical manifestations, laboratory abnormalities and disease activity. Ninety-five were diagnosed with PAH of 1639 patients with SLE. The presence of high fibrinogen, serositis, and thrombocytopenia were significantly higher in patients with PAH than in those without PAH (all P < 0.05). Multivariate logistic regression found the associations between high fibrinogen (OR = 1.629), serositis (OR = 2.866), and thrombocytopenia (OR = 1.825) with PAH. The point prevalence of PAH was 5.8% in our cohort of patients with SLE. The significant association of high fibrinogen, serositis, and thrombocytopenia with PAH suggested that hypercoagulable state, organ damage, and hematological abnormality may all contribute to the development of PAH in SLE. This is important, as it is treatable.
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Affiliation(s)
- Shu-Zhen Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, Anhui, 230032, China
| | - Yan Liang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China
| | - Xiang-Pei Li
- Department of Rheumatology and Immunology, Anhui Provincial Hospital Affiliated to Anhui Medical University, 17 Lujiang Road, Hefei, Anhui, 230001, China
| | - Xiao-Mei Li
- Department of Rheumatology and Immunology, Anhui Provincial Hospital Affiliated to Anhui Medical University, 17 Lujiang Road, Hefei, Anhui, 230001, China
| | - Zong-Wen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui, 230022, China
| | - Rui-Xue Leng
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, Anhui, 230032, China
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, Anhui, 230032, China
| | - Dong-Qing Ye
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, People's Republic of China. .,Anhui Province Key Laboratory of Major Autoimmune Diseases, 81 Meishan Road, Hefei, Anhui, 230032, China.
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12
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Prevalence of pulmonary hypertension in systemic lupus erythematosus: a meta-analysis. Ir J Med Sci 2017; 187:723-730. [PMID: 29256037 DOI: 10.1007/s11845-017-1727-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 12/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Pulmonary hypertension (PH) has been suggested to be associated with systemic lupus erythematosus (SLE). However, the results of prevalence studies on PH in SLE vary substantially. To derive a more precise estimation on the prevalence of PH in SLE, a meta-analysis was performed. METHODS Relevant literatures were searched in PubMed and EMBASE until November 2017. A total of 1366 articles were obtained after searching databases, and 23 studies were finally included in the meta-analysis. Heterogeneity test was performed, and publication bias was evaluated. RESULTS The result of analysis in random effect model showed that the pooled prevalence was 8% (95%CI 5-12%). There was no evidence of publication bias (p = 0.51). To evaluate the stability of our results, sensitivity analyses were performed, and the results showed no significant change when any one study was excluded. Subgroup analyses demonstrated that there were significant differences in PH prevalence in SLE patients of different gender, age, regions, year of publication, and diagnostic methods. CONCLUSIONS PH is prevalent in SLE patients, but it was significantly different between different gender, age, regions, year of publication, and diagnostic methods.
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13
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Ghofraniha L, Mirfeizi Z, Khabbaz FS, Vakilian F, Eslami S. Correlation of echocardiographic findings of pulmonary hypertension with six-minute walk test and plasma pro b-type natriuretic peptide level in systemic lupus erythematous. Electron Physician 2017; 9:5122-5128. [PMID: 28979751 PMCID: PMC5614301 DOI: 10.19082/5122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 03/14/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Pulmonary arterial hypertension (PAH) is an increasingly recognized complication of systemic lupus erythematous (SLE), which may remain undiagnosed if asymptomatic. Objective This study aimed to determine the correlation between echocardiographic findings of PAH and six-minute walk test (6WMT) and serum pro b-type natriuretic peptide (proBNP) level in patients with SLE. Methods This cross-sectional study was performed on 50 SLE patients selected from patients referring to the outpatient’s department of the Rheumatology Clinic at Imam Reza Hospital in Mashhad, Iran, from July 2013 through September 2014, using resting transthoracic echocardiography to estimate systolic pulmonary artery pressure (sPAP). Variables were summarized as counts and/or percentages or as mean±SD. Inter-group comparisons were made performing two-tailed Fisher’s exact test or Mann–Whitney U test, using SPSS 22. Results In general, five out of fifty patients were diagnosed to have PAH with sPAP>30 mmHg (range: 31–40 mmHg) based on echocardiographic findings. Spirometric parameters did not show any differences between the two groups (p>0.05), while the difference in total distance walked during six minutes and serum proBNP level between SLE patients with and without PAH was significant (P<0.05). A high correlation was found between PAP and serum proBNP level, but not between PAP and the distance walked during six-minutes in SLE patients. Conclusion The point prevalence of PAH in SLE patients was 10%; the significant correlation between PAP and serum proBNP level suggests that it can be used as a valuable marker for early diagnosis of asymptomatic pulmonary hypertension in patients with SLE.
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Affiliation(s)
- Leila Ghofraniha
- Pulmonologist, Lung Disease Research Center, School of Medicine, Mashhad University of Medicine Sciences, Mashhad, Iran
| | - Zahra Mirfeizi
- MD, Associate Professor of Rheumatology, Rheumatic Diseases Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Seyyedi Khabbaz
- MD, Associate Professor of Rheumatology, Rheumatic Diseases Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farveh Vakilian
- Internist, Rheumatic Diseases Research Center, Preventive Atherosclerotic Research Center, Cardiology Department, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Eslami
- Internal Medicine, Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Medical Informatics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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14
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Dhakal BP, Kim CH, Al-Kindi SG, Oliveira GH. Heart failure in systemic lupus erythematosus. Trends Cardiovasc Med 2017; 28:187-197. [PMID: 28927572 DOI: 10.1016/j.tcm.2017.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 11/19/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by a constellation of cardiovascular (CV) and non-CV manifestations. Even though CV complications such as accelerated atherosclerosis and elevated risk of myocardial infarction (MI) have been recognized for many years, there is limited evidence regarding SLE and its association with heart failure (HF). Traditional risk factors of atherosclerotic CV disease, as well as various SLE manifestations and therapies, independently or together, increase the risk of HF in this population. There is a need for sufficiently powered intervention studies focusing on specific risk factors to improve CV outcomes in SLE patients.
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Affiliation(s)
- Bishnu P Dhakal
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Chang H Kim
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Sadeer G Al-Kindi
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Guilherme H Oliveira
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106.
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15
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Wang J, Qian J, Wang Y, Zhao J, Wang Q, Tian Z, Li M, Zeng X. Serological biomarkers as risk factors of SLE-associated pulmonary arterial hypertension: a systematic review and meta-analysis. Lupus 2017; 26:1390-1400. [PMID: 28409522 DOI: 10.1177/0961203317702255] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective This article aims to determine the serological biomarkers which can be considered as risk factors of systemic lupus erythematosus (SLE)-associated pulmonary arterial hypertension by a systematic review and meta-analysis. Methods This study was conducted in accordance with the PRISMA statement. The search database included MEDLINE, EMBASE, Cochrane Library and Scopus. The Newcastle-Ottawa scale was used for the quality assessment. The odds ratio was the primary measure of effect of the risk factors. Results Twelve studies were included in this meta-analysis. The results identified the anti-RNP antibody and anti-Sm antibody as risk factors for SLE-associated pulmonary arterial hypertension with the pooled odds ratios 3.68 (95% confidence interval 2.04-6.63, P < 0.0001) and 1.71 (95% confidence interval 1.06-2.76, P = 0.03), respectively. Conclusion Pulmonary arterial hypertension is a serious complication of SLE with a worse prognosis than SLE patients without pulmonary arterial hypertension. The early recognition of pulmonary arterial hypertension with transthoracic echocardiography routinely performed in SLE patients with risk factors is necessary, especially in Asian patients.
