1
|
Ren H, Liu L, Xiao Y, Shi Y, Zeng Z, Ding Y, Zou P, Xiao R. Further insight into systemic sclerosis from the vasculopathy perspective. Biomed Pharmacother 2023; 166:115282. [PMID: 37567070 DOI: 10.1016/j.biopha.2023.115282] [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: 06/26/2023] [Revised: 07/30/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by immune dysfunction, vascular system dysfunction, and tissue fibrosis. Vascular injury, vascular remodeling, and endothelial dysfunction are the hallmark pathological changes of the disease. In the early stages of SSc development, endothelial cell injury and apoptosis can lead to vascular and perivascular inflammation, oxidative stress, and tissue hypoxia, which can cause clinical manifestations in various organs from the skin to the parenchymal organs. Early diagnosis and rational treatment can improve patient survival and quality of life. Ancillary examinations such as nailfold capillaroscopy as well as optical coherence tomography can help early detect vascular injury in SSc patients. Studies targeting the mechanisms of vascular lesions will provide new perspectives for treatment of SSc.
Collapse
Affiliation(s)
- Hao Ren
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Licong Liu
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Yangfan Xiao
- Clinical Nursing Teaching and Research Section, Second Xiangya Hospital, Central South University, Changsha 410011, China; Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Yaqian Shi
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhuotong Zeng
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Yan Ding
- Department of Dermatology, Hainan Provincial Dermatology Disease Hospital, Haikou, China
| | - Puyu Zou
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Rong Xiao
- Department of Dermatology, Second Xiangya Hospital of Central South University, Changsha, China.
| |
Collapse
|
2
|
Zagouras AA, Tang WHW. Myocardial Involvement in Systemic Autoimmune Rheumatic Diseases. Rheum Dis Clin North Am 2023; 49:45-66. [PMID: 36424026 DOI: 10.1016/j.rdc.2022.08.002] [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: 11/22/2022]
Abstract
Systemic autoimmune rheumatic diseases (SARDs) are defined by the potential to affect multiple organ systems, and cardiac involvement is a prevalent but often overlooked sequela. Myocardial involvement in SARDs is medicated by macrovascular disease, microvascular dysfunction, and myocarditis. Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, eosinophilic granulomatosis with polyangiitis, and sarcoidosis are associated with the greatest risk of myocardial damage and heart failure, though myocardial involvement is also seen in other SARDs or their treatments. Management of myocardial involvement should be disease-specific. Further research is required to elucidate targetable mechanisms of myocardial involvement in SARDs.
Collapse
Affiliation(s)
- Alexia A Zagouras
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, , EC-10 Cleveland Clinic, 9501 Euclid Avenue, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, , EC-10 Cleveland Clinic, 9501 Euclid Avenue, Cleveland, OH 44195, USA; Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
3
|
Chennakesavulu PV, Uppaluri S, Koyi J, Jhaveri S, Avanthika C, Sakhamuri LT, Ashokbhai PK, Singh P. Pulmonary Hypertension in Scleroderma- Evaluation and Management. Dis Mon 2022:101468. [PMID: 36163292 DOI: 10.1016/j.disamonth.2022.101468] [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: 11/25/2022]
Abstract
Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/hemodynamic criteria that are a consequence of several etiologies. Systemic Sclerosis (SSc), one of the most common causes of PAH, is an autoimmune disorder of the connective tissue leading to fibrosis that involves the skin, gastrointestinal tract, lungs, heart, kidney etc. SSc has an annual prevalence of one to five cases for every 1000 individuals and nearly 15 percent of all cases develop PAH. At its core, Pulmonary hypertension (PH) in SSc is an obliterative vasculopathy in small to medium-sized pulmonary arterioles. A host of other local and systemic mechanisms operate in concert to gradually alter the hemodynamics resulting in elevated pulmonary vascular resistance and thus right ventricular afterload. A diagnosis of PAH in SSc is virtually a death sentence, with studies reporting a mortality rate of 50 per cent in the 3 years of diagnosis. Therefore, developing and implementing a robust screening and diagnosis protocol is crucial in the fight against this pervasive disease. This review aims to summarize the current literature of PAH in SSc, with a special focus on the screening and diagnosis protocols, newer treatment options and prognostic indicators for the same.
