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Sen G, Scully P, Gordon P, Sado D. Advances in the diagnosis of myocarditis in idiopathic inflammatory myopathies: an overview of diagnostic tests. Rheumatology (Oxford) 2024; 63:1825-1836. [PMID: 38230760 PMCID: PMC11215992 DOI: 10.1093/rheumatology/keae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024] Open
Abstract
Cardiac involvement in idiopathic inflammatory myopathies (IIM) purports to worse clinical outcomes, and therefore early identification is important. Research has focused on blood biomarkers and basic investigations such as ECG and echocardiography, which have the advantage of wide availability and low cost but are limited in their sensitivity and specificity. Imaging the myocardium to directly look for inflammation and scarring has therefore been explored, with a number of new methods for doing this gaining wider research interest and clinical availability. Cardiovascular magnetic resonance (CMR) with contemporary multiparametric mapping techniques and late gadolinium enhancement imaging, is an extremely valuable and increasingly used non-invasive imaging modality for the diagnosis of myocarditis. The recently updated CMR-based Lake Louise Criteria for the diagnosis of myocarditis incorporate the newer T1 and T2 mapping techniques, which have greatly improved the diagnostic accuracy for IIM myocarditis.18F-FDG-PET/CT is a well-utilized imaging modality in the diagnosis of malignancies in IIM, and it also has a role for the diagnosis of myocarditis in multiple systemic inflammatory diseases. Endomyocardial biopsy, however, remains the gold standard technique for the diagnosis of myocarditis and is necessary for the diagnosis of specific cases of myocarditis. This article provides an overview of the important tests and imaging modalities that clinicians should consider when faced with an IIM patient with potential myocarditis.
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Affiliation(s)
- Gautam Sen
- Department of Cardiovascular Medicine, King’s College London, London, UK
- School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King’s College London, London, UK
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Paul Scully
- Department of Nuclear Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Patrick Gordon
- Department of Rheumatology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Daniel Sado
- Department of Cardiovascular Medicine, King’s College London, London, UK
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, UK
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Markousis-Mavrogenis G, Pepe A, Lupi A, Apostolou D, Argyriou P, Velitsista S, Vartela V, Quaia E, Mavrogeni SI. Combined brain-heart MRI identifies cardiac and white matter lesions in patients with systemic lupus erythematosus and/or antiphospholipid syndrome: A pilot study. Eur J Radiol 2024; 176:111500. [PMID: 38772161 DOI: 10.1016/j.ejrad.2024.111500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/19/2024] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) can occur primarily (PAPS) or secondary to another autoimmune disease (SAPS), most commonly systemic lupus erythematosus (SLE). Recently, we reported that subclinical brain involvement was highly prevalent in patients with autoimmune diseases, including SLE. We aimed to investigate whether patients with SLE, PAPS or SAPS and cardiac symptoms showed differences in cardiac/brain involvement based on combined brain-heart magnetic resonance imaging (MRI). METHODS We prospectively recruited 15 patients with SAPS (86 % with SLE) and 3 patients with PAPS and compared their MRI findings to those of 13 patients with SLE from our previous publication. All patients underwent routine cardiovascular/neurological examination and standard echocardiography. RESULTS No patients had abnormalities in routine clinical workup/echocardiography. The vast majority had white matter hyperintensities (WMHs) and all had evidence of myocardial fibrosis and/or inflammation. Patients with SAPS had a lower median WMH number [1.00 (1.00, 2.00)] than those with PAPS [3.00 (2.50, 3.00)] or SLE [2.00 (2.00, 3.00)] (p = 0.010). Subcortical and deep WM were highly prevalent. Periventricular WMHs were more frequent in patients with SLE [6 (46.2 %)] or PAPS [2 (66.7 %)] (p = 0.023). Higher lesion burdens (1 WMH vs. 2 WMHs vs. ≥ WMHs) were associated with the presence of cardiac fibrosis [3 (33.3 %) vs. 10 (83.3) vs. 7 (77.8), p = 0.039] and affected the deep and periventricular WM (p < 0.001 for both). CONCLUSION In patients with PAPS, SAPS or SLE, cardiac symptoms and normal routine workup, combined brain-heart MRI identified abnormalities in both organs in the majority of patients. Combined brain-heart MRI offers excellent diagnostic value, but its incorporation into routine clinical practice should be further investigated. Clinical relevance statement Combined brain-heart magnetic resonance imaging in antiphospholipid syndrome may help to assess the presence of abnormalities in both organs.
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Affiliation(s)
- George Markousis-Mavrogenis
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Amalia Lupi
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | | | | | | | - Vasiliki Vartela
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Sophie I Mavrogeni
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece; Onassis Cardiac Surgery Center, 17674 Athens, Greece.
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Varghese B, Gustafson A, Chew E, Chew C, Frech T, El-Harasis MA, Kumar A, Shoemaker B, Chrispin J, Mukherjee M, Dendy JM, Hughes SG, Clark DE. The role of comprehensive stress cardiac MRI in autoimmune rheumatic disease: A review. IJC HEART & VASCULATURE 2024; 52:101381. [PMID: 38854746 PMCID: PMC11156705 DOI: 10.1016/j.ijcha.2024.101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 06/11/2024]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with autoimmune rheumatic diseases. Much of this may be attributed to systemic inflammation resulting in coronary atherosclerosis and myocarditis. Cardiac magnetic resonance imaging is the gold standard for the evaluation of cardiac structure and function, including tissue characterization, which allows for detection of myocardial edema, inflammation, and fibrosis. Advances in parametric mapping and coronary flow reserve measurement techniques have the potential to change the diagnosis, risk stratification, and management of patients with autoimmune rheumatic diseases. We provide an overview of the current evidence and suggest potential future roles for the use of comprehensive cardiac magnetic resonance in patients with autoimmune rheumatic diseases in the field of cardio-rheumatology.
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Affiliation(s)
- Bibin Varghese
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Andrew Gustafson
- Department of Medicine, Northwestern University School of Medicine, Chicago, IL, United States
| | - Erin Chew
- Division of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christopher Chew
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Tracy Frech
- Division of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Majd A. El-Harasis
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Anupam Kumar
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Benjamin Shoemaker
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jonathan Chrispin
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Monica Mukherjee
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jeffrey M. Dendy
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sean G. Hughes
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Daniel E. Clark
- Department of Medicine, Stanford University, Palo Alto, CA, United States
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4
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Werakiat J, Pussadhamma B, Mahakkanukrauh A, Suwannaroj S, Foocharoen C. Clinical courses and predictors of left ventricular systolic dysfunction in systemic sclerosis: A cohort study. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:107-116. [PMID: 39015847 PMCID: PMC11248551 DOI: 10.1515/rir-2024-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/19/2024] [Indexed: 07/18/2024]
Abstract
Background and Objectives Left ventricular systolic dysfunction (LVSD) is a cardiac involvement that is the leading cause of death among patients with systemic sclerosis (SSc). We aimed to define the clinical course and predictors of LVSD among SSc patients. Methods We conducted a cohort study among adult patients with SSc who were followed up from 2013 to 2020. Semiparametric Cox regression analysis with robust clustering by cohort identification number was used to evaluate the predictors of LVSD. Results Among the 3, 987 person-years, LVSD was defined in 35 of 419 SSc patients for an incidence of 0.88 per 100 person-years. The median duration of the disease was 8.5 (interquartile range (IQR) 4.9-12.9) years. Every 1-point increase in the modified Rodnan skin score (mRSS) and salt and pepper skin were strong predictors of LVSD, with a respective adjusted hazard ratio (HR) of 1.05 and 3.17. During follow-up, 26 cases (74.3%) had unimproved LVSD. The strong predictors of the unimprovement of LVSD were every 1-point increase in mRSS (HR 1.05), every 1 mg increase in prednisolone treatment (HR 1.05), and every 1 U/L increase in creatine kinase (CK) (HR 1.001). Mycophenolate treatment was a protective factor against the unimprovement of LVSD in SSc (HR 0.15). Conclusions LVSD was frequently found in patients with diffuse cutaneous SSc, and in most cases, it remained unimproved during follow-up. High mRSS, steroid use, and high CK levels were predictors of unimproved LVSD, whereas mycophenolate treatment might prevent the progression of LVSD. Steroids should be prescribed with caution in patients with longer disease duration.
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Affiliation(s)
- Jakrapan Werakiat
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Burabha Pussadhamma
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Karur GR, Aneja A, Stojanovska J, Hanneman K, Latchamsetty R, Kersting D, Rajiah PS. Imaging of Cardiac Fibrosis: An Update, From the AJR Special Series on Imaging of Fibrosis. AJR Am J Roentgenol 2024; 222:e2329870. [PMID: 37753860 DOI: 10.2214/ajr.23.29870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Myocardial fibrosis (MF) is defined as excessive production and deposition of extra-cellular matrix proteins that result in pathologic myocardial remodeling. Three types of MF have been identified: replacement fibrosis from tissue necrosis, reactive fibrosis from myocardial stress, and infiltrative interstitial fibrosis from progressive deposition of nondegradable material such as amyloid. Although echocardiography, nuclear medicine, and CT play important roles in the assessment of MF, MRI is pivotal in the evaluation of MF, with the late gadolinium enhancement (LGE) technique used as a primary end point. The LGE technique focuses on the pattern and distribution of gadolinium accumulation in the myocardium and assists in the diagnosis and establishment of the cause of both ischemic and nonischemic cardiomyopathy. LGE MRI also aids prognostication and risk stratification. In addition, LGE MRI is used to guide the management of patients considered for ablation for arrhythmias. Parametric mapping techniques, including T1 mapping and extracellular volume measurement, allow detection and quantification of diffuse fibrosis, which may not be detected by LGE MRI. These techniques also allow monitoring of disease progression and therapy response. This review provides an update on the imaging of MF, including prognostication and risk stratification tools, electrophysiologic considerations, and disease monitoring.
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Affiliation(s)
- Gauri R Karur
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Medical Imaging Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Ashish Aneja
- Department of Cardiology, MetroHealth System, Cleveland, OH
| | | | - Kate Hanneman
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Medical Imaging Toronto, Toronto General Hospital, Toronto, ON, Canada
| | | | - David Kersting
- Department of Nuclear Medicine and German Cancer Consortium (DKTK), University Hospital Essen, Essen, Germany
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Gargani L, Bruni C, Todiere G, Pugliese NR, Bandini G, Bellando-Randone S, Guiducci S, D’Angelo G, Campochiaro C, De Luca G, Stagnaro C, Lombardi M, Dagna L, Pepe A, Allanore Y, Moggi-Pignone A, Matucci-Cerinic M. Digital Ulcers and Ventricular Arrhythmias as Red Flags to Predict Replacement Myocardial Fibrosis in Systemic Sclerosis. J Clin Med 2023; 13:89. [PMID: 38202095 PMCID: PMC10779804 DOI: 10.3390/jcm13010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Echocardiography is the first line imaging tool to detect cardiac involvement, but it is not able to routinely detect myocardial fibrosis. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for replacement myocardial fibrosis assessment, but its availability is currently limited. AIM We aimed to assess the clinical and instrumental parameters that would be useful for predicting the presence of LGE-CMR, to achieve a better selection of patients with SSc that could benefit from third-level CMR imaging. METHODS 344 SSc patients underwent a comprehensive echocardiogram and LGE-CMR on the same day; for 189 patients, a 24 h ECG Holter monitoring was available. RESULTS CMR showed non-junctional replacement myocardial fibrosis via LGE in 25.1% patients. A history of digital ulcers (OR 2.188; 95% C.I. 1.069-4.481) and ventricular arrhythmias at ECG Holter monitoring (OR 3.086; 95% C.I. 1.191-7.998) were independent predictors of replacement myocardial fibrosis. CONCLUSIONS CMR can detect patterns of clinical and subclinical cardiac involvement, which are frequent in SSc. A history of digital ulcers and evidence of ventricular arrhythmias at ECG Holter monitoring are red flags for the presence of replacement myocardial fibrosis in CMR. The association between digital ulcers and myocardial fibrosis suggests that a similar pathological substrate of abnormal vascular function may underlie peripheral vascular and cardiac complications.