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Affiliation(s)
- J Wang
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - J Qian
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Y Wang
- 2 Department of Epidemiology and Biostatistics, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - J Zhao
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Q Wang
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Z Tian
- 3 Department of Cardiology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - M Li
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - X Zeng
- 1 Department of Rheumatology, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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16
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El-Garf AK, Gheith RE, Badran SN. Clinical pattern in Egyptian systemic lupus erythematosus patients with pleuropulmonary involvement. THE EGYPTIAN RHEUMATOLOGIST 2017. [DOI: 10.1016/j.ejr.2017.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Tselios K, Gladman DD, Urowitz MB. Systemic lupus erythematosus and pulmonary arterial hypertension: links, risks, and management strategies. Open Access Rheumatol 2016; 9:1-9. [PMID: 28053559 PMCID: PMC5191623 DOI: 10.2147/oarrr.s123549] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is characterized by the second highest prevalence of pulmonary arterial hypertension (PAH), after systemic sclerosis, among the connective tissue diseases. SLE-associated PAH is hemodynamically defined by increased mean pulmonary artery pressure at rest (≥25 mmHg) with normal pulmonary capillary wedge pressure (≤15 mmHg) and increased pulmonary vascular resistance. Estimated prevalence ranges from 0.5% to 17.5% depending on the diagnostic method used and the threshold of right ventricular systolic pressure in studies using transthoracic echocardiogram. Its pathogenesis is multifactorial with vasoconstriction, due to imbalance of vasoactive mediators, leading to hypoxia and impaired vascular remodeling, collagen deposition, and thrombosis of the pulmonary circulation. Multiple predictive factors have been recognized, such as Raynaud’s phenomenon, pleuritis, pericarditis, anti-ribonuclear protein, and antiphospholipid antibodies. Secure diagnosis is based on right heart catheterization, although transthoracic echocardiogram has been shown to be reliable for patient screening and follow-up. Data on treatment mostly come from uncontrolled observational studies and consist of immunosuppressive drugs, mainly corticosteroids and cyclophosphamide, as well as PAH-targeted approaches with endothelin receptor antagonists (bosentan), phosphodiesterase type 5 inhibitors (sildenafil), and vasodilators (epoprostenol). Prognosis is significantly affected, with 1- and 5-year survival estimated at 88% and 68%, respectively.
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Affiliation(s)
- Konstantinos Tselios
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
| | - Dafna D Gladman
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
| | - Murray B Urowitz
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
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18
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Gonzalez-Lopez L, Cardona-Muñoz EG, Celis A, García-de la Torre I, Orozco-Barocio G, Salazar-Paramo M, Garcia-Gonzalez C, Garcia-Gonzalez A, Sanchez-Ortiz A, Trujillo-Hernandez B, Gamez-Nava JI. Therapy with intermittent pulse cyclophosphamide for pulmonary hypertension associated with systemic lupus erythematosus. Lupus 2016; 13:105-12. [PMID: 14995003 DOI: 10.1191/0961203304lu509oa] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [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 compare the efficacy of intravenouscyclophosphamide(IVCYC) versus oral enalapril in mild or moderate pulmonary hypertension (PH) in systemic lupus erythematosus (SLE). Thirty-four patients with SLE who had systolic pulmonary artery pressure (SPAP) > 30mmHg by Doppler echocardiography were randomized to receive IVCYC (0.5g/mt2 body surface area, monthly), or oral enalapril (10mg/day) for six months. The primary outcome was the significant decrease in SPAP. An additional outcome measure included the improvement in the heart functional class (NYHA). Sixteen patients received cyclophosphamide and 18 enalapril. IVCYC decreased the median values of SPAP from 41 to 28mmHg (P < 0.001), and enalapril from 35 to 27mmHg (P 0.02). IVCYC reduced more than twice as much SPAP than enalapril (P 0.04). In those patients with SPAP ≥35mmHg, cyclophosphamidedecreased from 43 to 27mmHg (P 0.003), but enalapril was not effective (P 0.14). The NYHA functional class improved only in those with cyclophosphamide (P 0.021). Also IVCYC had a higher frequency of side effects including infections (RR 1.6; 95% CI, 1.001-2.47), and gastrointestinal side effects (RR 14.6; 95% CI,2.15-99.68). We concluded that IVCYC was effective in mild and moderate PH associated with SLE. Further research is needed to evaluate its long-term efficacy.
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Affiliation(s)
- L Gonzalez-Lopez
- Department of Internal Medicine-Rheumatology, Hospital General Regional 110-Instituto Mexicano del Seguro Social, Guadalajara, México.
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Kim KJ, Baek IW, Yoon CH, Kim WU, Cho CS. Association of Anemic Hypoxia and Increased Pulmonary Artery Systolic Pressure in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2016; 67:1702-11. [PMID: 26018410 DOI: 10.1002/acr.22630] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 04/20/2015] [Accepted: 05/19/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH) is a rare but serious complication of systemic lupus erythematosus (SLE). Chronic hypoxia is known to cause PAH resulting from pulmonary vascular remodeling. We investigated the association between anemic hypoxia and PAH in SLE patients. METHODS Systolic pulmonary artery pressure (PAP) was measured in 132 SLE patients by echocardiography. Increased PAP was defined as resting PAP > 40 mm Hg. Oxygen delivery (DO2) was estimated as the product of cardiac output and arterial oxygen content. RESULTS Of 132 patients, 17 (12.9%) had increased PAP, and these patients had significantly lower DO2 values than patients with normal PAP (P = 0.002). The DO2 values inversely correlated with PAP values (γ = -0.308, P < 0.001) and plasma N-terminal pro-brain natriuretic peptide levels (γ = -0.323, P = 0.001), but positively correlated with hemoglobin levels (γ = 0.402, P < 0.001). Compared to those with normal PAP, patients with increased PAP had significantly longer durations of anemia over the preceding 6-24 months. Patients with anemia of longer durations (≥3 months) in the preceding 6 months had a higher risk of increased PAP compared to those with shorter durations (P < 0.001). When SLE patients were divided into 3 groups according to hemoglobin and PAP, serum interleukin-6 (IL-6) levels increased across groups with higher PAP (P = 0.001 for trend), but decreased across tertiles of hemoglobin levels (P = 0.008 for trend). CONCLUSION Our data indicate an association between chronic anemic hypoxia and increased PAP in SLE patients and suggest that increased IL-6 might participate in this process.