Collapse
Affiliation(s)
| | - Srikar Uppaluri
- Kamineni Academy of medical sciences and research centre, Hyderabad, India.
| | | | | | | | | | | | - Priyanka Singh
- United health services hospital, Wilson medical center, New York
| |
Collapse
|
4
|
Zagouras AA, Chatterjee S, Tang WHW. Heart Failure with Preserved Ejection Fraction and Cardiomyopathy: an Under-recognized Complication of Systemic Sclerosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
5
|
Giucă A, Mihai C, Jurcuț C, Gheorghiu AM, Groșeanu L, Dima A, Săftoiu A, Coman IM, Popescu BA, Jurcuț R. Screening for Pulmonary Hypertension in Systemic Sclerosis-A Primer for Cardio-Rheumatology Clinics. Diagnostics (Basel) 2021; 11:diagnostics11061013. [PMID: 34206055 PMCID: PMC8229459 DOI: 10.3390/diagnostics11061013] [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: 05/06/2021] [Revised: 05/20/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare disease, with unfavorable clinical course and prognosis, characterized by progressive multisystemic involvement. SSc associated pulmonary hypertension (SSc-PAH) and interstitial lung disease (ILD) are the most important factors for morbi-mortality in these patients, being responsible for more than 60% of total deaths. Though pulmonary arterial hypertension (PAH) is the dominant subtype seen in SSc, PH secondary to ILD, left-heart pathology, and pulmonary veno-occlusive disease (PVOD) are also possible occurrences. Initial evaluation of a SSc case is complex and should be performed with a multidisciplinary approach. Early detection of SSc-PAH is imperative, given the fact that new and effective medications are available and early treatment was shown to improve outcomes. Therefore, screening algorithms must be used adequately and in a cost-effective manner. Sensitivity and negative predictive value (NPV) are the most important performance measures in a screening test. Several algorithms were developed in the last decade (e.g., DETECT and ASIG) and demonstrated higher efficiency when compared to older algorithms. The present manuscript details the risk factors for SSc-PAH and includes a critical description of current detection algorithms, as a primer for clinicians working in the field of cardio-rheumatology.
Collapse
Affiliation(s)
- Adrian Giucă
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
| | - Carina Mihai
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Ciprian Jurcuț
- Department of Internal Medicine, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Ana Maria Gheorghiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology and Internal Medicine, Cantacuzino Clinical Hospital, Str.Ion Movilă nr 5-7, 020475 Bucharest, Romania
| | - Laura Groșeanu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology, “Sf. Maria” Clinical Hospital, Bd Ion Mihalache nr 37-39, 011172 Bucharest, Romania
| | - Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Sos Stefan cel Mare nr 19-21, 020125 Bucharest, Romania;
| | - Adrian Săftoiu
- Department of Internal Medicine, Craiova University of Medicine and Pharmacy, Str Petru Rares nr 2, 200349 Craiova, Romania;
| | - Ioan Mircea Coman
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
| | - Bogdan A. Popescu
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
| | - Ruxandra Jurcuț
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Correspondence:
| |
Collapse
|
6
|
Naranjo M, Hassoun PM. Systemic Sclerosis-Associated Pulmonary Hypertension: Spectrum and Impact. Diagnostics (Basel) 2021; 11:911. [PMID: 34065226 PMCID: PMC8161029 DOI: 10.3390/diagnostics11050911] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a catastrophic complication of one of the most common and devastating autoimmune diseases. Once diagnosed, it becomes the leading cause of mortality among this patient population. Screening modalities and risk assessments have been designed and validated by various organizations and societies in order to identify patients early in their disease course and promptly refer them to expert centers for a hemodynamic assessment and formal diagnosis. Moreover, several large multicenter clinical trials have now included patients with SSc-PAH to assess their response to therapy. Despite an improved understanding of the condition and significant advances in supportive and targeted therapy, outcomes have remained far from optimal. Therefore, rigorous phenotyping and search for novel therapies are desperately needed for this devastating condition.
Collapse
Affiliation(s)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Lung involvement is a distinctive feature of antisynthetase syndrome (ASS) and it is considered a basic disease-classifying criterion. In this review, we go over clinical features, radiological patterns, prognostic factors, pathogenesis and treatment of lung involvement in ASS patients, focusing on the clinical differences linked to the different antibody specificities known so far. RECENT FINDINGS The lung is the most common extramuscular organ involved in ASS and has the greatest impact on patient prognosis. The pulmonary disease-defining manifestation in ASS is interstitial lung disease (ILD), yet a proportion of patients also develop pulmonary arterial hypertension and, less frequently, obstructive bronchiolitis or acute respiratory failure according to drivers not yet fully understood but likely associated with the underlying autoantibody pattern. Clinical presentation of pulmonary involvement can range from milder forms to a rapidly progressive disease which may lead to chronic lung damage if misdiagnosed and not properly treated. SUMMARY The knowledge of risk factors associated with progressive or refractory lung damage is important to identify and properly treat patients with the poorest prognosis. For those with a disease not responsive to conventional therapy the efficacy of other therapeutic option is under evaluation.
Collapse
|
8
|
Almaaitah S, Highland KB, Tonelli AR. Management of Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Integr Blood Press Control 2020; 13:15-29. [PMID: 32280271 PMCID: PMC7125406 DOI: 10.2147/ibpc.s232038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare and complex immune-mediated connective tissue disease characterized by multi-organ fibrosis and dysfunction. Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a leading cause of death in this population. Pulmonary arterial hypertension (PAH) can coexist with other forms of pulmonary hypertension in SSc, including pulmonary hypertension related to left heart disease, interstitial lung disease, chronic thromboembolism and pulmonary venous occlusive disease, which further complicates diagnosis and management. Available pulmonary arterial hypertension therapies target the nitric oxide, endothelin and prostacyclin pathways. These therapies have been studied in SSc-PAH in addition to idiopathic PAH, often with different treatment responses. In this article, we discuss the management as well as the treatment options for patients with SSc-PAH.
Collapse
Affiliation(s)
- Saja Almaaitah
- Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kristin B Highland
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
9
|
Al Otair HA, Idrees MM, Saleemi SA, Eltoukhy AM, Alhijji AA, Al Habeeb WA, Omair MA. Pulmonary arterial hypertension in Saudi patients with systemic sclerosis: Clinical and hemodynamic characteristics and mortality. Ann Thorac Med 2019; 14:83-89. [PMID: 30745940 PMCID: PMC6341865 DOI: 10.4103/atm.atm_33_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a major cause of morbidity and mortality in patients with systemic sclerosis (SSc). The objective of this study is to describe the clinical characteristics, mortality, and predictors of SSc-PAH in Saudi patients. METHODS Retrospective chart review study of SSc patients who were followed for at least 1 year in three tertiary care centers in Saudi Arabia was conducted. Clinical information, echocardiographic findings, and right heart catheterization (RHC) results were collected. Descriptive statistics were used for demographic and disease characteristics. RESULTS Fifty-seven patients with SSc were reviewed. PAH was confirmed by RHC in 40 patients (87.5%, females). Their mean age was 45.43 ± 13.48 years. The mean pulmonary artery pressure was 42.9 ± 12.7 mmHg, the pulmonary vascular resistance index was 19.4 ± 7.7 woods unit, and cardiac index was 2.43 ± 0.68 min/m2. The median time from symptoms to first assessment was 42.8 ± 115.62 months. Most patients (77.5%) presented with functional Class III or IV and more than half (22.55%) were on dual combination therapy. Ten patients (25%) SSc PAH died over a follow up period of 37 ± 7 months. Compared to SSc patients without PAH, SSc-PAH patients had shorter 6-min walk distance (6MWD) (296.1 ± 116.5 vs. 399.59 ± 40.60 m, P < 0.0001), higher pro-brain natriuretic peptide (1755.8 ± 2123.4 vs. 69.8 ± 44.3 pg/ml P = 0.004), and more frequent Raynaud's phenomenon (RP) (90% vs. 35%, P < 0.0001). Logistic regression showed RP (odds ratio [OR] =48.58, 95% confidence interval [CI]; 3.73-633.10) and 6MWD (OR 1.02: 95% CI; 1.01-1.03) were associated with the development of PAH. CONCLUSION Our cohort of Saudi SSc-PAH patients has a younger disease onset and a lower mortality than what is described worldwide despite late presentation and requirement of combination therapy. The presence of RP and lower were associated with the development of SSc-PAH.
Collapse
Affiliation(s)
- Hadil Ak Al Otair
- Department of Critical Care, King Saud University, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Department of Medicine, Division of Pulmonology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sarfraz A Saleemi
- Department of Medicine, Division of Pulmonology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed M Eltoukhy
- Department of Critical Care, King Saud University, Riyadh, Saudi Arabia
| | - