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Tsujimoto Y, Kumasawa J, Shimizu S, Nakano Y, Kataoka Y, Tsujimoto H, Kono M, Okabayashi S, Imura H, Mizuta T. Doppler trans-thoracic echocardiography for detection of pulmonary hypertension in adults. Cochrane Database Syst Rev 2022; 5:CD012809. [PMID: 35532166 PMCID: PMC9132178 DOI: 10.1002/14651858.cd012809.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is an important cause of morbidity and mortality, which leads to a substantial loss of exercise capacity. PH ultimately leads to right ventricular overload and subsequent heart failure and early death. Although early detection and treatment of PH are recommended, due to the limited responsiveness to therapy at late disease stages, many patients are diagnosed at a later stage of the disease because symptoms and signs of PH are nonspecific at earlier stages. While direct pressure measurement with right-heart catheterisation is the clinical reference standard for PH, it is not routinely used due to its invasiveness and complications. Trans-thoracic Doppler echocardiography is less invasive, less expensive, and widely available compared to right-heart catheterisation; it is therefore recommended that echocardiography be used as an initial diagnosis method in guidelines. However, several studies have questioned the accuracy of noninvasively measured pulmonary artery pressure. There is substantial uncertainty about the diagnostic accuracy of echocardiography for the diagnosis of PH. OBJECTIVES To determine the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH. SEARCH METHODS We searched MEDLINE, Embase, Web of Science Core Collection, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform from database inception to August 2021, reference lists of articles, and contacted study authors. We applied no restrictions on language or type of publication. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH, where right-heart catheterisation was the reference standard. We excluded diagnostic case-control studies (two-gate design), studies where right-heart catheterisation was not the reference standard, and those in which the reference standard threshold differed from 25 mmHg. We also excluded studies that did not provide sufficient diagnostic test accuracy data (true-positive [TP], false-positive [FP], true-negative [TN], and false-negative [FN] values, based on the reference standard). We included studies that provided data from which we could extract TP, FP, TN, and FN values, based on the reference standard. Two authors independently screened and assessed the eligibility based on the titles and abstracts of records identified by the search. After the title and abstract screening, the full-text reports of all potentially eligible studies were obtained, and two authors independently assessed the eligibility of the full-text reports. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. We assessed the methodological quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We estimated a summary receiver operating characteristic (SROC) curve by fitting a hierarchical summary ROC (HSROC) non-linear mixed model. We explored sources of heterogeneity regarding types of PH, methods to estimate the right atrial pressure, and threshold of index test to diagnose PH. All analyses were performed using the Review Manager 5, SAS and STATA statistical software. MAIN RESULTS We included 17 studies (comprising 3656 adult patients) assessing the diagnostic accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH. The included studies were heterogeneous in terms of patient distribution of age, sex, WHO classification, setting, country, positivity threshold, and year of publication. The prevalence of PH reported in the included studies varied widely (from 6% to 88%). The threshold of index test for PH diagnosis varied widely (from 30 mmHg to 47 mmHg) and was not always prespecified. No study was assigned low risk of bias or low concern in each QUADAS-2 domain assessed. Poor reporting, especially in the index test and reference standard domains, hampered conclusive judgement about the risk of bias. There was little consistency in the thresholds used in the included studies; therefore, common thresholds contained very sparse data, which prevented us from calculating summary points of accuracy estimates. With a fixed specificity of 86% (the median specificity), the estimated sensitivity derived from the median value of specificity using HSROC model was 87% (95% confidence interval [CI]: 78% to 96%). Using a prevalence of PH of 68%, which was the median among the included studies conducted mainly in tertiary hospitals, diagnosing a cohort of 1000 adult patients under suspicion of PH would result in 88 patients being undiagnosed with PH (false negatives) and 275 patients would avoid unnecessary referral for a right-heart catheterisation (true negatives). In addition, 592 of 1000 patients would receive an appropriate and timely referral for a right-heart catheterisation (true positives), while 45 patients would be wrongly considered to have PH (false positives). Conversely, when we assumed low prevalence of PH (10%), as in the case of preoperative examinations for liver transplantation, the number of false negatives and false positives would be 13 and 126, respectively. AUTHORS' CONCLUSIONS Our evidence assessment of echocardiography for the diagnosis of PH in adult patients revealed several limitations. We were unable to determine the average sensitivity and specificity at any particular index test threshold and to explain the observed variability in results. The high heterogeneity of the collected data and the poor methodological quality would constrain the implementation of this result into clinical practice. Further studies relative to the accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH in adults, that apply a rigorous methodology for conducting diagnostic test accuracy studies, are needed.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Department of Clinical Research and Epidemiology, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshio Nakano
- Department of Respiratory Medicine, Sakai City Medical Center, Sakai City, Japan
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Michihiko Kono
- Department of Critical Care Medicine, Sakai City Medical Center, Osaka, Japan
| | - Shinji Okabayashi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruki Imura
- Department of Health Informatics, School of Public Health in Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Mizuta
- Department of Dermatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Valenzuela A, Nandagopal S, Steen VD, Chung L. Monitoring and Diagnostic Approaches for Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Rheum Dis Clin North Am 2015. [PMID: 26210131 DOI: 10.1016/j.rdc.2015.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary arterial hypertension (PAH) is one of the leading causes of death in patients with systemic sclerosis (SSc). Given the high prevalence and poor survival of SSc-PAH, and that aggressive management of mild disease may be associated with better outcomes, screening is critical. Right heart catheterization (RHC) is the gold standard for the definitive diagnosis of PAH, and should be performed in those patients in whom this diagnosis is suspected. Once a diagnosis of PAH is confirmed by RHC, treatment with PAH-specific therapies should be initiated as soon as possible.
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Affiliation(s)
- Antonia Valenzuela
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA
| | - Saranya Nandagopal
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 2nd Floor, Redwood City, CA 94063, USA
| | - Virginia D Steen
- Division of Rheumatology, Allergy, and Immunology, Georgetown University School of Medicine, Pasquerilla Health Center, 6th Floor 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA.
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Bégneu E, Aïssou M, Lescot T, Cabane JP, Beaussier M. [Perioperative management of patients with systemic scleroderma]. ACTA ACUST UNITED AC 2014; 33:669-76. [PMID: 25447779 DOI: 10.1016/j.annfar.2014.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/30/2014] [Indexed: 11/17/2022]
Abstract
Systemic sclerosis (SSc) is an auto-immune disease characterized by vasculopathy and the combination of microangiopathy and tissue collagen deposit leading to skin, digestive, pulmonary, myocardial and renal injuries. These repercussions could be challenging for anesthesiologists and associated with difficulties in airway management, and occurrence of congestive right heart failure or acute kidney crisis. The aim of this review is to review the physiopathology and the progression of the SSc, as well as to provide a strategy of perioperative management of these patients.
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Affiliation(s)
- E Bégneu
- Département d'anesthésie réanimation, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - M Aïssou
- Département d'anesthésie réanimation, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - T Lescot
- Département d'anesthésie réanimation, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - J P Cabane
- Département d'anesthésie réanimation, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - M Beaussier
- Département d'anesthésie réanimation, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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Frea S, Capriolo M, Marra WG, Cannillo M, Fusaro E, Libertucci D, Morello M, Gaita F. Echo Doppler predictors of pulmonary artery hypertension in patients with systemic sclerosis. Echocardiography 2012; 28:860-9. [PMID: 21906161 DOI: 10.1111/j.1540-8175.2011.01467.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Evaluate echocardiographic predictors of pulmonary artery hypertension (PAH) in a prospective cohort of patients with systemic sclerosis (SSc). METHODS 38 patients with SSc who did not have PAH and significant left heart disease, with peak tricuspid regurgitant velocity (TRV) ≤ 2.8 m/sec and systolic pulmonary artery pressure (sPAP) < 40 mmHg on echo Doppler were enrolled. Patients underwent: clinical assessment, NT-proBNP, and DLco measurements. Echo Doppler evaluation included right ventricular (RV) dimensions, tricuspid annular plan systolic excursion, fractional area change, tricuspid DTI systolic velocity, Tei index, pulmonary flow acceleration time (AcT), ratio of TRV to RV outflow tract time-velocity integral (TVI) and a parameter of disturbed RV ejection (TRV/AcT). After a planned 12-month follow-up we evaluated the predictive value of these parameters for the development of PAH, as demonstrated by right heart catheterization (RHC). Criteria for RHC were TRV ≥ 3 m/sec or sPAP ≥ 40 mmHg. RESULTS Four patients developed PAH. Only TRV/TVI and TRV/AcT ratios significantly predicted PAH development (TRV/TVI ratio ≥ 0.16 [predefined and ROC confirmed]: OR 99, CI 95%: 4.865-2015, P = 0.004; TRV/AcT ratio ≥ 0.022 [predefined and ROC confirmed]: OR 12.68, CI 95% 1.163-379.3, P = 0.036). Both parameters showed a good diagnostic power (TRV/TVI ratio: ROC area 79%, sensitivity 75%, specificity 97% and diagnostic accuracy 94.74% for cutoff value of 0.16; TRV/AcT ratio: ROC area 75%, sensitivity 75%, specificity 71% and diagnostic accuracy 72% for cutoff value of 0.022). CONCLUSIONS This prospective study identified increased values of the two ratios TRV/TVI and TRV/AcT as predictors of PAH in SSc.