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Affiliation(s)
- Ki-Jo Kim
- St. Vincent Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - In-Woon Baek
- Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chong-Hyeon Yoon
- Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Wan-Uk Kim
- Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul-Soo Cho
- Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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20
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Qian J, Wang Y, Huang C, Yang X, Zhao J, Wang Q, Tian Z, Li M, Zeng X. Survival and prognostic factors of systemic lupus erythematosus-associated pulmonary arterial hypertension: A PRISMA-compliant systematic review and meta-analysis. Autoimmun Rev 2016; 15:250-7. [DOI: 10.1016/j.autrev.2015.11.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/24/2015] [Indexed: 12/21/2022]
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21
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Electrocardiograms in a Woman With Systemic Lupus Erythematosus. Am J Cardiol 2016; 117:697-698. [PMID: 26718228 DOI: 10.1016/j.amjcard.2015.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 11/24/2022]
Abstract
A woman with systemic lupus erythematosus and a regular supraventricular tachycardia continues to have electrocardiographic abnormalities after the spontaneous return of normal sinus rhythm.
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22
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Olsson KM, Palazzini M. Challenges in pulmonary hypertension: managing the unexpected. Eur Respir Rev 2015; 24:674-81. [PMID: 26621981 PMCID: PMC9487621 DOI: 10.1183/16000617.0060-2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/12/2015] [Indexed: 12/01/2022] Open
Abstract
The diverse challenges associated with diagnosis and management of patients with pulmonary hypertension are illustrated in this case-based review. Case 1 describes a patient diagnosed with pulmonary arterial hypertension (PAH) with right heart failure and active systemic lupus erythematosus who was effectively treated with an up-front triple combination of PAH therapies and immunosuppressive therapy. In case 2, a diagnosis of pulmonary veno-occlusive disease was reached after a combined approach of clinical suspicion, physical examination, and invasive and noninvasive tests. Cautious PAH therapy and high-dose diuretics provided clinical benefit in this patient and served as a bridge to lung transplantation. These cases highlight the need for ongoing follow-up of patients with PAH, comprising frequent assessment of treatment success and continued diagnostic evaluation.
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Affiliation(s)
- Karen M Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Massimiliano Palazzini
- Dept of Specialised, Experimental, and Diagnostic Medicine, University of Bologna, Bologna, Italy
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Choi JH, Joo SJ, Kim J. Determining the necessity for right heart catheterization in pulmonary hypertension associated with connective tissue diseases assessed by echocardiography. Int J Rheum Dis 2015; 19:65-73. [PMID: 26820839 DOI: 10.1111/1756-185x.12769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The prognosis of pulmonary hypertension (PH) in systemic sclerosis (SSC) and in systemic lupus erythematosus (SLE) is different. According to the guidelines, right heart catheterization (RHC) is necessary in pulmonary arterial hypertension (PAH) associated with connective tissue diseases (CTD). However, there is little supporting evidence. Therefore, we attempted to determine the necessity for RHC and the causes of differences in prognosis of PH by comparing SSC to SLE. METHODS The inclusion criteria were all patients with SSC or SLE with exertional dyspnea. Echocardiography and carotid Doppler ultrasound were performed. RESULTS Twenty-three patients with SSC and 23 with SLE participated in this study. There was no difference in the right ventricular systolic pressure (RVSP) between SSC and SLE (33.0 mmHg, range 25.3-41.7 mmHg vs. 32.4 mmHg, range 27.0-37.7 mmHg; P = 0.835). In multiple linear regression analysis, the ratio of peak tricuspid regurgitant velocity to right ventricular outflow tract time-velocity integral, which represents pulmonary vascular resistance (PVR), was correlated with RVSP in SSC (r(2) = 0.928, β = 0.362, P = 0.003), and the independent predictor of increased RVSP was the ratio of early diastolic transmitral filling velocity to early diastolic septal mitral annular velocity, which represents diastolic dysfunction in SLE (R(2) = 0.806, β = 0.803, P = 0.023). CONCLUSIONS PVR was an important cause of PH in SSC. Left ventricular dysfunction was an important cause of PH in SLE. Thus, these findings demonstrate the necessity for RHC and differences in prognosis of PH in CTD.
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Affiliation(s)
- Joon Hyouk Choi
- Division of Cardiology, Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Seung-Jae Joo
- Division of Cardiology, Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Jinseok Kim
- Division of Rheumatology, Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
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Min HK, Lee JH, Jung SM, Lee J, Kang KY, Kwok SK, Ju JH, Park KS, Park SH. Pulmonary hypertension in systemic lupus erythematosus: an independent predictor of patient survival. Korean J Intern Med 2015; 30:232-41. [PMID: 25750566 PMCID: PMC4351331 DOI: 10.3904/kjim.2015.30.2.232] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 03/26/2014] [Accepted: 04/01/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We investigated whether transthoracic echocardiography-suspected pulmonary hypertension (PH) affects survival in systemic lupus erythematosus (SLE) patients and examined factors associated with PH occurrence and survival. METHODS This retrospective single-center study included 154 Korean SLE patients fulfilling the American College of Rheumatology criteria (January 1995 to June 2013). Student t test, Mann-Whitney U test, Kaplan-Meier curves, and log-rank tests were used for comparisons. RESULTS A total of 35 SLE patients with PH (SLE/PH+) and 119 without PH (SLE/PH-) were analyzed. Higher percentages of interstitial lung disease, Raynaud's phenomenon (RP), World Health Organization functional classification III/IV, and cardiomegaly were found in SLE/PH+ compared to SLE/PH-. Furthermore, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was significantly higher in SLE/PH+ (2.46 ± 1.245 vs. 1.00 ± 1.235), whereas survival rates were significantly higher in SLE/PH- in log-rank tests (p = 0.001). In multivariate analysis, the adjusted mortality hazard ratio (HR) for SLE/PH+ patients was 3.10. Subgroup analysis demonstrated a higher percentage of lupus nephritis in the SLE/PH+ patients who died (p = 0.039) and low complement-3 levels (p = 0.007). In univariate analysis, the mortality HR for SLE/PH+ patients with lupus nephritis was 4.62, whereas the presence of RP decreased the mortality risk in multivariate analysis; adjusted HR, 0.10. CONCLUSIONS PH is an independent factor predicting survival in SLE patients. The presence of lupus nephritis resulted in an increased trend for mortality, whereas coexistence of RP was associated with a better survival prognosis in SLE/PH+ patients.