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Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Giancarlo Todiere
- U.O.C. Risonanza Magnetica Specialistica, Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | | | - Giulia Bandini
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
| | - Silvia Bellando-Randone
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Serena Guiducci
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Gennaro D’Angelo
- U.O.C. Risonanza Magnetica Specialistica, Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Chiara Stagnaro
- Department of Rheumatology, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Massimo Lombardi
- Multimodality Cardiac Imaging Section, Policlinico San Donato, 20097 Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, 35122 Padua, Italy
| | - Yannick Allanore
- French National Institute of Health and Medical Research (INSERM) U1016, Université de Paris, Hôpital Cochin, 75014 Paris, France
| | - Alberto Moggi-Pignone
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
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Azzam M, Awad A, Abugharbyeh A, Kahaleh B. Myocarditis in connective tissue diseases: an often-overlooked clinical manifestation. Rheumatol Int 2023; 43:1983-1992. [PMID: 37587233 DOI: 10.1007/s00296-023-05428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
To discuss what is currently known about myocarditis in the context of major connective tissue diseases, including Systemic lupus erythematosus, Rheumatoid Arthritis, Sjogren, Dermato-myositis and Polymyositis, Systemic Sclerosis, and Mixed connective tissue disease. Variability exists between studies regarding the incidence of myocarditis in connective tissue diseases, which is hypothesized to be the result of its subclinical course in most cases. Extensive gaps of knowledge exist in the field of pathophysiology. Although endomyocardial biopsy remains to be the gold standard for diagnosis, the advancement in non-invasive modalities such as cardiac MRI, echocardiography, and nuclear medicine has allowed for earlier and more frequent detection of myocarditis. A lack of treatment guidelines was found across the different connective tissue diseases. Most of the literature available revolved around myocarditis in the context of Systemic lupus erythematosus. Numerous recent studies were published that contributed to advancements in diagnosis and treatment however, there remains a lack of diagnostic and treatment guidelines.
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Affiliation(s)
- Muayad Azzam
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Amro Awad
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Aya Abugharbyeh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
| | - Bashar Kahaleh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
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Gulhane A, Ordovas K. Cardiac magnetic resonance assessment of cardiac involvement in autoimmune diseases. Front Cardiovasc Med 2023; 10:1215907. [PMID: 37808881 PMCID: PMC10556673 DOI: 10.3389/fcvm.2023.1215907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Cardiac magnetic resonance (CMR) is emerging as the modality of choice to assess early cardiovascular involvement in patients with autoimmune rheumatic diseases (ARDs) that often has a silent presentation and may lead to changes in management. Besides being reproducible and accurate for functional and volumetric assessment, the strength of CMR is its unique ability to perform myocardial tissue characterization that allows the identification of inflammation, edema, and fibrosis. Several CMR biomarkers may provide prognostic information on the severity and progression of cardiovascular involvement in patients with ARDs. In addition, CMR may add value in assessing treatment response and identification of cardiotoxicity related to therapy with immunomodulators that are commonly used to treat these conditions. In this review, we aim to discuss the following objectives: •Illustrate imaging findings of multi-parametric CMR approach in the diagnosis of cardiovascular involvement in various ARDs;•Review the CMR signatures for risk stratification, prognostication, and guiding treatment strategies in ARDs;•Describe the utility of routine and advanced CMR sequences in identifying cardiotoxicity related to immunomodulators and disease-modifying agents in ARDs;•Discuss the limitations of CMR, recent advances, current research gaps, and potential future developments in the field.
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Affiliation(s)
- Avanti Gulhane
- Department of Radiology, University of Washington, School of Medicine, Seattle, WA, United States
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9
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Trybuch A, Tarnacka B. Cardiac involvement in polymyositis and dermatomyositis: diagnostic approaches. Reumatologia 2023; 61:202-212. [PMID: 37522146 PMCID: PMC10373167 DOI: 10.5114/reum/168362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 08/01/2023] Open
Abstract
Polymyositis (PM) and dermatomyositis (DM) are rare idiopathic inflammatory myopathies (IIM). Myocardial involvement in patients with IIM is an unfavorable prognostic factor and one of the most common cause of mortality in this group of patients. The purpose of this review is to present current knowledge on cardiovascular manifestations observed in IIM. Data published in English until December 2021 were selected. Clinical symptoms suggesting cardiac involvement are non-specific and require a differential diagnosis in accordance with cardiological guidelines. Troponin I is specific to cardiac injury and should be preferred to other markers to evaluate the myocardium in IIM. Abnormalities in electrocardiography are common in IIM, especially non-specific changes of the ST-T segment. In standard echocardiography left ventricular diastolic dysfunction is reported frequently. New diagnostic technologies can reveal clinically silent myocardial abnormalities. However, the prognostic value of subclinical impairment of myocardial function require further studies.
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Affiliation(s)
- Agnieszka Trybuch
- Department of Rehabilitation, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Beata Tarnacka
- Department of Rehabilitation, Medical University of Warsaw, Poland
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Ali AM, Yakupoglu HY, Fuchs TA, Larsen TH, Aukrust P, Gunnarsson R, Saeed S. Cardiac involvement in systemic and local vasculitides: The value of non-invasive multimodality imaging. Curr Probl Cardiol 2023; 48:101718. [PMID: 37003450 DOI: 10.1016/j.cpcardiol.2023.101718] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
Despite significant advances in managing systemic vasculitides, cardiovascular morbidity and mortality are still of primary concern. Advances in non-invasive imaging have broadened our understanding of the clinical heterogeneity of cardiac involvement in vasculitides. Common cardiovascular complications in primary or secondary vasculitides are; coronary artery aneurysms, acute coronary syndromes, myocarditis, pericarditis, endocarditis, and valvular dysfunction. Echocardiography, cardiac magnetic resonance (CMR), positron emission tomography (PET), and CT angiography are essential in identifying cardiac involvement and guiding treatment. Here, we present our experiences of cardiac involvement in systemic vasculitides, covering most aspects of common cardiac complications based on a multi-modality approach to challenging (real-world) cases. As many cardiac manifestations are clinically silent, heart function should be systemically assessed by a multi-modality imaging-based approach, including ECG, serial echocardiograms with strain imaging and 3D, and CMR to detect early signs of cardiac manifestations. This enables timely intervention and optimal medical treatment, which is essential for a better prognosis. There is a need for better and closer collaboration in clinical practice and research fields between Cardiologists and Rheumatologists.
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Affiliation(s)
- Abukar Mohamed Ali
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - H Yakup Yakupoglu
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Tobias A Fuchs
- Medical University Clinic, Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Terje H Larsen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.; Department of Biomedicine, University of Bergen, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital - Rikshospitalet, Oslo; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo.; Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital - Rikshospitalet, Oslo
| | | | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway..
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11
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Yan W, Luo Q, Nie Q, Wang H, Wu J. Association between systemic sclerosis and left ventricle dysfunction: Findings from observational studies. Heliyon 2023; 9:e14110. [PMID: 36938434 PMCID: PMC10020007 DOI: 10.1016/j.heliyon.2023.e14110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives Cardiac involvement is common in systemic sclerosis (SSc) patients. In this study, we aimed to systematically evaluate the relationship between SSc and left ventricular dysfunction (LVD), especially the left ventricular diastolic dysfunction, by ultrasound and cardiac magnetic resonance data. Methods We searched The Cochrane Library, PubMed and Embase databases collected studies about comparing LVD parameters in SSc patients and controls from establishment to January 2022. Furthermore, we also performed a two-sample MR using summary statistics from genome-wide association studies (GWAS) important LVD parameters, including left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM) and left ventricular ejection fraction (LVEF). Results Our meta-analysis included 31 eligible studies with 1448 SSc patients. According to the results, SSc patients had lower peak of early diastolic flow velocity/peak of late diastolic flow velocity ratio (E/A ratio), E, trans-mitral early filling peak velocity (E'), and left ventricular end-diastolic diameter (LVEDD) compared to controls. The E/E' ratio, A, left ventricular isovolumetric relaxation time (IVRT), deceleration Time (DT) and left atrial (LA) diameter were higher in SSc patients in comparison with controls. Moreover, we observed that the SSc patients had lower LVEF than controls. And in MR analysis, we also found that SSc was causally correlated with LVEF (OR = 0.9966, 95% CI 0.9935-0.998, P = 0.0398). However, unfortunately, there was no significant correlation between SSC and LVM (OR = 1.0048, 95% CI 0.9919-1.0179, P = 0.4661) and LVEDV (LVEDV OR = 0.9976, 95%CI 0.9888-1.0066, P = 0.6019). Conclusion SSc patients had diastolic/systolic dysfunction. However, MR analysis cannot confirm the genetic relationship between SSc and LVDD because of insufficient data. More research is needed to confirm the causal relationship between the two.
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Affiliation(s)
- Wei Yan
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Qiang Luo
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Qiong Nie
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Han Wang
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
- Corresponding author.
| | - Jing Wu
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
- Corresponding author.
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12
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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13
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Markousis-Mavrogenis G, Belegrinos A, Giannakopoulou A, Papavasiliou A, Koulouri V, Marketos N, Patsilinakou E, Lazarioti F, Bacopoulou F, Mavragani CP, Chrousos GP, Mavrogeni SI. Cardiovascular Magnetic Resonance Demonstrates Myocardial Inflammation of Differing Etiologies and Acuities in Patients with Genetic and Inflammatory Myopathies. J Clin Med 2023; 12:jcm12041575. [PMID: 36836108 PMCID: PMC9961874 DOI: 10.3390/jcm12041575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/03/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Abstract
INTRODUCTION Myopathies are heterogeneous neuromuscular diseases of genetic and/or inflammatory etiology that affect both cardiac and skeletal muscle. We investigated the prevalence of cardiac inflammation in patients with myopathies, cardiovascular symptoms, and normal echocardiography using cardiovascular magnetic resonance (CMR). METHODS We prospectively evaluated 51 patients with various genetic (n = 23) and inflammatory (n = 28) myopathies (median age, IQR: 12 (11-15) years, 22% girls; 61 (55-65) years, 46% women, respectively) and compared their CMR findings to corresponding age- and sex-matched controls (n = 21 and 20, respectively) and to each other. RESULTS Patients with genetic myopathy had similar biventricular morphology and function to healthy controls but showed higher late gadolinium enhancement (LGE), native T1 mapping, extracellular volume fraction (ECV), and T2 mapping values. Collectively, 22 (95.7%) patients with genetic myopathy had a positive T1-criterion and 3 (13.0%) had a positive T2-criterion according to the updated Lake Louise criteria. Compared with healthy controls, patients with inflammatory myopathy showed preserved left ventricular (LV) function and reduced LV mass, while all CMR-derived tissue characterization indices were significantly higher (p < 0.001 for all). All patients had a positive T1-criterion, and 27 (96.4%) had a positive T2-criterion. A positive T2-criterion or T2-mapping > 50 ms could discriminate between patients with genetic and inflammatory myopathies with a sensitivity of 96.4% and a specificity of 91.3% (AUC = 0.9557). CONCLUSIONS The vast majority of symptomatic patients with inflammatory myopathies and normal echocardiography show evidence of acute myocardial inflammation. In contrast, acute inflammation is rare in patients with genetic myopathies, who show evidence of chronic low-grade inflammation.
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Affiliation(s)
- George Markousis-Mavrogenis
- Olympic Diagnostic/Research Center, 17674 Athens, Greece
- Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antonios Belegrinos
- Faculty of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | | | | | - Vasiliki Koulouri
- Department of Physiology “Molecular Physiology and Clinical Applications Unit”, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Marketos
- Department of Physiology “Molecular Physiology and Clinical Applications Unit”, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | | | - Flora Bacopoulou
- University Research Institute for Maternal and Child Health and Precision Medicine, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece
| | - Clio P. Mavragani
- Department of Physiology “Molecular Physiology and Clinical Applications Unit”, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Attikon Hospital, 12462 Athens, Greece
| | - George P. Chrousos
- University Research Institute for Maternal and Child Health and Precision Medicine, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece
| | - Sophie I. Mavrogeni
- Olympic Diagnostic/Research Center, 17674 Athens, Greece
- Onassis Cardiac Surgery Center, 17674 Athens, Greece
- University Research Institute for Maternal and Child Health and Precision Medicine, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece
- Correspondence:
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14
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Cardiac inflammation and fibrosis patterns in systemic sclerosis, evaluated by magnetic resonance imaging: An update. Semin Arthritis Rheum 2023; 58:152126. [PMID: 36434895 DOI: 10.1016/j.semarthrit.2022.152126] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
Systemic sclerosis (SSc) presents high morbidity/mortality, due to internal organ fibrosis, including the heart. Cardiac magnetic resonance (CMR) can perform myocardial function and tissue characterization in the same examination. The Lake Louise criteria (LLC) can identify recent myocardial inflammation using CMR. Abnormal values include: (a) myocardial over skeletal muscle ratio in STIRT2-W images >2, (b) early gadolinium enhancement values >4, (c) epicardial/intramyocardial late gadolinium enhancement (LGE). The diagnosis of myocarditis using LLC is considered if 2/3 criteria are positive. Parametric imaging including T2, native T1 mapping and extracellular volume fraction (ECV) has been recently used to diagnose inflammatory cardiomyopathy. According to expert recommendations, myocarditis should be considered if at least 2 indices, one T2 and one T1 parameter are positive, whereas native T1 mapping and ECV assess diffuse fibrosis or oedema, even in the absence of LGE. Moreover, transmural/subendocardial fibrosis following the distribution of coronary arteries and diffuse subendocardial fibrosis not related with epicardial coronary arteries are indicative of epicardial and micro-vascular coronary artery disease, respectively. To conclude, CMR can identify acute/active myocardial inflammation and myocardial infarction using classic and parametric indices in parallel with ventricular function evaluation.
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15
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Cardiovascular magnetic resonance for the evaluation of patients with cardiovascular disease: An overview of current indications, limitations, and procedures. Hellenic J Cardiol 2023; 70:53-64. [PMID: 36706867 DOI: 10.1016/j.hjc.2023.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
Cardiovascular disease (CVD) is the most common cause of morbidity/mortality worldwide. Early diagnosis is the key to improve CVD prognosis, and cardiovascular imaging plays a crucial role in this direction. Echocardiography is the most commonly used imaging modality. However, the need for early diagnosis/treatment favors the development of modalities providing information about tissue characterization beyond echocardiography. In this context, the rapid evolution of cardiovascular magnetic resonance (CMR) led to the coexistence of cardiologists and radiologists in the CMR field. Our aim was to provide an overview of indications, sequences, and reporting of CMR findings in various CVDs. The indications/limitations of CMR as well as the pathophysiological significance of various sequences in adult/pediatric CVDs are presented and discussed in detail. The role of CMR indices in the evaluation of the most common clinical scenarios in cardiology and their impact on CVD diagnosis/prognosis were analyzed in detail. Additionally, the comparison of CMR versus other imaging modalities is also discussed. Finally, future research directions are presented. CMR can provide cardiac tissue characterization and biventricular/biatrial functional assessment in the same examination, allowing for early and accurate identification of important subclinical abnormalities, before clinically overt CVD takes place.
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16
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Markousis-Mavrogenis G, Giannakopoulou A, Belegrinos A, Pons MR, Bonou M, Vartela V, Papavasiliou A, Christidi A, Kourtidou S, Kolovou G, Bacopoulou F, Chrousos GP, Mavrogeni SI. Cardiovascular Magnetic Resonance Imaging Patterns in Rare Cardiovascular Diseases. J Clin Med 2022; 11:6403. [PMID: 36362632 PMCID: PMC9657782 DOI: 10.3390/jcm11216403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 08/27/2023] Open
Abstract
Rare cardiovascular diseases (RCDs) have low incidence but major clinical impact. RCDs' classification includes Class I-systemic circulation, Class II-pulmonary circulation, Class III-cardiomyopathies, Class IV-congenital cardiovascular diseases (CVD), Class V-cardiac tumors and CVD in malignancy, Class VI-cardiac arrhythmogenic disorders, Class VII-CVD in pregnancy, Class VIII-unclassified rare CVD. Cardiovascular Magnetic Resonance (CMR) is useful in the diagnosis/management of RCDs, as it performs angiography, function, perfusion, and tissue characterization in the same examination. Edema expressed as a high signal in STIRT2 or increased T2 mapping is common in acute/active inflammatory states. Diffuse subendocardial fibrosis, expressed as diffuse late gadolinium enhancement (LGE), is characteristic of microvascular disease as in systemic sclerosis, small vessel vasculitis, cardiac amyloidosis, and metabolic disorders. Replacement fibrosis, expressed as LGE, in the inferolateral wall of the left ventricle (LV) is typical of neuromuscular disorders. Patchy LGE with concurrent edema is typical of myocarditis, irrespective of the cause. Cardiac hypertrophy is characteristic in hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA) and Anderson-Fabry Disease (AFD), but LGE is located in the IVS, subendocardium and lateral wall in HCM, CA and AFD, respectively. Native T1 mapping is increased in HCM and CA and reduced in AFD. Magnetic resonance angiography provides information on aortopathies, such as Marfan, Turner syndrome and Takayasu vasculitis. LGE in the right ventricle is the typical finding of ARVC, but it may involve LV, leading to the diagnosis of arrhythmogenic cardiomyopathy. Tissue changes in RCDs may be detected only through parametric imaging indices.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Flora Bacopoulou
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - George P. Chrousos
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sophie I. Mavrogeni
- Onassis Cardiac Surgery Center, 17674 Athens, Greece
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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17
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Panopoulos S, Mavrogeni S, Vlachopoulos C, Sfikakis PP. Cardiac magnetic resonance imaging before and after therapeutic interventions for systemic sclerosis-associated myocarditis. Rheumatology (Oxford) 2022; 62:1535-1542. [PMID: 36083014 DOI: 10.1093/rheumatology/keac504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/25/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Cardiac Magnetic Resonance (CMR) imaging is increasingly used to evaluate cardiac involvement in Systemic Sclerosis (SSc). We assessed changes, including inflammatory and/or fibrotic myocardial lesions detected by CMR, following therapeutic interventions for SSc-associated symptomatic myocarditis. METHODS In this retrospective study, myocarditis was diagnosed by CMR (2018 revised Lake Louise criteria) in 14 diffuse and 4 limited SSc patients (16/18 women, aged 56 ± 11 years, disease duration 8 ± 11 years, 17/18 with lung involvement) with cardiac symptoms and abnormal findings in echocardiography (4/18) and/or in 24-h Holter monitoring (12/14). CMR was repeated after 8 ± 3 months following administration of cyclophosphamide (n = 11, combined with corticosteroids in 3 and rituximab in 1), mycophenolate (n = 1), tocilizumab (n = 1), methotrexate/corticosteroids (n = 2), corticosteroids (n = 1) or autologous stem cell transplantation (n = 2). RESULTS Functional cardiac improvement was evident by increases in left (by 5.8%±7.8%, p= 0.006) and right ventricular ejection fraction (by 4.5%±11.4%, p= 0.085) in the second CMR compared with the first. Notably, Late Gadolinium Enhancement, currently considered to denote replacement fibrosis, decreased by 3.1%±3.8% (p= 0.003), resolving in 6 patients. Markers of myocardial oedema, namely T2-ratio and T2-mapping, decreased by 0.27 ± 0.40 (p= 0.013) and 6.0 ± 7 (p= 0.025), respectively. Conversely, both T1-mapping, considered to reflect acute oedema and diffuse fibrosis, and extracellular volume fraction, reflecting diffuse fibrosis, remained unchanged. CONCLUSIONS CMR may distinguish between reversible inflammatory/fibrotic and irreversible fibrotic lesions in SSc patients with active myocarditis, confirming the unique nature of primary cardiac involvement in SSc. Whether, and how, CMR should be used to monitor treatment effects in SSc-associated myocarditis warrants further study.
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Affiliation(s)
- Stylianos Panopoulos
- First Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Charalambos Vlachopoulos
- First Cardiology Department, Hippokration General Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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18
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Vidusa L, Kalejs O, Maca-Kaleja A, Strumfa I. Role of Endomyocardial Biopsy in Diagnostics of Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12092104. [PMID: 36140505 PMCID: PMC9497694 DOI: 10.3390/diagnostics12092104] [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: 07/03/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022] Open
Abstract
Endomyocardial biopsy as the cornerstone of diagnostics has been re-evaluated throughout the years, leaving unanswered questions on the precedence of it. The reported incidence of myocarditis has increased during the pandemic of coronavirus disease 2019 (COVID-19), reinforcing discussions on appropriate diagnostics of myocarditis. By analysis of evidence-based literature published within the last demi-decade, we aimed to summarize the most recent information in order to evaluate the current role of endomyocardial biopsy in diagnostics and management of myocarditis. For the most part, research published over the last five years showed ongoing uncertainty regarding the use, informativeness, safety and necessity of performing a biopsy. Special circumstances, such as fulminant clinical course or failure to respond to empirical treatment, were reconfirmed as justified indications, with a growing applicability of non-invasive diagnostic approaches for most other cases. We concluded that endomyocardial biopsy, if performed properly and with adjunct diagnostic methods, holds a critical role for treatment correction in specific histological subtypes of myocarditis and for differential diagnosis between immune-mediated myocarditis and secondary infections due to immunosuppressive treatment. A high level of possible misdiagnosing was detected, indicating the need to review terminology used to describe findings of myocardial inflammation that did not meet Dallas criteria.
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Affiliation(s)
- Liga Vidusa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Aija Maca-Kaleja
- Department of Internal Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Street, LV-1002 Riga, Latvia
| | - Ilze Strumfa
- Department of Pathology, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia
- Correspondence:
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19
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Mavrogeni S, Pepe A, Nijveldt R, Ntusi N, Sierra-Galan LM, Bratis K, Wei J, Mukherjee M, Markousis-Mavrogenis G, Gargani L, Sade LE, Ajmone-Marsan N, Seferovic P, Donal E, Nurmohamed M, Cerinic MM, Sfikakis P, Kitas G, Schwitter J, Lima JAC, Dawson D, Dweck M, Haugaa KH, Keenan N, Moon J, Stankovic I, Donal E, Cosyns B. Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2022; 23:e308-e322. [PMID: 35808990 DOI: 10.1093/ehjci/jeac134] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/12/2022] Open
Abstract
Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.
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Affiliation(s)
- S Mavrogeni
- Onassis Cardiac Surgery Center, Leof. Andrea Siggrou 356, Kallithea 176 74, Greece.,Exercise Physiology and Sport Medicine Clinic, Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 115 27 Athens, Greece
| | - A Pepe
- Institute of Radiology, Department of Medicine, University of Padua, 35122 Padua, Italy
| | - R Nijveldt
- Department of Cardiology, Radboud University Medical Center, 6525 GA, Nijmegen, the Netherlands
| | - N Ntusi
- University of Cape Town & Groote Schuur Hospital, City of Cape Town, 7700 Western Cape, South Africa
| | - L M Sierra-Galan
- Department of Cardiology, American British Cowdray Medical Center, 05330 Mexico City, Mexico
| | - K Bratis
- Department of Cardiology, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - J Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA 90048, USA.,Preventive and Rehabilitative Cardiac Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA 90048, USA
| | - M Mukherjee
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - L Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - L E Sade
- University of Pittsburgh, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA 15260, USA.,Department of Cardiology, Baskent University, 06790 Ankara, Turkey
| | - N Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, 2311 EZ Leiden, the Netherlands
| | - P Seferovic
- Department of Cardiology, Belgrade University, 11000 Belgrade, Serbia
| | - E Donal
- Université RENNES-1, CHU, 35000 Rennes, France
| | - M Nurmohamed
- Amsterdam Rheumatology Immunology Center, Amsterdam University Medical Centers, 1105 AZ, Amsterdam, the Netherlands
| | - M Matucci Cerinic
- Experimental and Clinical Medicine, Division of Internal Medicine and Rheumatology, Azienda Ospedaliera Universitaria Careggi, University of Florence, 50121 Florence, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS, San Raffaele Hospital, 20132 Milan, Italy
| | - P Sfikakis
- First Department of Propeudeutic and Internal medicine, Laikon Hospital, Athens University Medical School, 115 27 Athens, Greece
| | - G Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PL, UK
| | - J Schwitter
- Lausanne University Hospital, CHUV, CH-1011 Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, 1015 UniL, Switzerland.,Director CMR Center of the University Hospital Lausanne, CHUV, CH-1011 Lausanne, Switzerland
| | - J A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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20
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Dorfman AL, Geva T, Samyn MM, Greil G, Krishnamurthy R, Messroghli D, Festa P, Secinaro A, Soriano B, Taylor A, Taylor MD, Botnar RM, Lai WW. SCMR expert consensus statement for cardiovascular magnetic resonance of acquired and non-structural pediatric heart disease. J Cardiovasc Magn Reson 2022; 24:44. [PMID: 35864534 PMCID: PMC9302232 DOI: 10.1186/s12968-022-00873-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is widely used for diagnostic imaging in the pediatric population. In addition to structural congenital heart disease (CHD), for which published guidelines are available, CMR is also performed for non-structural pediatric heart disease, for which guidelines are not available. This article provides guidelines for the performance and reporting of CMR in the pediatric population for non-structural ("non-congenital") heart disease, including cardiomyopathies, myocarditis, Kawasaki disease and systemic vasculitides, cardiac tumors, pericardial disease, pulmonary hypertension, heart transplant, and aortopathies. Given important differences in disease pathophysiology and clinical manifestations as well as unique technical challenges related to body size, heart rate, and sedation needs, these guidelines focus on optimization of the CMR examination in infants and children compared to adults. Disease states are discussed, including the goals of CMR examination, disease-specific protocols, and limitations and pitfalls, as well as newer techniques that remain under development.
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Affiliation(s)
- Adam L. Dorfman
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan C.S. Mott Children’s Hospital, 1540 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Tal Geva
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Margaret M. Samyn
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin/Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226 USA
| | - Gerald Greil
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75235 USA
| | - Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr. E4A, Columbus, OH 43205 USA
| | - Daniel Messroghli
- Department of Internal Medicine-Cardiology, Deutsches Herzzentrum Berlin and Charité-University Medicine Berlin, Berlin, Germany
| | - Pierluigi Festa
- Department of Cardiology, Fondazione Toscana G. Monasterio, Massa, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Brian Soriano
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Andrew Taylor
- Department of Cardiovascular Imaging, Great Ormond Street Hospital for Sick Children, University College London, London, UK
| | - Michael D. Taylor
- Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children’s Hospital, 3333 Burnet Ave #2129, Cincinnati, OH 45229 USA
| | - René M. Botnar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Wyman W. Lai
- CHOC Children’s, 1201 W. La Veta Avenue, Orange, CA 92868 USA
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21
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Wang J, Gao Y, Yang ZG, Guo YK, Jiang L, Shi R, Xu HY, Huang S, Li Y. Quantitative assessment of left ventricular myocardial involvement in patients with connective tissue disease: a 3.0T contrast-enhanced cardiovascular magnetic resonance study. Int J Cardiovasc Imaging 2022; 38:1545-1554. [PMID: 35284973 PMCID: PMC11143006 DOI: 10.1007/s10554-022-02539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/23/2022] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate left ventricular (LV) myocardial involvement in connective tissue disease (CTD) patients using multiparemetric imaging derived from cardiovascular magnetic resonance (CMR). CMR was performed on 146 CTD patients (comprising of 74 with idiopathic inflammatory myopathy (IIM) and 72 with non-IIM) and 72 healthy controls and included measures of LV global strains [including peak strain (PS), peak systolic (PSSR) and diastolic strain rate (PDSR)], myocardial perfusion [including upslope, max signal intensity (MaxSI), and time to maximum signal intensity (TTM)], and late gadolinium enhancement (LGE) parameters. Univariable and multivariable linear regression analyses were performed to determine the association between LV deformation and microvascular perfusion, as well as LGE. Our results indicated that CTD patients had decreased global longitudinal PS (GLPS), PSSR, PDSR, and myocardial perfusion (all p < 0.017) compared with normal controls. Non-IIM patients exhibited lower LV global strain and longer TTM than IIM patients. The presence of LGE was independently associated with global radial PS (GRPS: β = - 0.165, p = 0.011) and global circumferential PS (GCPS: β = - 0.122, p = 0.022). TTM was independently correlated with GLPS (β = - 0.156, p = 0.027). GLPS was the best indicator for differentiating CTD patients from normal controls (area under curve of 0.78). This study indicated that CTD patients showed impaired LV global myocardial deformation and microvascular perfusion, and presence of LGE. Cardiac involvement might be more severe in non-IIM patients than in IIM patients. Impaired microvascular perfusion and the presence of LGE were independently associated with LV global deformation.
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Affiliation(s)
- Jin Wang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yue Gao
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, 20# Section 3, Renmin South Road, Chengdu, 610041, Sichuan, China
| | - Li Jiang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Rui Shi
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, 20# Section 3, Renmin South Road, Chengdu, 610041, Sichuan, China
| | - Shan Huang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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22
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Using multi-parametric quantitative MRI to screen for cardiac involvement in patients with idiopathic inflammatory myopathy. Sci Rep 2022; 12:9819. [PMID: 35701509 PMCID: PMC9198094 DOI: 10.1038/s41598-022-13858-y] [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: 10/08/2021] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIM) is a group of heterogeneous autoimmune systemic diseases, which not only involve skeletal muscle but also myocardium. Cardiac involvement in IIM, which eventually develops into heart failure, is difficult to identify by conventional examinations at early stage. The aim of this study was to investigate if multi-parametric cardiac magnetic resonance (CMR) imaging can screen for early cardiac involvement in IIM, compared with clinical score (Myositis Disease Activity Assessment Tool, MDAAT). Forty-nine patients of IIM, and 25 healthy control subjects with comparable age-range and sex-ratio were enrolled in this study. All subjects underwent CMR examination, and multi-slice short-axis and 4-chamber cine MRI were acquired to evaluate biventricular global circumferential strain (GCS) and global longitudinal strain (GLS). Native T1 and T2 mapping were performed, and post-contrast T1 mapping and LGE were acquired after administration of contrast. A CMR score was developed from native T1 mean and T2 mean for the identification of cardiac involvement in the IIM cohort. Using contingency tables MDAAT and CMR were compared and statistically analyzed using McNemar test. McNemar’s test revealed no significant difference between CMR score and MDAAT (p = 0.454). CMR score had potential to screen for early cardiac involvement in IIM patients, compared to MDAAT.
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23
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Kozor R, Abiodun A, Kott K, Manisty C. Non-invasive Imaging in Women With Heart Failure - Diagnosis and Insights Into Disease Mechanisms. Curr Heart Fail Rep 2022; 19:114-125. [PMID: 35507121 PMCID: PMC9177491 DOI: 10.1007/s11897-022-00545-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE OF REVIEW To summarise the role of different imaging techniques for diagnosis and investigation of heart failure in women. RECENT FINDINGS Although sex differences in heart failure are well recognised, and the scope of imaging techniques is expanding, there are currently no specific guidelines for imaging of heart failure in women. Diagnosis and stratification of heart failure is generally performed first line using transthoracic echocardiography. Understanding the aetiology of heart failure is central to ongoing management, and with non-ischaemic causes more common in women, a multimodality approach is generally required using advanced imaging techniques including cardiovascular magnetic resonance imaging, nuclear imaging techniques, and cardiac computed tomography. There are specific considerations for imaging in women including radiation risks and challenges during pregnancy, highlighting the clear unmet need for cardiology and imaging societies to provide imaging guidelines specifically for women with heart failure.
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Affiliation(s)
- Rebecca Kozor
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Aderonke Abiodun
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
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24
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Dressler F, Maurer B. [Dermatomyositis and juvenile dermatomyositis]. Z Rheumatol 2022; 82:233-245. [PMID: 35486206 DOI: 10.1007/s00393-022-01205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
Dermatomyositis (DM) is an inflammatory multisystem disease of unknown etiology, which can already occur in children but first onset can also be in older adulthood. Myalgia and muscle weakness can occur later in the course of the disease or even be completely absent in some forms. Classical signs on the skin include heliotrope rash, facial erythema, Gottron's papules and nailfold capillary abnormalities. For the diagnosis, screening for the presence of myositis-specific autoantibodies has become increasingly more relevant. Muscle enzymes may be elevated but not in approximately one third of patients. In the absence of typical clinical or serologic findings, additional examination methods such as nailfold capillaroscopy, magnetic resonance imaging, electromyography, skin or muscle biopsies may help to establish the diagnosis. Depending on the clinical and serological subtype, additional screening for gastrointestinal or cardiopulmonary involvement should be considered. In adults, an age-appropriate tumor screening should also be performed. Apart from corticosteroids as induction therapy, biologics and small molecule inhibitors are gaining in importance in addition to conventional disease-modifying anti-rheumatic drugs and intravenous immunoglobulins. The prognosis for DM and juvenile DM (JDM) has improved. Most patients recover at least to some extent; however, a few patients die and a minority develop persisting muscle atrophy or severe calcinosis.
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Affiliation(s)
- Frank Dressler
- Kinderklinik, Medizinische Hochschule Hannover, 30623, Hannover, Deutschland.
| | - Britta Maurer
- Universitätsklinik für Rheumatologie und Immunologie, Inselspital Bern, 3010, Bern, Schweiz.