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Affiliation(s)
- Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, AOU S. Giovanni Battista di Torino and University of Torino, Torino, Italy.
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Serra W, Chetta A, Santilli D, Mozzani F, Dall'Aglio PP, Olivieri D, Cattabiani MA, Ardissino D, Gherli T. Echocardiography may help detect pulmonary vasculopathy in the early stages of pulmonary artery hypertension associated with systemic sclerosis. Cardiovasc Ultrasound 2010; 8:25. [PMID: 20598164 PMCID: PMC2908574 DOI: 10.1186/1476-7120-8-25] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 07/05/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) in patients with systemic sclerosis is associated with a poor prognosis, but this can be improved by early disease detection. Abnormal pulmonary and cardiac function can be detected early by means of echocardiography, whereas right heart catheterization is usually performed later. OBJECTIVES The purpose of this prospective study was to detect early the presence of pulmonary artery vasculopathy in patients with verified systemic sclerosis without significant pulmonary fibrosis, normal lung volumes and a mildly reduced lung diffusion capacity of carbon monoxide (DLCO). METHODS Nineteen consecutive female NYHA class I-II patients with scleroderma and a PAPs of < 35 mm/Hg measured by echocardiography, were enrolled between September 2007 and September 2009. They had a mean age of 51 +/- 13 years, body mass index of 25 +/- 5 kg/m2). They all underwent complete Doppler echocardiography, CPET, a pulmonary ventilation test (carbon monoxide lung diffusion, DLCO), HRCT. To investigate PAH by means of complete resting Doppler echocardiography estimates of systolic pulmonary artery pressure (PAPs) derived from tr icuspid regurgitation, mean PAP derived from pulmonary regurgitation, pulmonary vessel resistance (PVR) derived from the acceleration time of the pulmonary outflow tract (ACTpo), and right ventricular function derived from tricuspid annular plane systolic excursion (TAPSE). Right heart catheterisation was conducted only, if pulmonary hypertension was suggested by echocardiography and an abnormal ventilator test.The data are given as mean values +/- SD, unless otherwise stated. The correlations between the variables were analysed using Pearson's r coefficient, and the predictive value of the variables was calculated using linear regression analysis. A p value of > 0.05 was considered significant. RESULTS Right heart catheterization detected PAH in 15/19 patients; mean PAP was 30.5 mm/Hg and RVP 3.6 UW. Coronary angiography of the patients aged more than 55 years showed some evidence of significant coronary artery disease. Echocardiography showed high systolic PAP values (46 +/- 8 mmHg), whereas right ventricular function was normal (TAPSE 23 +/- 3 mm), and in line with the NYHA class. ACTpo was reduced in the patients with a systolic PAP of < 46 mm/Hg (p > 0.001) and positively correlated with DLCO (p > 0.001) and the hemodynamic data.There was a good correlation between ACTpo and PVR (hemodynamic data) (r = -0615; p > 0.01). CONCLUSIONS Although they need to be confirmed by studies of larger series of patients, our findings suggest that, in comparison with hemodynamic data, non-invasive echocardiographic measurements are an excellent means of identifying early-stage PAH.