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Affiliation(s)
- Hong Ki Min
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jennifer Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwi Young Kang
- Division of Rheumatology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung-Su Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Condliffe R, Howard LS. Connective tissue disease-associated pulmonary arterial hypertension. F1000PRIME REPORTS 2015; 7:06. [PMID: 25705389 PMCID: PMC4311276 DOI: 10.12703/p7-06] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although rare in its idiopathic form, pulmonary arterial hypertension (PAH) is not uncommon in association with various associated medical conditions, most notably connective tissue disease (CTD). In particular, it develops in approximately 10% of patients with systemic sclerosis and so these patients are increasingly screened to enable early detection. The response of patients with systemic sclerosis to PAH-specific therapy appears to be worse than in other forms of PAH. Survival in systemic sclerosis-associated PAH is inferior to that observed in idiopathic PAH. Potential reasons for this include differences in age, the nature of the underlying pulmonary vasculopathy and the ability of the right ventricle to cope with increased afterload between patients with systemic sclerosis-associated PAH and idiopathic PAH, while coexisting cardiac and pulmonary disease is common in systemic sclerosis-associated PAH. Other forms of connective tissue-associated PAH have been less well studied, however PAH associated with systemic lupus erythematosus (SLE) has a better prognosis than systemic sclerosis-associated PAH and likely responds to immunosuppression.
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26
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The lung in rheumatic disease. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Arterial stiffness, antiphospholipid antibodies, and pulmonary arterial hypertension in systemic lupus erythematosus. J Cardiol 2014; 64:450-5. [PMID: 24755203 DOI: 10.1016/j.jjcc.2014.02.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 02/03/2014] [Accepted: 02/20/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the role of arterial stiffness in pulmonary arterial hypertension (PAH) in systemic lupus erythematosus (SLE) patients and its relationship with antiphospholipid antibody (aPL). METHODS Measurement of brachial ankle pulse wave velocity (baPWV), carotid arterial stiffness, and pulmonary vascular resistance (PVR) was performed in 51 patients with SLE. PAH was diagnosed if the pulmonary artery systolic pressure was >40mmHg. Information concerning SLE duration, medication, and serum autoantibodies was recorded. SLE activity was assessed by the SLE disease activity index (SLEDAI). RESULTS aPL was present in 10 patients (20%), and PAH was detected in 6 patients (12%). The prevalence of Raynaud's phenomenon, baPWV, positive aPL, and titers of IgG anticardiolipin antibody (aCL) were increased in SLE with PAH; however, no difference was found in inflammatory markers, disease duration, and SLEDAI compared to SLE without PAH. Carotid artery deformation and right ventricular function were reduced in patients with PAH (all p<0.05). Carotid artery circumferential strain (r=0.34, p=0.021), radial strain (r=-0.30, p=0.045), and baPWV (r=0.46, p=0.001) showed significant correlation between IgG aCL. Univariate and multiple regression analysis revealed that the only significant independent predictors of the presence of PAH were baPWV, carotid artery stiffness, and IgG aCL. CONCLUSION Arterial stiffness might contribute to the pathogenesis of PAH related to SLE as well as aPLs. Furthermore, the significant association of aPL with arterial stiffness suggests its important role in PAH with SLE.
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Li M, Wang Q, Zhao J, Li Z, Ye Z, Li C, Li X, Zhu P, Wang Z, Zheng Y, Li X, Zhang M, Tian Z, Liu Y, He J, Zhang F, Zhao Y, Zeng X. Chinese SLE Treatment and Research group (CSTAR) registry: II. Prevalence and risk factors of pulmonary arterial hypertension in Chinese patients with systemic lupus erythematosus. Lupus 2014; 23:1085-91. [PMID: 24651670 DOI: 10.1177/0961203314527366] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To estimate the prevalence of pulmonary arterial hypertension (PAH) and risk factors for PAH in patients registered in the Chinese SLE Treatment and Research group (CSTAR) database, the first online registry of Chinese patients with systemic lupus erythematosus (SLE). Methods A prospective cross-sectional study of patients with SLE was conducted using the CSTAR registry. Resting transthoracic echocardiography was used to estimate pulmonary artery pressure (PAP); PAH was defined as systolic PAP (PASP) ≥40 mmHg. Patients with interstitial lung disease, valvular disease or cardiomyopathy were excluded because of disease influence on PAP. We explored potential risk factors for PAH including patient characteristics, organ involvement, laboratory findings and SLE disease activity. Results Of 1934 patients with SLE, 74 had PASP with 54.2 ± 17.1 (40,106) mmHg and were diagnosed with probable PAH. The incidences of lupus nephritis, pleuritis, pericarditis, hypocomplementemia, anti-SSA, and anti-ribonucleoprotein (RNP) were significantly higher in patients with PAH than in those without ( p<0.05). SLE disease activity was significantly higher in patients with PAH than in unaffected patients ( p<0.05). Multivariate analysis indicated that pericarditis (odds ratio (OR) = 4.248), pleuritis (OR = 3.061) and anti-RNP (OR = 2.559) were independent risk factors for PAH in patients with SLE ( p<0.05). Conclusions The possible prevalence of PAH was 3.8% in Chinese patients with SLE in the CSTAR registry. The significant association of pericarditis, pleuritis and anti-RNP positivity with PAH suggests that higher disease activity and vasculopathy may both contribute to the development of PAH in SLE, which need be treated aggressively to improve prognosis.
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Affiliation(s)
- M Li
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Q Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - J Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Z Li
- Department of Rheumatology, the Affiliated Hospital of Bengbu Medical College, China
| | - Z Ye
- Department of Rheumatology, the Fourth People's Hospital of Shenzhen Affiliated to Guangdong Medical College, China
| | - C Li
- Department of Rheumatology, Beijing Children Hospital Affiliated to Capital Medical University, China
| | - X Li
- Department of Rheumatology, the Second Hospital of Shanxi Medical University, China
| | - P Zhu
- Department of Clinical Immunology and Rheumatology, Xijing Hospital affiliated to the Fourth Military Medical University, China
| | - Z Wang
- Department of Rheumatology, Beijing Tongren Hospital affiliated to Capital Medical University, China
| | - Y Zheng
- Department of Rheumatology, Beijing Chao-Yang Hospital affiliated to Capital Medical University, China
| | - X Li
- Department of Rheumatology, Anhui Provincial Hospital, China
| | - M Zhang
- Department of Rheumatology, Jiangsu Provincial People's Hospital, China
| | - Z Tian
- Department of Cardiology, Peking Union Medical College Hospital, China
| | - Y Liu
- Department of Cardiology, Peking Union Medical College Hospital, China
| | - J He
- Pulmonary Vascular Center, Fu Wai Cardiovascular Hospital, China
| | - F Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Y Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
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Hübbe-Tena C, Gallegos-Nava S, Márquez-Velasco R, Castillo-Martínez D, Vargas-Barrón J, Sandoval J, Amezcua-Guerra LM. Pulmonary hypertension in systemic lupus erythematosus: echocardiography-based definitions predict 6-year survival. Rheumatology (Oxford) 2014; 53:1256-63. [PMID: 24599923 DOI: 10.1093/rheumatology/keu012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate whether a core of echocardiography-based definitions of pulmonary hypertension (PH), as proposed by the European Society of Cardiology, European Respiratory Society and International Society of Heart and Lung Transplantation (ESC/ERS/ISHLT), may predict long-term survival in patients with SLE. METHODS A post hoc analysis from a cohort of SLE patients followed over 6 years was performed. Clinical associations, serum biomarkers, autoantibody profile, length of survival and all-cause mortality were assessed. RESULTS Out of 115 patients from the original cohort, 55 satisfied our inclusion criteria and were grouped according to echocardiography as unlikely (n = 26), possible (n = 16) or likely (n = 13) to have PH. Likely PH was associated with a history of pulmonary thromboembolism, higher cumulated organ damage and active arthritis. The 6-year survival rate was 88% in the unlikely PH group, 87% in the possible PH group and 68% in the likely PH group (P < 0.05). Serum levels of endothelin-1, monocyte chemotactic protein-1, IL-17, and IFN-γ as well as a number of autoantibodies were no different between groups. CONCLUSION The ESC/ERS/ISHLT echocardiography-based definitions of PH are useful to predict 6-year mortality in SLE patients. A history of pulmonary thromboembolism and lung vasculitis/haemorrhage, cumulated organ damage and long-lasting disease are associated with PH in SLE.