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25
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Asatani S, Kobayashi H, Nagasawa Y, Nishihara M, Tanikawa Y, Hamaguchi M, Yoshizawa S, Tsuzuki H, Sugiyama K, Tsukamoto M, Kitamura N, Nakamura H. Successful Treatment for Eosinophilic Granulomatosis with Polyangiitis Causing Severe Myocarditis Followed by Cardiac Magnetic Resonance. Mod Rheumatol Case Rep 2022; 6:248-253. [PMID: 35403190 DOI: 10.1093/mrcr/rxac027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/28/2022] [Accepted: 03/16/2022] [Indexed: 11/14/2022]
Abstract
A 38-year-old woman had a history of asthma for 20 years. Bullous lesions had appeared in her left side of the back. Two months before admission, and biopsy revealed eosinophilic cellulitis. She experienced numbness in both legs one month later. She was admitted to our hospital for emergency treatment due to chest pain and loss of consciousness. Emergency coronary angiography revealed triple-vessel vasospasm. She had cardiac arrest for four minutes during the examination. We suspected eosinophilic granulomatosis with polyangiitis due to pulmonary infiltrate, eosinophilia, and a history of illness. We therefore started methylprednisolone pulse therapy. Although her condition and laboratory findings improved, cardiac magnetic resonance (CMR) imaging performed on day 16 showed myocardial edema and myocardial fibrosis on late gadolinium enhancement (LGE). Coronary angiography on day 35 revealed no spasm, and myocardial biopsy showed absence of vasculitis. There was no improvement in myocardial edema. CMR showed enlargement of LGE and formation of ventricular aneurysm. As myocarditis did not improve sufficiently, five courses of intravenous cyclophosphamide pulse therapy were administered. CMR on day 152 showed disappearance of the myocardial edema. We report a unique case of successful treatment of severe myocarditis and the usefulness of follow-up CMR.
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Affiliation(s)
- Shinya Asatani
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Tanikawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Marina Hamaguchi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shoei Yoshizawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Tsuzuki
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kaita Sugiyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Tsukamoto
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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26
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Androulakis E, Mohiaddin R, Bratis K. Magnetic resonance coronary angiography in the era of multimodality imaging. Clin Radiol 2022; 77:e489-e499. [DOI: 10.1016/j.crad.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
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27
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Cardiovascular Magnetic Resonance Detects Inflammatory Cardiomyopathy in Symptomatic Patients with Inflammatory Joint Diseases and a Normal Routine Workup. J Clin Med 2022; 11:jcm11051428. [PMID: 35268519 PMCID: PMC8911388 DOI: 10.3390/jcm11051428] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/05/2023] Open
Abstract
Background. Patients with inflammatory joint diseases (IJD) are more likely to develop cardiovascular disease compared with the general population. We hypothesized that cardiovascular magnetic resonance (CMR) could identify cardiac abnormalities in patients with IJD and atypical symptoms unexplained by routine clinical evaluation. Patients-Methods. A total of 51 consecutive patients with IJD (32 with rheumatoid arthritis, 10 with ankylosing spondylitis, and 9 with psoriatic arthritis) and normal clinical, electrocardiographic and echocardiographic workups, were referred for CMR evaluation due to atypical chest pain, shortness of breath, and/or palpitations. Their CMR findings were compared with those of 40 non-IJD controls who were referred for the same reason. All participants were examined using either a 1.5 T or 3.0 T CMR system. For T1/T2 mapping, comparisons were performed separately for each field strength. Results. Biventricular systolic function was similar between groups. In total, 25 (49%) patients with IJD vs. 0 (0%) controls had replacement-type myocardial fibrosis (p < 0.001). The T2 signal ratio, early/late gadolinium enhancement, and extracellular volume fraction were significantly higher in the IJD group. Native T1 mapping was significantly higher in patients with IJD independent of the MRI field strength (p < 0.001 for both). T2 mapping was significantly higher in patients with IJD compared with controls only in those examined using a 1.5 T MR system—52.0 (50.0, 55.0) vs. 37.0 (33.5, 39.5), p < 0.001. Conclusions. In patients with IJD and a mismatch between cardiac symptoms and routine non-invasive evaluation, CMR uniquely identified a significant proportion of patients with myocardial inflammation. A CMR examination should be considered in patients with IJD in similar clinical settings.
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28
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Liu Y, Hsu J, Liu X, Lin X, Zhu Y, Jia F, Wu W, Chen W, Wang Q, Fang L. Electrophysiological, structural, and functional disorders in patients with inflammatory cardiomyopathy secondary to inflammatory myopathy. Ann Noninvasive Electrocardiol 2022; 27:e12938. [PMID: 35184366 PMCID: PMC9296788 DOI: 10.1111/anec.12938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background Inflammatory cardiomyopathy (IC) is a syndrome with chronic myocarditis and cardiac remodeling. This study aimed to explore predicting factors of adverse outcomes in patients with IC secondary to idiopathic inflammatory myopathy (IIM‐IC). Methods By means of a single‐center retrospective study, 52 patients with IIM‐IC at Peking Union Medical College Hospital were identified from January 1999 to June 2019. Electrocardiogram and echocardiography data were analyzed for the primary outcome (defined as all‐cause death) and secondary outcomes (defined as re‐hospitalization of heart failure and all‐cause death), using regression and survival analysis. Results The prevalence of atrial fibrillation, ventricular tachycardia, Q‐wave abnormality, left ventricular conduction abnormalities, and reduced left ventricular ejection fraction (LVEF) (≤40%) were 65.4%, 67.3%, 67.3%, 61.6%, and 50.5%. After a median follow‐up of 2 years (IQR 0.8–3.0), 26 cases were readmitted due to heart failure. Twenty‐two deaths were recorded, including 20 cardiogenic deaths. Among the patients with adverse events, the incidence of poor R‐wave progression, low‐voltage of the limb leads, Q‐wave abnormality, QRS duration >130 ms, left ventricular enlargement, and impaired systolic function were higher. Kaplan–Meier analysis showed that Q‐wave abnormality, limb leads low‐voltage, LVEF ≤40%, and left ventricular end‐diastolic dimension >60 mm were correlated with shorter survival. However, multivariate Cox regression analysis revealed that only Q‐wave abnormality (HR = 12.315) and LVEF ≤40% (HR = 5.616) were independent risk factors for all‐cause death. Conclusion Q‐wave abnormality and reduced LVEF are predictive of poor prognosis in patients with IIM‐IC.
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Affiliation(s)
- Yingxian Liu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jeffrey Hsu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohang Liu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Lin
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanlin Zhu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuwei Jia
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Wu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Chen
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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29
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Kumar K, Seetharam K, Poonam F, Gulati A, Sadiq A, Shetty V. The Role of Cardiac Imaging in the Evaluation of Cardiac Involvement in Systemic Diseases. Cureus 2021; 13:e20708. [PMID: 35106243 PMCID: PMC8788898 DOI: 10.7759/cureus.20708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/05/2022] Open
Abstract
For systemic diseases like rheumatoid arthritis, systemic lupus erythematosus (SLE), systemic sclerosis, systemic vasculitis, myopathies, and mixed connective tissue diseases, cardiac disease is a major contributing factor for morbidity and mortality. The cardiovascular manifestations are the result of various pathophysiological components, which complicate management. Furthermore, the signs and symptoms can be subtle and missed due to the complex nature of the underlying condition. As a result, various imaging approaches play an imperative role in diagnosis and prognosis. The evolving role of these modalities could lead to risk stratification and improved therapies in the future. In conclusion, our review article will highlight the role of cardiac imaging in the evaluation of cardiac involvement for systemic diseases.
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30
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Casteleyn V, Barzen G, Knebel F, Schneider U. Kardiale Beteiligungen bei rheumatologischen Erkrankungen –
eine Übersicht. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1552-3049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungRheumatische Erkrankungen gehen mit einem erhöhten
kardiovaskulären Risiko einher, können darüber hinaus
jedoch im Bereich aller kardialen Strukturen zu spezifischen
entzündlichen Veränderungen führen. Symptome wie
Dyspnoe, Tachykardie und Leistungsminderung stehen patientenseitig im
Vordergrund, wenngleich kardiale Beteiligungen nicht selten asymptomatisch
verlaufen. Diagnostisch werden neben der klinischen Untersuchung und
laborchemischen Verfahren apparative Diagnostiken wie Echokardiografie und
Kardio-MRT aber auch invasive Verfahren wie die Herzkatheteruntersuchung und
Myokardbiopsie angewendet. Die Therapie richtet sich nach der Grunderkrankung,
den betroffenen kardialen Strukturen und reicht von einer medikamentösen
Therapie bis zu interventionell-operativem Vorgehen.
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Affiliation(s)
- Vincent Casteleyn
- Rheumatologie, Charité Universitätsmedizin Berlin
Campus Charité Mitte, Berlin, Deutschland
| | - Gina Barzen
- Kardiologie, Charité Universitätsmedizin Berlin Campus
Charité Mitte, Berlin, Deutschland
| | - Fabian Knebel
- Kardiologie, Charité Universitätsmedizin Berlin Campus
Charité Mitte, Berlin, Deutschland
| | - Udo Schneider
- Rheumatologie, Charité Universitätsmedizin Berlin
Campus Charité Mitte, Berlin, Deutschland
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31
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Patnaik S, Jain MK, Ahmed S, Dash AK, P RK, Sahoo B, Mishra R, Behera MR. Short-term outcomes in children recovered from multisystem inflammatory syndrome associated with SARS-CoV-2 infection. Rheumatol Int 2021; 41:1957-1962. [PMID: 34259880 PMCID: PMC8278175 DOI: 10.1007/s00296-021-04932-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022]
Abstract
Multi-system inflammatory syndrome in children (MIS-C) associated with COVID-19 is a recently recognised potentially life-threatening entity. There is limited data on post-MIS-C sequelae. 21 children fulfilling the WHO criteria for MIS-C were included in our study. Data were collected at baseline and at 12–16 weeks post-discharge to look for any persistent sequelae mainly relating to the lungs or heart including coronary arteries. Fever was the most common presentation, found in 18 (85.7%) patients. All had a marked hyper-inflammatory state. Low ejection fraction (EF) was found in 10 (47.6%), but none had any coronary artery abnormality. All received corticosteroids, while 7 (33.3%) children required additional treatment with intravenous Immunoglobulins. 20 children improved while 1 left against medical advice. At discharge, 3 children had impaired left ventricular function. At median 15 weeks’ follow-up, no persistent complications were found. EF had returned to normal and no coronary artery abnormalities were found during repeat echocardiography. Chest radiographs showed no fibrosis and all biochemical parameters had normalized. The children with MIS-C are extremely sick during the acute stage. Timely and adequate management led to full recovery without any sequelae at a median follow-up of 15 weeks.
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Affiliation(s)
- Sibabratta Patnaik
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India.
| | - Mukesh Kumar Jain
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Arun Kumar Dash
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ram Kumar P
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Bandya Sahoo
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Reshmi Mishra
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Manas Ranjan Behera
- Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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32
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Porter A, Youngstein T, Babar S, Mason JC. A rare life-threatening presentation of Takayasu arteritis. Rheumatology (Oxford) 2021; 60:iii6-iii8. [PMID: 34137876 DOI: 10.1093/rheumatology/keab036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/08/2021] [Indexed: 01/14/2023] Open
Affiliation(s)
- Andrew Porter
- Rheumatology Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 OHS, UK
| | - Taryn Youngstein
- Rheumatology Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 OHS, UK
| | - Syed Babar
- Radiology Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 OHS, UK
| | - Justin C Mason
- Rheumatology Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 OHS, UK.,National Heart and Lung Institute, Imperial College London, London W12 ONN, UK
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33
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Mavrogeni SI, Bacopoulou F, Markousis-Mavrogenis G, Giannakopoulou A, Kariki O, Vartela V, Kolovou G, Charmandari E, Chrousos G. Cardiovascular Magnetic Resonance as Pathophysiologic Tool in Diabetes Mellitus. Front Endocrinol (Lausanne) 2021; 12:672302. [PMID: 34194393 PMCID: PMC8237858 DOI: 10.3389/fendo.2021.672302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/12/2021] [Indexed: 01/02/2023] Open
Abstract
Diabetes mellitus can independently contribute to cardiovascular disease and represents a severe risk factor for premature development of cardiovascular disease. A three-fold higher mortality than the general population has been observed in type 1 diabetes mellitus whereas a two- to four-fold increased probability to develop cardiovascular disease has been observed in type 2 diabetes mellitus. Cardiovascular magnetic resonance, a non-radiative modality, is superior to all other modalities in detecting myocardial infarction. The main cardiovascular magnetic resonance sequences used include a) balanced steady-state free precession (bSSFP) for function evaluation; b) T2-W for oedema detection; c) T1 W for ischemia detection during adenosine stress; and d) late gadolinium enhanced T1-W images (LGE), evaluated 15 min after injection of paramagnetic contrast agent gadolinium, which permit the diagnosis of replacement fibrosis, which appears white in the middle of suppressed, nulled myocardium. Although LGE is the technique of choice for diagnosis of replacement fibrosis, it cannot assess diffuse myocardial fibrosis. The application of T1 mapping (native or pre contrast and post contrast) allows identification of diffuse myocardial fibrosis, which is not detectable my other means. Native T1 and Contrast-enhanced T1 mapping are involved in the extracellular volume fraction (ECV) calculation. Recently, 1H-cardiovascular magnetic resonance spectroscopy has been applied to calculate the amount of myocardial triglycerides, but at the moment it is not part of the routine assessment of diabetes mellitus. The multifaceted nature of cardiovascular magnetic resonance has the great potential of concurrent evaluation of function and myocardial ischemia/fibrosis in the same examination and represents an indispensable tool for accurate diagnosis of cardiovascular disease in diabetes mellitus.