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Affiliation(s)
- Walter Serra
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Alfredo Chetta
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | - Daniele Santilli
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | - Flavio Mozzani
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | | | - Dario Olivieri
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | | | - Diego Ardissino
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Tiziano Gherli
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
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Kabunga P, Coghlan G. Endothelin receptor antagonism: role in the treatment of pulmonary arterial hypertension related to scleroderma. Drugs 2009; 68:1635-45. [PMID: 18681488 DOI: 10.2165/00003495-200868120-00003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease, which is associated with a 1-year survival of about 50% without specific treatment. Pulmonary vascular remodelling, thrombosis and vasoconstriction are thought to be directly involved in increasing pulmonary vascular resistance (PVR), which, left untreated, ultimately leads to right ventricular failure and death. A total of 10-12% of patients with systemic sclerosis (SSc) develop PAH, which is a leading cause of mortality in these patients. Targeted treatment regimens involving oral therapies, in particular endothelin receptor antagonists (ERAs), such as bosentan, sitaxsentan (sitaxentan) and ambrisentan, are now being used and this approach has improved symptoms as well as survival. 1-Year survival has improved to about 80%, while 3-year survival in advanced SSc-PAH has improved from 44% to 65% since the introduction of ERAs. Subanalysis of BREATHE-1, a pilot study and the STRIDE-2X randomized controlled trials has reported improvements in time to clinical worsening, 6-minute walk distance (6mwd) and right heart haemodynamics in SSc-PAH patients given bosentan and sitaxsentan, respectively, compared with placebo. The ARIES studies have also demonstrated a delay in the time to clinical worsening and improvement in 6mwd in connective tissue associated-PAH patients given ambrisentan compared with placebo. Unfortunately, these drugs are expensive and also have the potential for adverse interactions with other PAH and supportive therapies. Mandatory monthly liver function tests are required for safe administration of bosentan, ambrisentan and sitaxsentan, while dose adjustment of warfarin and careful monitoring are required when sitaxsentan is initiated. Earlier diagnosis and treatment of PAH may further improve outcomes with current ERAs. WHO functional class (FC) has traditionally been used to determine which patients with PAH will start therapy. The EARLY study has reported significant reductions in PVR and time to clinical worsening in mildly symptomatic PAH patients treated with bosentan, and many PAH clinicians now believe WHO FC should be used as a monitoring tool once targeted therapies have been initiated and not as a tool for deciding when to start PAH specific therapies.Many pathways are thought to be involved in the pathophysiology of the PAH. There is growing evidence that combination therapies targeting different pathophysiological steps may be necessary to effectively treat SSc-PAH. The COMPASS-1 study has reported an acute haemodynamic benefit in PAH when a single-dose of sildenafil is used in combination with bosentan and COMPASS-2 will investigate whether this acute response translates into long-term benefit. Well designed morbidity and mortality trials in SSc-PAH should help increase our understanding and treatment of this orphan disease.
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Affiliation(s)
- Peter Kabunga
- Department of Cardiology, Royal Free Hospital, London, UK.
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7
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Frachon I, Jaïs X, Leroyer C, Jobic Y, Huchot E, Simonneau G, Dartevelle P. [Diagnosis and care of postembolic pulmonary hypertension: the role of the pneumologist]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:316-324. [PMID: 19084211 DOI: 10.1016/j.pneumo.2008.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 09/23/2008] [Indexed: 05/27/2023]
Abstract
The prognosis of postembolic pulmonary hypertension, a rare and serious disease, has been transformed with the curative intervention of pulmonary endarteriectomy. The screening is based on two key non invasive examinations, the cardiac ultrasound and ventilation-perfusion scintigraphy. The confirmation of the diagnosis and the determination of the best therapeutic options then relies on the expertise of the national reference centre, based on the haemodynamics and the morphological data provided by pulmonary angiography and spiral computerised tomography. Although the technique of endarteriectomy is fully validated, a drug approach is in the assessment process, both in the inoperable forms or when confronted with persistent postsurgical pulmonary hypertension.
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Affiliation(s)
- I Frachon
- Equipe d'accueil 3878, groupe HTAP de Bretagne occidentale, département de médecine interne et pneumologie, hôpital de la Cavale-Blanche, 29609 Brest, France.
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Coghlan JG, Handler CE, Kottaridis PD. Cardiac assessment of patients for haematopoietic stem cell transplantation. Best Pract Res Clin Haematol 2007; 20:247-63. [PMID: 17448960 DOI: 10.1016/j.beha.2006.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The expanding role of haematopoietic stem-cell transplantation (HSCT) renders the previous policy of avoiding transplantation in high-risk cardiac patients obsolete. Patients with amyloid, autoimmune conditions, sickle-cell disease, or thalassaemia, and patients over the age of 60 years are increasingly being offered HSCT. It is evident that the policy of avoiding transplantation in patients with impaired systolic function fails to identify all high-risk patients in such groups, and will deprive some patients of the benefits of HSCT unnecessarily. The development of an appropriate algorithm for cardiac pre-assessment and peri-transplant management is hampered by an inadequate understanding of the predictive value of various tests of cardiovascular function, the rapid evolution of advanced management strategies for cardiac dysfunction, and the development of non-cardiotoxic conditioning regimens. To meet this need we propose that an algorithm based on evidence from other clinical situations - already been found to be successful in the management of HSCT in patients with systemic sclerosis - should be used uniformly, and registry studies should be undertaken to distinguish those aspects of the algorithm that positively help to expand the remit of HSCT from those that add little of value.