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Affiliation(s)
- Claudia Hübbe-Tena
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Selma Gallegos-Nava
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Ricardo Márquez-Velasco
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Diana Castillo-Martínez
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Jesus Vargas-Barrón
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Julio Sandoval
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Luis M Amezcua-Guerra
- Department of Rheumatology, Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Department of Dermatology, Hospital General de Zona 1-A Dr Rodolfo Antonio de Mucha Macías, Instituto Mexicano del Seguro Social, Division of Research, Department of Echocardiography and Cardio Respiratory Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
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Gladue H, Altorok N, Townsend W, McLaughlin V, Khanna D. Screening and diagnostic modalities for connective tissue disease-associated pulmonary arterial hypertension: a systematic review. Semin Arthritis Rheum 2014; 43:536-41. [PMID: 24012044 PMCID: PMC3882308 DOI: 10.1016/j.semarthrit.2013.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/04/2013] [Accepted: 08/05/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH) is a frequent complication in connective tissue diseases (CTD), especially in systemic sclerosis (SSc), and is associated with a high degree of morbidity and mortality. We undertook a systematic review for the screening tests for CTD-PAH. METHODS A systematic literature search of PAH in CTD was performed in available databases through June 2012. Our evaluation of diagnostic tests was focused on patients with PAH confirmed by right heart catheterization (RHC). RESULTS The search resulted in 2805 titles and 838 abstracts. Our final inclusion encompassed 22 articles-six of which were case-control studies and 16 were cohort studies. Twelve studies assessed the tricuspid regurgitation velocity (VTR) or equivalent right ventricular systolic pressure (RVSP) using transthoracic echocardiogram (TTE) as a threshold for RHC in patients suspected as having PAH. The screening threshold for RHC was VTR from >2.73 to >3.16 m/s without symptoms or 2.5-3.0m/s with symptoms and resulted in 20-67% of patients having RHC-proven PAH. Three studies looked at pulmonary function tests and found that a low lung diffusing capacity for carbon monoxide (DLCO) (45-70% of predicted) is associated with a 5.6-7.4% development of PAH, and a decline in DLCO% is associated with an increase in the specificity (for DLCO ≤ 60%, spec = 45%; and for DLCO ≤ 50%, spec = 90%) for PAH. Five studies assessed N-terminal prohormone of brain natriuretic peptide (NT-ProBNP), where a cutoff >239 pg/ml had a sensitivity of 90-100%. CONCLUSIONS Our systematic review revealed that most evidence exists for TTE, pulmonary function tests, and NT-ProBNP for screening and diagnosis of SSc-PAH; however, more robust studies are needed.
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Affiliation(s)
- Heather Gladue
- Department of Rheumatology, University of Michigan, Ann Arbor, MI
| | - Nezam Altorok
- Department of Rheumatology, University of Michigan, Ann Arbor, MI
| | - Whitney Townsend
- Taubman Health Sciences, University of Michigan Library, Ann Arbor, MI
| | | | - Dinesh Khanna
- Department of Rheumatology, University of Michigan, Ann Arbor, MI.
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Kim KJ, Baek IW, Park YJ, Yoon CH, Kim WU, Cho CS. High levels of uric acid in systemic lupus erythematosus is associated with pulmonary hypertension. Int J Rheum Dis 2014; 18:524-32. [DOI: 10.1111/1756-185x.12262] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ki-Jo Kim
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - In-Woon Baek
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Yune-Jung Park
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Chong-Hyeon Yoon
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Wan-Uk Kim
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Chul-Soo Cho
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
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Abstract
Pulmonary hypertension (PH) can occur at any time during the course of systemic lupus erythematosus (SLE), and can be independent of lupus disease activity in other systems. The pathogenesis of PH in SLE can be multifactorial, but pulmonary arterial hypertension (PAH) is the commonest cause of PH in SLE. The international PH registries have published that approximately 15% of connective tissue disease-associated PH is lupus related in their cohorts. As the symptoms of PH in SLE can be mild and non-specific in early stages, an increasing awareness of this devastating complication is essential for early diagnosis. Echocardiographic evaluation of several right heart variables in addition to systolic pulmonary artery pressure estimation reduces false positive rates for PH detection. Antiphospholipid antibodies may predict SLE-PAH. Prompt treatment of PAH with newer PAH therapy as well as immunosuppression can reduce morbidity and prolong survival. The survival in SLE-associated PAH is better compared with systemic sclerosis-associated PH but worse than idiopathic PAH. Pregnancy in SLE-PAH can result in a fatal outcome, especially in severe and poorly controlled PH at onset.
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Affiliation(s)
- A Prabu
- Department of Rheumatology, School of Immunity and Infection, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - C Gordon
- Department of Rheumatology, School of Immunity and Infection, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Shahane A. Pulmonary hypertension in rheumatic diseases: epidemiology and pathogenesis. Rheumatol Int 2013; 33:1655-67. [PMID: 23334373 DOI: 10.1007/s00296-012-2659-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 12/28/2012] [Indexed: 11/26/2022]
Abstract
The focus of this review is to increase awareness of pulmonary arterial hypertension (PAH) in patients with rheumatic diseases. Epidemiology and pathogenesis of PAH in rheumatic diseases is reviewed, with recommendations for early screening and diagnosis and suggestion of possible role of immunosuppressive therapy in treatment for PAH in rheumatic diseases. A MEDLINE search for articles published between January 1970 and June 2012 was conducted using the following keywords: pulmonary hypertension, scleroderma, systemic sclerosis, pulmonary arterial hypertension, connective tissues disease, systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis, Sjogren's syndrome, vasculitis, sarcoidosis, inflammatory myopathies, dermatomyositis, ankylosing spondylitis, spondyloarthropathies, diagnosis and treatment. Pathogenesis and disease burden of PAH in rheumatic diseases was highlighted, with emphasis on early consideration and workup of PAH. Screening recommendations and treatment were touched upon. PAH is most commonly seen in systemic sclerosis and may be seen in isolation or in association with interstitial lung disease. Several pathophysiologic processes have been identified including an obliterative vasculopathy, veno-occlusive disease, formation of microthrombi and pulmonary fibrosis. PAH in systemic lupus erythematosus is associated with higher prevalence of antiphospholipid and anticardiolipin antibodies and the presence of Raynaud's phenomenon. Endothelial proliferation with vascular remodeling, abnormal coagulation with thrombus formation and immune-mediated vasculopathy are the postulated mechanisms. Improvement with immunosuppressive medications has been reported. Pulmonary fibrosis, extrinsic compression of pulmonary arteries and granulomatous vasculitis have been reported in patients with sarcoidosis. Intimal and medial hyperplasia with luminal narrowing has been observed in Sjogren's syndrome, mixed connective tissue disease and inflammatory myopathies. Pulmonary arterial hypertension (PAH) associated with rheumatic diseases carries a particularly grim prognosis with faster progression of disease and poor response to therapy. Though largely associated with systemic sclerosis, it is being increasingly recognized in other rheumatic diseases. An underlying inflammatory component may explain the poor response to therapy in patients with rheumatic diseases and is a rationale for consideration of immunosuppressive therapy in conjunction with vasodilator therapy in treatment for PAH. Further studies identifying pathogenetic pathways and possible targets of therapy, especially the role of immunomodulatory medications, are warranted.
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Affiliation(s)
- Anupama Shahane
- Division of Rheumatology, University of Pennsylvania, 8 Penn Tower, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Xia YK, Tu SH, Hu YH, Wang Y, Chen Z, Day HT, Ross K. Pulmonary hypertension in systemic lupus erythematosus: a systematic review and analysis of 642 cases in Chinese population. Rheumatol Int 2012; 33:1211-7. [PMID: 22983159 PMCID: PMC3632720 DOI: 10.1007/s00296-012-2525-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 08/23/2012] [Indexed: 02/04/2023]
Abstract
Pulmonary hypertension (PH) is an increasingly recognized complication of systemic lupus erythematosus (SLE). To develop a more comprehensive understanding of the clinical and pathological characteristics of pulmonary hypertension associated with systemic lupus erythematosus (PH/SLE) in the Chinese population, a systematic review of the literature up to 2012 was conducted. Six hundred and forty-two Chinese PH/SLE cases from 22 studies were identified as well documented and further analyzed. Transthoracic echocardiography (TTE), X-ray, electrocardiogram and right heart catheterization (RHC) were performed to diagnose PH in SLE patients. The mean age of subjects was 35.5 years, the male to female ratio was 1:14, and the mean duration of SLE when PH was diagnosed was 10.7 years. The prevalence of PH in SLE was 2.8–23.3 %. Symptoms were usually nonspecific, and the observed clinical characteristics include Raynaud’s phenomenon (41.4 %), serous effusion (27.7 %), positive RNP (51.5 %) and positive ACL (46.6 %). Gold standard RHC is strongly recommended, especially for those who had resting pulmonary arterial systolic pressure >30 mmHg on TTE with the aforementioned clinical characteristics. Corticosteroids, immunosuppressants and vasodilators were the most common medications employed in treatment. Early identification and standard PH treatment with intensive SLE treatment can improve the prognosis.
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Affiliation(s)
- Y K Xia
- Department of Integrated Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Central-China (Huazhong) University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, Hubei, People's Republic of China
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Pulmonary hypertension in systemic lupus erythematosus: prevalence, predictors and diagnostic strategy. Autoimmun Rev 2012; 12:410-5. [PMID: 22841984 DOI: 10.1016/j.autrev.2012.07.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/18/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To investigate the prevalence and predictors of pulmonary hypertension (PH) in patients with systemic lupus erythematosus (SLE) and to validate a diagnostic strategy. METHODS 245 patients with SLE entered a screening program. Possible PH was defined as two consecutive systolic pulmonary arterial pressure (PAP) values ≥ 40mmHg by echocardiography. The subsequent diagnostic procedure, including right heart catheterization if needed, confirmed or excluded the diagnosis of PH secondary to cardiopulmonary disease or SLE-related pulmonary arterial hypertension (PAH). Independent predictors of PH were identified by multivariant multiple linear or logistic regression models. The sensitivity (S), specificity (SP), positive (PPV) and negative predictive values (NPV) were calculated for different screening cutoff values. RESULTS 88% patients were women. The mean (SD) age at the time of enrolment was 45 (16) years. 12 cases of PH were detected, all secondary, with a resulting prevalence of 5%. Two consecutive echocardiographic PAP measurements ≥ 40mmHg performed best as the cutoff point for screening (S 100%, SP 97%, PPV 70, NPV 100), as compared with single PAP measurements ≥ 30mmHg or ≥ 40mmHg The age at the time of enrolment was the only variable independently associated with PAP values (p=0.0001), with the SLICC damage index score showing a borderline association (p=0.08). Only the age at the time of enrolment showed an independent association with PH (OR 1.10, 95% CI 1.06-1.17). CONCLUSION We found a low prevalence of PH. Screening echocardiograms in asymptomatic lupus patients are thus not recommended. Two consecutive PAP values ≥ 40mmHg by echocardiogram is the best screening cutoff for starting investigations in SLE patients with suspected PH.
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Pulmonary arterial hypertension in systemic lupus erythematosus: current status and future direction. Clin Dev Immunol 2012; 2012:854941. [PMID: 22489252 PMCID: PMC3318206 DOI: 10.1155/2012/854941] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 01/02/2012] [Indexed: 12/18/2022]
Abstract
Pulmonary arterial hypertension (PAH) is commonly associated with connective tissue diseases (CTDs) including systemic sclerosis and systemic lupus erythematosus (SLE). The prevalence of PAH in SLE is estimated to be 0.5% to 17.5%. The pathophysiology of PAH involves multiple mechanisms from vasculitis and in-situ thrombosis to interstitial pulmonary fibrosis which increases pulmonary vascular resistance, potentially leading to right heart failure. Immune and inflammatory mechanisms may play a significant role in the pathogenesis or progression of PAH in patients with CTDs, establishing a role for anti-inflammatory and immunosuppressive therapies. The leading predictors of PAH in SLE are Raynaud phenomenon, anti-U1RNP antibody, and anticardiolipin antibody positivity. The first-line of diagnostic testing for patients with suspected SLE-associated PAH (SLE-aPAH) involves obtaining a Doppler echocardiogram. Once the diagnosis is confirmed by right heart catheterization, SLE-aPAH patients are generally treated with oxygen, anticoagulants, and vasodilators. Although the prognosis and therapeutic responsiveness of these patients have improved with the addition of intensive immunosuppressive therapies, these treatments are still largely unproven. Recent data put the one-year survival rate for SLE-aPAH patients at 94%. Pregnant women are most at risk of dying due to undiagnosed SLE-aPAH, and screening should be considered essential in this population.
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Cinquetti G, Sordet C, Chatelus E, Ronde-Oustau C, Javier RM, Gottenberg JE, Sibilia J. Pulmonary arterial hypertension during systemic lupus. Joint Bone Spine 2012; 79:205-6. [DOI: 10.1016/j.jbspin.2011.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2011] [Indexed: 11/15/2022]
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Chow SL, Chandran V, Fazelzad R, Johnson SR. Prognostic factors for survival in systemic lupus erythematosus associated pulmonary hypertension. Lupus 2011; 21:353-64. [DOI: 10.1177/0961203311429815] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Pulmonary hypertension (PH) is a rare but severe manifestation of systemic lupus erythematosus (SLE) that can ultimately result in death. The identification of factors that prognosticate survival in SLE-PH is necessary for appropriate monitoring, timing of therapeutics and lung transplantation. The primary objective of this study was to identify prognostic factors for survival in SLE-PH through review of the literature. The methodological quality of the prognostic studies was also evaluated .Methods: A systematic review of the literature was performed to identify studies evaluating prognostic factors for survival in SLE-PH. Medline, EMBASE, CINAHL, and Cochrane Central Registry of Controlled Trials (inception – week 2 2010) were searched. A standardized abstraction form was used by two independent reviewers to extract prognostic factors. Methodological quality was evaluated using a validated quality index. Results: Twenty-three observational studies from 375 citations were evaluated. Elevated mean pulmonary artery pressure, Raynaud’s phenomenon, thrombocytopenia, plexiform lesion, infection, thrombosis, pregnancy, pulmonary vasculitis and anticardiolipin antibodies were associated with decreased survival. Lupus disease activity, nephritis and central nervous system disease were not associated with survival. The sample sizes were small and methodological quality of the studies was variable. Conclusion: This study summarizes factors that may be associated with decreased survival in SLE-PH. The small sample sizes and variable methodological quality preclude definitive conclusions. This study provides the groundwork for further research using large cohorts.
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Affiliation(s)
- SL Chow
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - V Chandran
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - R Fazelzad
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
| | - SR Johnson
- Division of Rheumatology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; 2University Health Network Health Sciences Library, Toronto, Canada; and 3University Health Network Pulmonary Hypertension Programme, Toronto General Hospital, Canada
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Kamel SR, Omar GM, Darwish AF, Asklany HT, Ellabban AS. Asymptomatic pulmonary hypertension in systemic lupus erythematosus. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2011; 4:77-86. [PMID: 22084605 PMCID: PMC3201107 DOI: 10.4137/cmamd.s7667] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a serious and often fatal complication of systemic lupus erythematosus (SLE). Because the diagnosis of PAH often is made years after symptom onset, early diagnostic strategies are essential. Doppler echocardiography currently is considered the noninvasive screening test of choice for evaluating pulmonary hypertension. AIM Screening for asymptomatic pulmonary hypertension in systemic lupus erythematosus patients using Doppler echocardiography, and correlating it with inflammatory parameters of the disease. PATIENTS AND METHODS Doppler echocardiography was performed in 74 patients with systemic lupus erythematosus over one year (66 adult and 8 juvenile), adult SLE included 57 patients with adult-onset and 9 patients with childhood-onset. Pulmonary hypertension was diagnosed if the peak systolic pressure gradient at the tricuspid valve was more than 30 mmHg. All patients were subjected to full history taking, rheumatological examination, laboratory studies and chest x-ray. RESULTS In seventy four SLE patients, the pulmonary hypertension was detected in 8 patients (10.8%), 7 adult-onset SLE patients (aged from 19 to 30 years) and 1 juvenile SLE (aged 12 years). The range of pulmonary artery systolic pressure was 34-61.2 mmHg (43.19 ± 9.28). No significant differences between patients with and those without pulmonary hypertension as regard clinical features. Significantly higher frequencies of rheumatoid factor and anti-cardiolipin antibodies were found in patients with pulmonary hypertension versus those without (P = 0.02, P = 0.008 respectively). Positive rheumatoid factor and ACL were significantly associated with occurrence of PAH in SLE (P = 0.007, P = 0.006 respectively). No significant correlations were found between pulmonary artery pressure, disease duration, SLE Disease Activity Index (SLEDAI), ESR, and anti-ds DNA. CONCLUSION Patients with SLE have an increased risk of pulmonary arterial hypertension. Echocardiography should be used as a screening tool in patients at high risk for development of pulmonary hypertension. Positive anti-cardiolipin antibodies and rheumatoid factor were significant predictors of pulmonary hypertension in our study.
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Affiliation(s)
- Shereen R Kamel
- Department of Rheumatology and Rehabilitation, Minia University, Egypt
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de Lauretis A, Veeraraghavan S, Renzoni E. Review series: Aspects of interstitial lung disease: connective tissue disease-associated interstitial lung disease: how does it differ from IPF? How should the clinical approach differ? Chron Respir Dis 2011; 8:53-82. [PMID: 21339375 DOI: 10.1177/1479972310393758] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The lung is frequently involved in connective tissue diseases (CTDs), although the frequency of lung manifestations varies according to the type of CTD. Interstitial lung diseases (ILD) are frequently seen in CTDs, particularly systemic sclerosis (SSc), polymyositis/dermatomyositis (PM/DM) and rheumatoid arthritis (RA), accounting for a significant proportion of deaths. A large percentage of patients with CTD-associated ILD has limited and stable disease, not requiring treatment. However, a significant minority has severe and/or progressive disease, necessitating prompt initiation of treatment. CTD-ILD histological patterns include non-specific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP). NSIP is the most common pattern in all CTDs, except for RA, characterized by a higher frequency of UIP. ILD can present acutely or chronically, with acute presentations being more common in systemic lupus erythematosus and PM/DM. Idiopathic pulmonary fibrosis (IPF) is a progressively worsening ILD characterized by inflammation and fibrosis. The characteristic histological pattern of IPF is UIP. Interestingly, a UIP pattern is associated with a significantly better survival in CTD-related disease compared to the idiopathic variety. Prognosis in IPF is dismal, with a median survival since diagnosis of 2-3 years. No treatment regimen has been shown to improve survival in IPF. By contrast, although there have been only two randomized placebo-controlled trials investigating the effect of immunosuppressive treatment in SSc-associated ILD, clinical experience suggests that immunosuppressive drugs in CTD-related ILDs are capable of benefiting a significant proportion of patients, particularly those with certain histological patterns of disease. This review will essentially focus on CTD-associated ILD and will compare aspects of clinical presentation and management to those of IPF.
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Affiliation(s)
- Angelo de Lauretis
- Department of Respiratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
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[Pulmonary arterial hypertension in systemic lupus erythematosus]. Rev Med Interne 2011; 32:689-97. [PMID: 21376432 DOI: 10.1016/j.revmed.2011.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 12/17/2010] [Accepted: 01/04/2011] [Indexed: 11/20/2022]
Abstract
Pulmonary hypertension (PH) is a serious complication of connective tissue diseases. The prevalence of PH in systemic lupus erythematosus (SLE) ranges from 0.5 to 17.5%, depending on whether echocardiography or right heart catheterization is used as the gold standard for diagnosis. The recent guidelines for the diagnosis and treatment of pulmonary hypertension include several potential causes of PH in SLE, including: a primary vasculopathy similar to idiopathic pulmonary arterial hypertension (PAH); left heart diseases; post-thromboembolic disease; hypoxia and fibrosis resulting from interstitial lung disease; and the infrequent SLE-associated pulmonary veno-occlusive disease. The pathogenesis of PAH associated with lupus is yet unclear, but likely includes a role for the genetic background, the presence of antiphospholipid antibodies, and some level of endothelial dysfunction. The evolution of SLE-associated PH is highly variable and difficult to elicit because the published series have used heterogeneous inclusion criteria. Optimal therapeutic management of PAH associated with lupus is unclear because no dedicated randomized controlled trial is yet available. Treatment usually includes arterial pulmonary vasodilators and immunosuppressive agents when the patients have NYHA functional class II, III or IV dyspnea.
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Pleural and pulmonary involvement in systemic lupus erythematosus. Presse Med 2011; 40:e19-29. [DOI: 10.1016/j.lpm.2010.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 11/18/2022] Open
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Dellaripa PF, O. Rosas I. The lung in rheumatic disease. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Claussen M, Riemekasten G, Hoeper MM. [Pulmonary arterial hypertension in collagenoses]. Z Rheumatol 2010; 68:630-2, 634-8. [PMID: 19593574 DOI: 10.1007/s00393-009-0480-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Pulmonary arterial hypertension is a rare disease of small pulmonary arteries of unknown origin characterised by endothelial dysfunction and cellular proliferation throughout all vessel layers, resulting in progressively elevated pulmonary arterial resistance with increasing right heart strain and finally right heart failure. The condition may develop in connective tissue diseases with variable frequency leading to a substantial worsening of prognosis. However, the spectrum of therapeutic options has broadened significantly in recent years. Several compounds have gained approval that act mainly as pulmonary vasodilators. Further drugs are under investigation, some of which target pulmonary vascular remodeling. Echocardiography remains the primary examination for disease detection. To classify pulmonary hypertension definite hemodynamic evaluation by means of right heart catheterisation and a thorough differential diagnosis are essential to provide the basis for further treatment. For differential therapy and assessment of follow-up profound knowledge is required, pointing to the need for close cooperation with specialised centres.
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Affiliation(s)
- M Claussen
- Abteilung für Pneumologie, Krankenhaus Grosshansdorf GmbH, Zentrum für Pneumologie und Thoraxchirurgie, Grosshansdorf, Deutschland.
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Pulmonary hypertension in systemic lupus erythematosus: relationship with antiphospholipid antibodies and severe disease outcome. Rheumatol Int 2009; 31:183-9. [DOI: 10.1007/s00296-009-1255-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 11/28/2009] [Indexed: 11/25/2022]
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Prabu A, Patel K, Yee CS, Nightingale P, Situnayake RD, Thickett DR, Townend JN, Gordon C. Prevalence and risk factors for pulmonary arterial hypertension in patients with lupus. Rheumatology (Oxford) 2009; 48:1506-11. [PMID: 19671698 DOI: 10.1093/rheumatology/kep203] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is associated with rapid deterioration and poor prognosis in SLE, especially during pregnancy. The prevalence of PAH in SLE in non-tertiary centres is uncertain. This study aims to estimate the point prevalence of PAH and identify risk factors for PAH in a large cohort of SLE patients. METHODS A prospective cross-sectional study of 288 patients with SLE were recruited from lupus clinics in Birmingham, UK. Resting transthoracic echocardiography was performed to estimate the pulmonary artery pressures and to assess cardiac morphology and function. PAH was defined as systolic pulmonary artery pressure (sPAP) >30 mmHg. We assessed potential risk factors such as the presence of lung disease, respiratory muscle weakness, autoantibodies, smoking, RP and APS. RESULTS Of 288 patients who consented for participation, 283 patients were suitable for analysis. Twelve patients were found to have PAH with sPAP >30 mmHg. The range of sPAP in our PAH patients was 31-59 mmHg and three patients had sPAP >40 mmHg. The only significant risk factor for PAH was LAC (P = 0.005). CONCLUSIONS The point prevalence of PAH was 4.2% in our cohort of patients with SLE. Most of the PAH cases were found to be of mild severity (<40 mmHg). The significant association of LAC and presence of APS in PAH cases suggests that thrombosis may play an important role in PAH with SLE. This is important, as it is treatable.
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Affiliation(s)
- Athiveeraramapandian Prabu
- Department of Rheumatology, Division of Infection and Immunology, University of Birmingham, Birmingham, UK
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Sugiura T, Kumon Y, Kataoka H, Matsumura Y, Takeuchi H, Doi YL. Asymptomatic pericardial effusion in patients with systemic lupus erythematosus. Lupus 2009; 18:128-32. [PMID: 19151113 DOI: 10.1177/0961203308094763] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine the frequency and clinical correlates of asymptomatic pericardial effusion (PE) in patients with systemic lupus erythematosus (SLE), echocardiography and electrocardiography were performed in 50 consecutive patients with SLE. Among 50 patients with SLE, 12 patients (24%) had PE and 17 patients (34%) had hypoalbuminaemia. Patients with PE had a significantly lower serum albumin (P < 0.001), higher incidence of proteinuria (P = 0.003), higher C-reactive protein (P = 0.036) and pulmonary artery systolic pressure (P = 0.011) and tended to have a higher incidence of PR-segment depression (P = 0.082) compared with those without PE. When four variables (PR-segment depression, C-reactive protein, serum albumin and pulmonary artery systolic pressure) were used in the multivariate analysis, serum albumin (P = 0.005, odds ratio = 0.016) and pulmonary artery systolic pressure (P = 0.010, odds ratio = 1.106) emerged as significant variables related to the occurrence of asymptomatic PE. Thus, an increase in hydrostatic pressure of the right heart cavities and a decrease in colloid osmotic pressure were important factors associated with the presence of asymptomatic PE in patients with SLE.
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Affiliation(s)
- T Sugiura
- Department of Laboratory Medicine, Kochi Medical School, Kochi, Japan.
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Rabinovitch M. Pathobiology of pulmonary hypertension. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2008; 2:369-99. [PMID: 18039104 DOI: 10.1146/annurev.pathol.2.010506.092033] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A variety of conditions can lead to the development of pulmonary arterial hypertension (PAH). Current treatments can improve symptoms and reduce the severity of the hemodynamic abnormality, but most patients remain quite limited, and deterioration in their condition necessitates a lung transplant. This review discusses current experimental and clinical studies that investigate the pathobiology of PAH. An emerging theme is the consideration of ways in which one might reverse the advanced occlusive structural changes in the pulmonary circulation causing PAH. The current debate concerning the role of regeneration through stem cells is presented. This review also highlights investigations in a number of laboratories relating the pathobiology of PAH to mutations causing loss of function of bone morphogenetic protein receptor II in patients with familial PAH, as well as sporadic cases.
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Affiliation(s)
- Marlene Rabinovitch
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305, USA.
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