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Affiliation(s)
- Sophie I. Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, Kallithea, Greece
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
| | | | | | - Ourania Kariki
- Department of Cardiology, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Vasiliki Vartela
- Department of Cardiology, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Genovefa Kolovou
- Department of Cardiology, Onassis Cardiac Surgery Center, Kallithea, Greece
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - George Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Fragoulis GE, Soulaidopoulos S, Sfikakis PP, Dimitroulas T, D Kitas G. Effect of Biologics on Cardiovascular Inflammation: Mechanistic Insights and Risk Reduction. J Inflamm Res 2021; 14:1915-1931. [PMID: 34017189 PMCID: PMC8131071 DOI: 10.2147/jir.s282691] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
It is increasingly recognized that atherosclerosis and consequently cardiovascular disease (CVD) are closely linked with inflammatory processes. The latter is in the center of the pathogenic mechanism underlying autoimmune rheumatic diseases (ARD). It follows then, that optimal control of inflammation in ARDs may lead to a decrease of the accompanied CVD risk. Major trials (eg, CANTOS, CIRT), aimed at examining the possible benefits of immunomodulatory treatments in CVD, demonstrated conflicting results. On the other hand, substantial evidence is accumulating about the possible beneficial effects of biologic disease modifying antirheumatic drugs (bDMARDs) in patients with ARDs, particularly those with rheumatoid arthritis (RA). It seems that bDMARDs (some more than others) alter the lipid profile in RA patients but do not adversely affect, in most cases, the TC/HDL ratio. Favorable effects are noted for arterial stiffness and endothelial function. This is reflected in the lower risk for CVD events, seen in observational studies of RA patients treated with bDMARDs. It should be stressed that more data exist for the TNF-inhibitors than for other bDMARDs, such as tocilizumab, abatacept and rituximab. As regards the spondyloarthropathies (SpA), data are less robust. For TNF-inhibitors, effects appear to be on par with those seen in RA but no conclusions can be drawn for newer biologic drugs used in SpA (eg, IL-17 blockers). Finally, there is accumulating evidence for a beneficial effect of immunosuppressive treatment in cardiac inflammation and function in several ARDs. Introduction of newer therapeutic options in clinical practice seem to have a positive impact on CVD in the setting of ARD. This is probably due to better control of inflammation, but direct improvement in vascular pathology is also a valid hypothesis. Most data are derived from observational studies and, therefore, randomized controlled trials are needed to assess the possible favorable effect of bDMARDs on CVD outcomes.
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Affiliation(s)
- George E Fragoulis
- Rheumatology Unit, Joint Rheumatology Program, Medical School, First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, 115 27, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, 115 27, Greece
| | - Petros P Sfikakis
- Rheumatology Unit, Joint Rheumatology Program, Medical School, First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, 115 27, Greece
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, 546 41, Greece
| | - George D Kitas
- Department of Rheumatology, Russells Hall Hospital, Dudley Group NHS FT, Dudley, DY1 2HQ, UK.,Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, M13 9PT, UK
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Abstract
PURPOSE OF REVIEW Autoimmune rheumatic diseases (ARDs) affect 8% of the population and approximately 78% of patients are women. Myocardial disease in ARDs is the endpoint of various pathophysiologic mechanisms including atherosclerosis, valvular disease, systemic, myocardial, and/or vascular inflammation, as well as myocardial ischemia and replacement/diffuse fibrosis. RECENT FINDINGS The increased risk of CVD in ARDs leads to excess comorbidity not fully explained by traditional cardiovascular risk factors. It seems that the chronic inflammatory status typically seen in ARDs, promotes both the development of myocardial inflammation/fibrosis and the acceleration of atherosclerosis. CMR (cardio-vascular magnetic resonance) is the ideal imaging modality for the evaluation of cardiac involvement in patients with ARDs, as it can simultaneously assess cardiac function and characterize myocardial tissues with regard to oedema and fibrosis. Due to its high spatial resolution, CMR is capable of identifying various disease entities such as myocardial oedema /inflammation, subendocardial vasculitis and myocardial fibrosis, that are often missed by other imaging modalities, notably at an early stage of development. Although generally accepted guidelines about the application of CMR in ARDs have not yet been formulated, according to our experience and the available published literature, we recommend CMR in ARD patientS with new-onset heart failure (HF), arrhythmia, for treatment evaluation/change or if there is any mismatch between patient symptoms and routine non-invasive evaluation.
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Ordovas KG, Baldassarre LA, Bucciarelli-Ducci C, Carr J, Fernandes JL, Ferreira VM, Frank L, Mavrogeni S, Ntusi N, Ostenfeld E, Parwani P, Pepe A, Raman SV, Sakuma H, Schulz-Menger J, Sierra-Galan LM, Valente AM, Srichai MB. Cardiovascular magnetic resonance in women with cardiovascular disease: position statement from the Society for Cardiovascular Magnetic Resonance (SCMR). J Cardiovasc Magn Reson 2021; 23:52. [PMID: 33966639 PMCID: PMC8108343 DOI: 10.1186/s12968-021-00746-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/17/2021] [Indexed: 01/09/2023] Open
Abstract
This document is a position statement from the Society for Cardiovascular Magnetic Resonance (SCMR) on recommendations for clinical utilization of cardiovascular magnetic resonance (CMR) in women with cardiovascular disease. The document was prepared by the SCMR Consensus Group on CMR Imaging for Female Patients with Cardiovascular Disease and endorsed by the SCMR Publications Committee and SCMR Executive Committee. The goals of this document are to (1) guide the informed selection of cardiovascular imaging methods, (2) inform clinical decision-making, (3) educate stakeholders on the advantages of CMR in specific clinical scenarios, and (4) empower patients with clinical evidence to participate in their clinical care. The statements of clinical utility presented in the current document pertain to the following clinical scenarios: acute coronary syndrome, stable ischemic heart disease, peripartum cardiomyopathy, cancer therapy-related cardiac dysfunction, aortic syndrome and congenital heart disease in pregnancy, bicuspid aortic valve and aortopathies, systemic rheumatic diseases and collagen vascular disorders, and cardiomyopathy-causing mutations. The authors cite published evidence when available and provide expert consensus otherwise. Most of the evidence available pertains to translational studies involving subjects of both sexes. However, the authors have prioritized review of data obtained from female patients, and direct comparison of CMR between women and men. This position statement does not consider CMR accessibility or availability of local expertise, but instead highlights the optimal utilization of CMR in women with known or suspected cardiovascular disease. Finally, the ultimate goal of this position statement is to improve the health of female patients with cardiovascular disease by providing specific recommendations on the use of CMR.
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Affiliation(s)
| | | | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol, UK
- Bristol National Institute of Health Research (NIHR) Biomedical , Research Centre, Bristol, UK
- University Hospitals Bristol, Bristol, UK
- University of Bristol, Bristol, UK
| | - James Carr
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Vanessa M Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- Medical College of Wisconsin, Wisconsin, USA
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
- Kapodistrian University of Athens, Athens, Greece
| | - Ntobeko Ntusi
- University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio C.N.R., Pisa, Italy
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University, Indianapolis, USA
| | - Hajime Sakuma
- Department of Radiology, Mie University School of Medicine, Mie, Japan
| | - Jeanette Schulz-Menger
- harite Hospital, University of Berlin, Berlin, Germany
- HELIOS-Clinics Berlin-Buch, Berlin, Germany
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Cohen R, Nhan P, Cholet C, Jachiet V, Ederhy S, Mékinian A, Boccara F, Fain O, Cohen A. Acute Myocarditis Revealing Adult-Onset Still's Disease. JACC Case Rep 2021; 3:1002-1006. [PMID: 34317673 PMCID: PMC8311366 DOI: 10.1016/j.jaccas.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 03/12/2021] [Indexed: 01/09/2023]
Abstract
A 34-year-old man presented with fever, palpitations, maculopapular rash, pharyngitis, left cheilitis, and bilateral gonalgia. High-sensitivity troponin I concentration was 4,900 ng/l. Transthoracic echocardiogram revealed reduced global longitudinal strain. Cardiac magnetic resonance imaging showed acute myocarditis. Adult-onset Still’s disease was diagnosed, and treatment with intravenous corticosteroids and tocilizumab was initiated. (Level of Difficulty: Beginner.)
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Affiliation(s)
- Raphaël Cohen
- Department of Cardiology, Saint-Antoine and Tenon Hospitals, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Pascal Nhan
- Department of Cardiology, Saint-Antoine and Tenon Hospitals, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Clément Cholet
- Radiology Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Vincent Jachiet
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine and Sorbonne University, Paris, France
| | - Stéphane Ederhy
- Department of Cardiology, Saint-Antoine and Tenon Hospitals, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Arsène Mékinian
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine and Sorbonne University, Paris, France
| | - Franck Boccara
- Department of Cardiology, Saint-Antoine and Tenon Hospitals, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France.,National de la Santé Et de la Recherche Médicale Unité Mixte de Recherche S_938, Centre de Recherche Saint-Antoine, Paris, France
| | - Olivier Fain
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine and Sorbonne University, Paris, France
| | - Ariel Cohen
- Department of Cardiology, Saint-Antoine and Tenon Hospitals, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France.,Institut National de la Santé Et de la Recherche Médicale Unité Mixte de Recherche en Sciences-Institute of Cardiometabolism And Nutrition 1166, Sorbonne University, Paris, France
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38
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Markousis-Mavrogenis G, Sfikakis PP, Koutsogeorgopoulou L, Dimitroulas T, Katsifis G, Giannakopoulou A, Voulgari P, Kolovou G, Kitas GD, Mavrogeni SI. Cardiovascular Magnetic Resonance Reveals Cardiac Pathophysiology in Autoimmune Rheumatic Diseases. Mediterr J Rheumatol 2021; 32:15-20. [PMID: 34386698 PMCID: PMC8314875 DOI: 10.31138/mjr.32.1.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/26/2020] [Accepted: 01/15/2020] [Indexed: 02/06/2023] Open
Abstract
Background/Aims The high incidence of cardiovascular disease (CVD) in patients with autoimmune rheumatic diseases (ARDs) is the main driver towards increased mortality in this patient group. Cardiovascular magnetic resonance (CMR) can non-invasively and robustly detect CVD in ARD patients at an early stage of development. The review summarises the diagnostic information provided by CMR in ARD patients. Summary CMR uses a strong magnetic field combined with radio-frequency pulses (pulse sequences) to generate images. Firstly, balanced steady-state free precession (bSSFP) can be used for evaluating cardiac anatomy, mass, wall motion, atrial/ventricular function. Secondly, T2-weighted imaging (T2-W) can be used for oedema detection, which appears as a high signal intensity area on STIR (short tau inversion recovery) images. T2 mapping is a newer T2-W technique that can provide more optimal identification of myocardial oedema. Lastly, late gadolinium enhanced (LGE) T1-W images, taken 15 min. after injection of contrast agent, allow the detection of myocardial replacement fibrosis, which appears as a bright area in a background of black myocardium. However, LGE has inherent disadvantages for the assessment of diffuse myocardial fibrosis. Therefore, T1 mapping and extracellular volume fraction (ECV) have been developed to quantify diffuse myocardial fibrosis. Results Although multicentre studies are still missing, the CMR parameters have been extensively applied for the identification of oedema/fibrosis and treatment decision making in ARDs. Conclusions Tissue characterisation with CMR allows early and robust identification of CVD in ARD patients and contributes to personalized management in the patients.
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Affiliation(s)
| | - Petros P Sfikakis
- Joint Rheumatology, Laikon Hospital, Athens, Greece.,Department of Pathophysiology, Laikon Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Loukia Koutsogeorgopoulou
- Department of Pathophysiology, Laikon Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Dimitroulas
- Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | - George D Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester, United Kingdom
| | - Sophie I Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece.,Department of Pathophysiology, Laikon Hospital, National Kapodistrian University of Athens, Athens, Greece
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39
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Feng C, Liu W, Sun X, Wang Q, Zhu X, Zhou X, Xu Y, Zhu Y. Myocardial involvement characteristics by cardiac MR imaging in patients with polymyositis and dermatomyositis. Rheumatology (Oxford) 2021; 61:572-580. [PMID: 33742670 DOI: 10.1093/rheumatology/keab271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/10/2021] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Myocardial involvement is frequently observed in polymyositis (PM) and dermatomyositis (DM) but typically remains subclinical. This study aimed to investigate characteristics of myocardial involvement and compare differences between patients with PM and DM by cardiac magnetic resonance (CMR) imaging. METHODS From March 2017 to December 2019, a total of 17 PM and 27 DM patients were enrolled in this retrospective study. In all patients, clinical assessment and CMR examination were performed. CMR parameters, including left ventricular (LV) morphologic and functional parameters and CMR tissue characterization imaging parameters, such as native T1, T2, extracellular volume (ECV), and late gadolinium enhancement (LGE) were analyzed. RESULTS Patients in both PM and DM groups, elevated global native T1 and ECV values were observed. Global ECV values were higher in the PM group when compared to the DM group (33.24 ± 2.97% vs. 30.36 ± 4.20%; P = 0.039). Furthermore, patients in PM and DM groups showed a different positive segment distribution of LGE, native T1 and ECV, whereas the number of positive segments in PM patients was greater compared to that in DM patients. No significant differences in LV morphological and functional parameters were observed between patients in PM and DM groups and most were in normal range. CONCLUSION CMR tissue characterization imaging could detect early myocardial involvement in PM and DM patients without overt LV dysfunction. Furthermore, characteristics of myocardial involvement were different between PM and DM patients with more serious seen in PM patients.
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Affiliation(s)
- Changjing Feng
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wangyan Liu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoxuan Sun
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Wang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaomei Zhu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ldt., Shanghai, China
| | - Yi Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yinsu Zhu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Markousis-Mavrogenis G, Poulos G, Dimitroulas T, Giannakopoulou A, Mavragani C, Vartela V, Manolopoulou D, Kolovou G, Voulgari P, Sfikakis PP, Kitas GD, Mavrogeni SI. Ventricular Tachycardia Has Mainly Non-Ischaemic Substrates in Patients with Autoimmune Rheumatic Diseases and a Preserved Ejection Fraction. Diagnostics (Basel) 2021; 11:diagnostics11030519. [PMID: 33804066 PMCID: PMC8001227 DOI: 10.3390/diagnostics11030519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/16/2021] [Accepted: 03/12/2021] [Indexed: 12/30/2022] Open
Abstract
Non-sustained ventricular tachycardia (NSVT) is a potentially lethal arrhythmia that is most commonly attributed to coronary artery disease. We hypothesised that among patients with NSVT and preserved ejection fraction, cardiovascular magnetic resonance (CMR) would identify a different proportion of ischaemic/non-ischaemic arrhythmogenic substrates in those with and without autoimmune rheumatic diseases (ARDs). In total, 80 consecutive patients (40 with ARDs, 40 with non-ARD-related cardiac pathology) with NSVT in the past 15 days and preserved left ventricular ejection fraction were examined using a 1.5-T system. Evaluated parameters included biventricular volumes/ejection fractions, T2 signal ratio, early/late gadolinium enhancement (EGE/LGE), T1 and T2 mapping and extracellular volume fraction (ECV). Mean age did not differ across groups, but patients with ARDs were more often women (32 (80%) vs. 15 (38%), p < 0.001). Biventricular systolic function, T2 signal ratio and EGE and LGE extent did not differ significantly between groups. Patients with ARDs had significantly higher median native T1 mapping (1078.5 (1049.0–1149.0) vs. 1041.5 (1014.0–1079.5), p = 0.003), higher ECV (31.0 (29.0–32.0) vs. 28.0 (26.5–30.0), p = 0.003) and higher T2 mapping (57.5 (54.0–61.0) vs. 52.0 (48.0–55.5), p = 0.001). In patients with ARDs, the distribution of cardiac fibrosis followed a predominantly non-ischaemic pattern, with ischaemic patterns being more common in those without ARDs (p < 0.001). After accounting for age and cardiovascular comorbidities, most findings remained unaffected, while only tissue characterisation indices remained significant after additionally correcting for sex. Patients with ARDs had a predominantly non-ischaemic myocardial scar pattern and showed evidence of diffuse inflammatory/ischaemic changes (elevated native T1-/T2-mapping and ECV values) independent of confounding factors.
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Affiliation(s)
| | - George Poulos
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.P.); (V.V.); (D.M.); (G.K.)
| | - Theodoros Dimitroulas
- Department of Internal Medicine, Rheumatology, Aristotle University, 54124 Thessaloniki, Greece;
| | | | - Clio Mavragani
- Pathophysiology Department, Laikon Hospital, 11527 Athens, Greece;
- First Department of Propaedeutic Internal Medicine and Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece;
| | - Vasiliki Vartela
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.P.); (V.V.); (D.M.); (G.K.)
| | - Dionysia Manolopoulou
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.P.); (V.V.); (D.M.); (G.K.)
| | - Genovefa Kolovou
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.P.); (V.V.); (D.M.); (G.K.)
| | | | - Petros P. Sfikakis
- First Department of Propaedeutic Internal Medicine and Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece;
- First Department of Propeudeutic and Internal Medicine, Laikon Hospital, 11527 Athens, Greece
| | - George D. Kitas
- Dudley Group NHS Foundation Trust, Dudley DY1 2HQ, UK;
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sophie I. Mavrogeni
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.P.); (V.V.); (D.M.); (G.K.)
- First Department of Propaedeutic Internal Medicine and Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece;
- Correspondence: ; Tel./Fax: +30-210-98-82-797
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Markousis-Mavrogenis G, Mavrogeni SI. Cutting the "Gordian Knot" - Cardiac Involvement in Primary Sjögren Syndrome. J Rheumatol 2021; 48:802-803. [PMID: 33722948 DOI: 10.3899/jrheum.201171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Sophie I Mavrogeni
- S.I. Mavrogeni, MD, PhD, Onassis Cardiac Surgery Center, and National and Kapodistrian University of Athens, Athens, Greece.
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Mavrogeni SI, Bacopoulou F, Markousis-Mavrogenis G, Chrousos G, Charmandari E. Cardiovascular Imaging in Obesity. Nutrients 2021; 13:744. [PMID: 33652678 PMCID: PMC7996902 DOI: 10.3390/nu13030744] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/21/2022] Open
Abstract
Obesity represents one of the most challenging public health problems of our century. It accounts for approximately 5% of deaths worldwide, mostly owing to cardiovascular disease and its associated complications. Cardiovascular noninvasive imaging may provide early accurate information about hypertrophy and ischemia/fibrosis in obese subjects. Echocardiography and nuclear cardiology have serious limitations in obese subjects owing to poor acoustic window and attenuation artifacts, respectively. Coronary computed tomography angiography can provide information about obstructive coronary disease; however, the use of radiation is a serious disadvantage. Finally, cardiac magnetic resonance (CMR) holds the promise of an "all in one" examination by combining evaluation of function, wall motion/thickness, stress rest/perfusion, replacement and diffuse fibrosis without radiation. Future studies are required to document the cost/benefit ratio of the CMR in the evaluation of cardiovascular risk in overweight/obese children and adolescents.
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Affiliation(s)
- Sophie I. Mavrogeni
- Onassis Cardiac Surgery Center, 17674 Athens, Greece; (S.I.M.); (G.M.-M.)
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, 11527 Athens, Greece; (F.B.); (G.C.)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, 11527 Athens, Greece; (F.B.); (G.C.)
| | | | - George Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, 11527 Athens, Greece; (F.B.); (G.C.)
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Νational and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, 11527 Athens, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 11527 Athens, Greece
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Νational and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, 11527 Athens, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 11527 Athens, Greece
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Cardiovascular Magnetic Resonance Mapping and Strain Assessment for the Diagnosis of Cardiac Involvement in Idiopathic Inflammatory Myopathy Patients With Preserved Left Ventricular Ejection Fraction. J Thorac Imaging 2021; 36:254-261. [PMID: 33560763 DOI: 10.1097/rti.0000000000000578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of the study was to evaluate the role of cardiac magnetic resonance (CMR) mapping and strain analysis in the identification of cardiac involvement in idiopathic inflammatory myopathy (IIM) patients with preserved left ventricular ejection fraction. MATERIALS AND METHODS In all, 38 IIM patients who underwent CMR examination at our institution were retrospectively included. Twenty-three age-matched healthy individuals served as controls. Mapping parameters including native T1, extracellular volume (ECV), and T2 mapping and strain parameters including global radial strain, global circumferential strain, and global longitudinal strain were measured semiautomatically using a dedicated processing software. All the mapping and strain values were compared between patients and controls. RESULTS Late gadolinium enhancement was only present in IIM patients (n=17, 44.7%). IIM patients showed higher native T1 (1346 vs. 1269 ms, P<0.001), ECV (31.1% vs. 27.4%, P<0.01), and higher T2 (44.4 vs. 39.2 ms, P<0.001) values compared with controls. The global radial strain (36.7% vs. 46.9%, P<0.001), global circumferential strain (-21.2% vs. -24.1%, P<0.01), and global longitudinal strain (-13.6% vs. -15.6%, P<0.05) values were significantly reduced compared with controls. CONCLUSIONS Native T1, ECV, T2 values, and global strain values may hold promise for the detection of subclinical myocardial involvement in IIM patients with preserved left ventricular ejection fraction.
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Clinical Outcomes of Myocarditis after Moderate-Dose Steroid Therapy in Systemic Sclerosis: A Pilot Study. Int J Rheumatol 2021; 2020:8884442. [PMID: 33414828 PMCID: PMC7769651 DOI: 10.1155/2020/8884442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 12/02/2022] Open
Abstract
Background Myocarditis is reported in systemic sclerosis (SSc); however, treatment options and outcomes are limited. Our objective was to define cardiac outcomes after moderate-dose steroid therapy in SSc patients with myocarditis. Method An open-label study was conducted among SSc patients with myocarditis—as defined by cardiovascular magnetic resonance (CMR), disease onset <5 years, and a NYHA functional class ≥II. All enrolled patients received prednisolone (30 mg/d) which would be tapered off by week 24, and CMR was followed up at the end of treatment. Results A total of 20 SSc patients were enrolled which 12 patients completed the study. At week 24, 8 of the 12 cases experienced improvement of myocarditis. Compared to those with no improvement, these 8 patients had significantly longer disease duration (p = 0.03), higher heart rate at baseline (p = 0.049) and week 24 (p = 0.04), lower left ventricular (LV) and right ventricular (RV) stroke volume at baseline (p = 0.002 and p = 0.01) and week 24 (p = 0.01 and p = 0.02), and lower LV and RV cardiac output at week 24 (p = 0.01 and p = 0.01). Four cases died during follow-up (3 due to cardiac complications, 1 due to renal crisis). The two who died from heart failure had very high NT-prohormone-brain natriuretic peptide (NT-proBNP) and impaired LV ejection fraction (LVEF), and the one who died from arrhythmia had very high sensitivity of cardiac Troponin-T (hs-cTnT). Conclusions Moderate-dose steroid therapy may improve myocarditis in SSc. A proportion of patients died due to cardiac complications during treatment, particularly those with high hs-cTnT, high NT-proBNP, and impaired LVEF. This trial is registered with NCT03607071.
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Sen G, Gordon P, Sado DM. Cardiac manifestations of rheumatological disease: a synopsis for the cardiologist. Heart 2020; 107:1173-1181. [PMID: 33310886 DOI: 10.1136/heartjnl-2019-316460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Gautam Sen
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Patrick Gordon
- Department of Rheumatology, King's College Hospital, London, UK
| | - Daniel M Sado
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Giollo A, Dumitru RB, Swoboda PP, Plein S, Greenwood JP, Buch MH, Andrews J. Cardiac magnetic resonance imaging for the detection of myocardial involvement in granulomatosis with polyangiitis. Int J Cardiovasc Imaging 2020; 37:1053-1062. [PMID: 33057879 PMCID: PMC7969556 DOI: 10.1007/s10554-020-02066-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
The prevalence of undiagnosed cardiac involvement in granulomatosis with polyangiitis (GPA) is unknown. In this prospective study we investigated the utility of cardiovascular magnetic resonance (CMR) to identify myocardial abnormalities in GPA and their correlation with disease phenotype. Twenty-six patients with GPA and no cardiovascular disease or diabetes mellitus underwent contrast-enhanced CMR, including late gadolinium-enhancement (LGE), T1-mapping for native T1 and extra-cellular volume (ECV) quantification for assessment of myocardial fibrosis, cine imaging and tissue tagging for assessment of left ventricular (LV) function. Twenty-five healthy volunteers (HV) with comparable age, sex, BMI and arterial blood pressure served as controls. Patients with GPA had similar cardiovascular risk profile to HV. A focal, non-ischaemic LGE pattern of fibrosis was detected in 24% of patients and no controls (p = 0.010). Patients with myocardial LGE were less frequently PR3 ANCA (7% vs 93%, p = 0.007), and had involvement of the lower respiratory tract and skin. LGE scar mass was higher in patients presenting with renal involvement. Native T1 and ECV were higher in patients with GPA than HV; ECV was higher in those with relapsing disease, and native T1 was inversely associated with PR3 ANCA (β = - 0.664, p = 0.001). Peak systolic strain was slightly reduced in GPA compared to controls; LV ejection function was inversely correlated with disease duration (β = - 0.454, p = 0.026). Patients with GPA have significant myocardial abnormalities on CMR. ANCA, systemic involvement and disease severity were associated with myocardial fibrosis. CMR could be a useful tool for risk stratification of myocardial involvement in GPA.
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Affiliation(s)
- Alessandro Giollo
- NIHR Leeds Biomedical Research Centre and Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK. .,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK. .,Rheumatology Section, Department of Medicine, University of Verona, Policlinico G.B. Rossi 10, 37134, Verona, Italy.
| | - Raluca B Dumitru
- NIHR Leeds Biomedical Research Centre and Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Peter P Swoboda
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sven Plein
- NIHR Leeds Biomedical Research Centre and Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- NIHR Leeds Biomedical Research Centre and Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Teaching Hospitals NHS Trust, Manchester, UK
| | - Jacqueline Andrews
- NIHR Leeds Biomedical Research Centre and Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Arsenaki E, Georgakopoulos P, Mitropoulou P, Koutli E, Thomas K, Charakida M, Georgiopoulos G. Cardiovascular Disease in Juvenile Idiopathic Arthritis. Curr Vasc Pharmacol 2020; 18:580-591. [DOI: 10.2174/1570161118666200408121307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 01/21/2023]
Abstract
Juvenile idiopathic arthritis (JIA), is a term used to describe a group of inflammatory disorders
beginning before the age of 16 years. Although for the majority of children remission is achieved
early, those with systemic or polyarticular form of the disease may present persistent symptoms in
adulthood. Considering that there is overlap in the pathogenesis of JIA with adult rheumatic diseases,
concerns have been raised as to whether JIA patients could be at increased cardiovascular (CV) risk in
the long-term. In this review, we summarize evidence for CV involvement in JIA and present data on
CV risk factors and surrogate markers of arterial disease. We also provide information on beneficial and
harmful CV effects of anti-inflammatory medications in the context of JIA and suggest strategies for
CV screening. Overall, patients with systemic forms of JIA demonstrate an adverse lipid profile and
early arterial changes relevant to accelerated arterial disease progression. Although there is paucity of
data on CV outcomes, we recommend a holistic approach in the management of JIA patients, which
includes CV risk factor monitoring and lifestyle modification as well as use, when necessary, of antiinflammatory
therapies with documented CV safety.
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Affiliation(s)
| | - Panagiotis Georgakopoulos
- National Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Evangelia Koutli
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marietta Charakida
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
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Soulaidopoulos S, Madenidou AV, Daoussis D, Melissaropoulos K, Mavrogeni S, Kitas G, Dimitroulas T. Cardiovascular Disease in the Systemic Vasculitides. Curr Vasc Pharmacol 2020; 18:463-472. [PMID: 32000652 DOI: 10.2174/1570161118666200130093432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/28/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
The vasculitides are a heterogeneous group of disorders, characterized by inflammatory cell infiltration and necrosis of blood vessels that cause vascular obstruction or aneurysm formation, affecting various organs such as lungs, kidneys, skin and joints. Cardiac involvement is commonly encountered in primary systemic vasculitis and it is associated with increased morbidity and mortality. Depending on the dominant pathophysiological mechanism, heart complications may manifest in different ways, including myocardial ischemia due to impaired micro- or macrovascular circulation, progressive heart failure following valvular heart disease and myocardial dysfunction, (sub) clinical myocarditis, pericarditis, pulmonary hypertension as well as arteritis of coronary vessels. Beyond cardioprotective regimens, aggressive immunosuppression reduces the inflammatory burden and modulates the progression of cardiovascular complications. Perioperative management of inflammation, when surgical treatment is indicated, improves surgical success rates and postoperative long-term prognosis. We aim to provide an overview of the pathogenetic, diagnostic and therapeutic principles of cardiovascular involvement disease in the various forms of systemic vasculitis.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | | | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, Faculty of Medicine, University of Patras Medical School, Patras, Greece
| | - Konstantinos Melissaropoulos
- Department of Rheumatology, Patras University Hospital, Faculty of Medicine, University of Patras Medical School, Patras, Greece
| | | | - George Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, United Kingdom
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Mavrogeni SI, Buch M, Markousis-Mavrogenis G, Dumitru B, Pugliese NR, Gargani L. The perpetual sword of Damocles: Cardiac involvement in systemic sclerosis and the role of non-invasive imaging modalities in medical decision making. Eur J Rheumatol 2020; 7:S203-S211. [PMID: 32697932 DOI: 10.5152/eurjrheum.2020.19110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/15/2020] [Indexed: 12/23/2022] Open
Abstract
Cardiac involvement in systemic sclerosis (SSc-CI) may be either primary or secondary to pathologic processes in other organs. In contrast to other autoimmune rheumatic diseases, primary SSc-CI preferentially manifests as non-ischemic myocardial fibrosis, with or without myocardial inflammation and minimal involvement of epicardial coronary arteries. Recent developments in cardiovascular (CV) imaging modalities and their increasing availability necessitate the creation of concrete recommendations for use in SSc patients, based on the most recent scientific evidence. Echocardiography offers rapid, effective, multiparametric, and widely available imaging evaluation of SSc patients, owing to its ability to analyze both left and right chambers, as well as pulmonary hemodynamics. However, it is an operator- and acoustic window-dependent modality that cannot perform tissue characterization, which is crucial in these conditions. CV magnetic resonance in SSc patients can accurately evaluate biventricular volumes, ejection fractions, myocardial fibrosis load, and changes suggestive of myocarditis. T2 mapping is the best index of edema indicating acute myocardial inflammation, while late gadolinium enhancement is an index of replacement fibrosis. Extracellular volume fraction (ECV) is an indicator of diffuse myocardial fibrosis only in the absence of significant myocardial inflammation. However, if myocardial inflammation/fibrosis coexist, ECV reflects a combination of the two, but it cannot completely discriminate between them. SSc-CI hangs like the sword of Damocles over physicians managing SSc patients. A constructive partnership between the rheumatologist and the cardiologist is necessary to provide each SSc patient with a comprehensive screening protocol for early detection and treatment of cardiopulmonary pathologic processes.
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Affiliation(s)
| | - Maya Buch
- Division of Rheumatic and Musculoskeletal Medicine, Institute of Rheumatic and Musculoskeletal Medicine, Leeds Institute of Molecular Medicine (LIMM), Section of Clinical Musculoskeletal Disease, Leeds, UK
| | | | - Bianca Dumitru
- Division of Rheumatic and Musculoskeletal Medicine, Institute of Rheumatic and Musculoskeletal Medicine, Leeds Institute of Molecular Medicine (LIMM), Section of Clinical Musculoskeletal Disease, Leeds, UK
| | - Nicola Riccardo Pugliese
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
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Current understanding and future perspectives of brain-heart-kidney axis in psoriatic arthritis. Rheumatol Int 2020; 40:1361-1368. [PMID: 32594220 DOI: 10.1007/s00296-020-04633-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
Psoriatic arthritis (PsA) patients are at a higher risk of systemic inflammatory sequelae, leading to microalbuminuria, cardiovascular (CVD) and neuropsychiatric (NPD) disease. Our aim is to present the existing literature about the relationship between CVD, kidney and NPD in PsA. The literature evaluation of PsA revealed that chronic T-cell activation and increased levels of circulating immune complexes can cause glomerular injury leading to microalbuminuria, which predicts CVD and all-cause mortality in both diabetic and non-diabetic patients. Furthermore, it is a marker of preclinical brain damage and identifies patients at higher risk of NPD/CVD events. Among the currently used imaging modalities in PsA, magnetic resonance imaging (MRI) maintains a crucial role, because it is ideal for concurrent evaluation of brain/heart involvement and serial follow up assessment. There is increasing evidence regarding the relationship between kidneys, heart and brain in PsA. Although currently there are no official recommendations about a combined brain/heart MRI in PsA, it could be considered in PsA with microalbuminuria, arrhythmia, HF, cognitive dysfunction and/or depression.
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