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Affiliation(s)
- J G Coghlan
- Department of Cardiology, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK.
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Denton CP, Nihtyanova SI. Therapy of pulmonary arterial hypertension in systemic sclerosis: An update. Curr Rheumatol Rep 2007; 9:158-64. [PMID: 17502047 DOI: 10.1007/s11926-007-0011-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pulmonary arterial hypertension (PAH) affects 10% to 15% of patients with systemic sclerosis and is a major cause for disease-related morbidity and mortality. Over the past decade, significant progress has been made in the understanding of the pathophysiologic mechanisms underlying PAH. This progress led to the development of several new treatment options and, as a result, dramatically improved survival among this severely affected cohort. The outcome in patients with scleroderma-related PAH is much worse than that in patients with idiopathic PAH, and unfortunately only a few studies have assessed treatment and outcome among patients suffering from connective tissue disease-related PAH. In recent years, publications of connective tissue disease subgroup analysis from large trials in PAH have emerged. We review the current treatment options for PAH and the evidence for their use in scleroderma-related PAH.
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Affiliation(s)
- Christopher P Denton
- Centre for Rheumatology, Pond Street, Royal Free Hospital, London, United Kingdom, NW3 2QG.
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Plastiras SC, Karadimitrakis SP, Kampolis C, Moutsopoulos HM, Tzelepis GE. Determinants of Pulmonary Arterial Hypertension in Scleroderma. Semin Arthritis Rheum 2007; 36:392-6. [PMID: 17204309 DOI: 10.1016/j.semarthrit.2006.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 09/25/2006] [Accepted: 10/29/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To define risk factors associated with pulmonary arterial hypertension (PAH) in a large cohort of patients with systemic sclerosis (SSc). METHODS SSc patients undergoing screening for PAH by means of Doppler echocardiography were identified and their charts were retrospectively reviewed. In all patients, we recorded systolic pulmonary artery pressure along with pulmonary function testing, clinical, and laboratory data. PAH was defined as right ventricular systolic pressure equal or greater than 40 mm Hg. RESULTS Of 114 SSc patients with echocardiographic measurements, PAH was found in 33 (29%) patients. In a multiple logistic regression analysis, the presence of pulmonary fibrosis on thoracic computed tomography (OR 6.78, CI 1.54 to 29.9), forced vital capacity less than 80% predicted (OR 3.03, CI 1.1 to 8.35), and duration of Raynaud's phenomenon preceding the onset of skin changes for at least 3 years (OR 5.75, CI 1.9 to 17.41) were found to be independent predictors of PAH. Age, disease duration, disease subtype, or autoantibodies were not associated with PAH in our patients. CONCLUSIONS The present analysis identified pulmonary fibrosis and Raynaud's phenomenon preceding SSc skin manifestations by at least 3 years as risk factors for PAH in our scleroderma cohort. Screening for PAH in these high-risk patients may detect PAH at an earlier stage and guide decisions on therapeutic interventions.
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Affiliation(s)
- Sotiris C Plastiras
- Department of Pathophysiology, University of Athens School of Medicine, 75 M. Asias Street, Athens 11527, Greece
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Williams MH, Handler CE, Akram R, Smith CJ, Das C, Smee J, Nair D, Denton CP, Black CM, Coghlan JG. Role of N-terminal brain natriuretic peptide (N-TproBNP) in scleroderma-associated pulmonary arterial hypertension. Eur Heart J 2006; 27:1485-94. [PMID: 16682379 DOI: 10.1093/eurheartj/ehi891] [Citation(s) in RCA: 225] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIMS The aims of this study were to evaluate the diagnostic value and to explore the prognostic value of N-terminal brain natriuretic peptide (N-TproBNP) in patients with systemic sclerosis (SSc) both with and without pulmonary arterial hypertension (PAH). METHODS AND RESULTS N-TproBNP, six-minute walk distance (SMWD), haemodynamics (at right heart catheterization) or tricuspid gradient (by echocardiography), and survival were assessed in 109 patients with SSc. The study population included 68 individuals with PAH [mean pulmonary artery pressure (PAP) >25 mmHg and pulmonary capillary wedge pressure <15 mmHg] and 41 individuals without PAH. In patients with PAH, the prognostic value of baseline and change in WHO functional class, N-TproBNP levels, and SMWD were compared using Kaplan-Meier survival curves and Cox proportional hazard analysis. The mean duration of follow-up was 10 months (range 1-18 months). One year survival in patients with normal PAP was 100% when compared with 83.5% in those with SSc-PAH (P < 0.05). The patients without PAH had a mean N-TproBNP level of 139 pg/mL (SD 151); those with SSc-PAH had a significantly higher mean N-TproBNP level of 1474 pg/mL (SD 2642) (P = 0.0002). Among patients with PAH for every order of magnitude increase in N-TproBNP level there was a four-fold increased risk of death (P = 0.002 for baseline level and P = 0.006 for follow-up level). Baseline N-TproBNP levels were correlated positively with mean PAP (r = 0.62; P < 0.0001), pulmonary vascular resistance (PVR) (r = 0.81; P < 0.0001), and inversely with SMWD (r = -0.46; P < 0.0001). Among patients with SSc-PAH, 13 patients (19%) were in WHO functional classes II and had mean N-TproBNP levels of 325 pg/mL (SD 388). Fifty-three patients (78%) were in WHO classes III and IV and had significantly higher mean N-TproBNP levels of 1677 pg/mL (SD 2835) (P = 0.02). At an N-TproBNP level of 395 pg/mL, the sensitivity and specificity for predicting the presence of SSc-PAH were 56 and 95% respectively. CONCLUSION Raised N-TproBNP levels are directly related to the severity of PAH. In screening programs, SSc patients with an N-TproBNP in excess of 395 pg/mL have a very high probability of having pulmonary hypertension. Baseline and serial changes in N-TproBNP levels are highly predictive of survival. A 10-fold increase in N-TproBNP level on therapy is associated with a greater than three-fold increase in mortality, and may indicate therapeutic failure.
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13
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Schotte H, Becker H, Domschke W, Gaubitz M. [Cardiovascular monitoring of patients with systemic lupus erythematosus]. Z Rheumatol 2005; 64:564-75. [PMID: 16328762 DOI: 10.1007/s00393-005-0668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Accepted: 10/05/2004] [Indexed: 11/28/2022]
Abstract
Accelerated atherosclerotic cardiovascular disease is increasingly recognized as a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac manifestations of SLE are frequent and can involve almost all components of the heart. Pulmonary hypertension often develops during the course of SLE. The high incidence of cardiovascular complications may justify a screening of SLE patients in order to ensure early diagnosis and therapy. Results of diagnostic procedures that detect coronary insufficiency, surrogates of atherosclerotic burden and echocardiographic findings are often abnormal in SLE. However, evidence to support a routine screening for cardiovascular disease is currently not available. Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest assessment of risk factors and the performance of echocardiography at least annually in asymptomatic SLE patients. If two or more risk factors are present, an exercise ECG is recommended. The benefit, however, of screening SLE patients for cardiovascular disease has to be confirmed in prospective studies.
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Affiliation(s)
- H Schotte
- Medizinische Klinik und Poliklinik B, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
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Kluger N, Gati S, Molinari E, Francès C. Manifestations pulmonaires dans la sclérodermie systémique. Ann Dermatol Venereol 2005; 132:905-14. [PMID: 16327725 DOI: 10.1016/s0151-9638(05)79514-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- N Kluger
- Dermatologie, Hôpital Tenon, Paris
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Provencher S, Martel S, Jais X, Sitbon O, Humbert M, Simonneau G. Diagnostic et classification des hypertensions artérielles pulmonaires. Presse Med 2005; 34:1435-44. [PMID: 16301975 DOI: 10.1016/s0755-4982(05)84205-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The clinical classification of types of pulmonary hypertension has made it possible to better standardize the approach to the diagnosis and treatment of patients, to perform clinical studies among homogeneous patients, and to discover common laboratory abnormalities that may serve as markers or help elucidate mechanisms of disease. Pulmonary arterial hypertension groups together different diseases that affect the small-caliber pulmonary arteries and lead to a progressive increase in pulmonary arterial resistance and right heart failure. A specific diagnosis of pulmonary arterial hypertension is generally based on a detailed and methodical clinical evaluation. Pulmonary biopsy is rarely indicated. Work-up in a center specialized in the management of this disease is frequently appropriate when the cause of the hypertension is not clear or when a specific treatment is envisaged.
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Affiliation(s)
- S Provencher
- Institut de cardiologie et de pneumologie de l'université Laval, service de pneumologie, Hôpital Laval, Québec, Canada.
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Granel B, Chevillard C, Dessein A. Facteurs de prédisposition génétiques à la fibrose au cours de la sclérodermie systémique. Rev Med Interne 2005; 26:294-303. [PMID: 15820565 DOI: 10.1016/j.revmed.2004.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2004] [Accepted: 12/12/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE Physiopathology of systemic sclerosis includes autoimmunity factors, endothelial lesions and abnormal fibrotic process which characterizes this disease in the field of systemic autoimmune disorders. Genetic factors of susceptibility are showed by possibility of familial forms of the disease, Choctaw American Indians homogenous population with high disease prevalence of systemic sclerosis and experimental animal models. KEY POINTS We propose a review of the articles published to date in the literature concerning genetical analysis of genes coding for factors potentially involved in the fibrotic process of systemic sclerosis. This includes cytokines (TNF-alpha, interleukin-1, chemokines), growth factors (TGF-beta), extracellular matrix proteins (collagen, fibrillin, fibronectine) and agents acting on vascular tone (angiotensin-converting enzyme and NO synthase). PERSPECTIVES Identification of genetic factors involved in the susceptibility to fibrosis of systemic sclerosis would lead to a better understanding of physiopathological mechanisms of this disease and to therapeutic targets using immunomodulation with drugs, such as already performed in rheumatoid arthritis.
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Affiliation(s)
- B Granel
- Inserm U 399, faculté de médecine de La Timone, 27, boulevard Jean-Moulin, 13385 Marseille cedex 05, France.
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El Khattabi A, Tiev KP, Ziani M, Baret M, Genereau T, Cabane J. [The methods for screening pulmonary hypertension related to systemic sclerosis in France. Descriptive survey of the French Research Group on Sclerosis]. Presse Med 2004; 33:1160-3. [PMID: 15523285 DOI: 10.1016/s0755-4982(04)98883-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
CONTEXT AND OBJECTIVES Pulmonary hypertension (PHT) represents one of the severest complications and is life-threatening for patients suffering from systemic sclerosis (SSc). In France, the modalities for screening and treating PHT related to SSc are not well codified and no consensus has been reached. We conducted a survey among physicians inscribed on the list of the French Research Group on Sclerosis (GRFS - Groupe de Recherche Francais sur la Sclerodermie) to gather information on the status of the management of PHT related to SSc. METHODS In 2002, we sent a questionnaire to 160 physicians, members of the GRFS, to assess the epidemiology and clinical profile of SSc patients as well as the modalities of screening and management of PHT in these patients. RESULTS Eighty-eight physicians in 71 centres replied to the questionnaire. Each centre followed-up a mean of 33 SSc patients, with a global distribution of 53% limited and 47% diffused SSc. These physicians saw a mean of 5 new cases of SSc per year. The patients had been referred by town practitioners (53%) or from the hospital (47%). The mean number of SSc patients with PHT was of 5.1 per physician (1.5 new SSc + PHT patients per year). Almost all the centres (65/67) who replied systematically screened for PHT in SSc patients using Doppler echocardiography a mean of every 1.3 years. For the management of the patients exhibiting PHT, the majority (41/63) of centres collaborated with a specialized unit. Around one third of the centres treated these patients with calcium channel inhibitors (82%) and/or prostacyclin (90%). All the patients were followed-up by Doppler echocardiography. The majority of the physicians (72%) were interested in a research protocol on the subject and each could have included 4 patients, i.e., a total of 160. CONCLUSION Pulmonary hypertension, a severe complication of SSc is screened for by the physicians of the GRFS using echocardiography with a frequency similar to Who guidelines (1.3 versus once/year).
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Affiliation(s)
- A El Khattabi
- Service de médecine interne, Horloge II, Hôpital Saint-Antoine, Paris
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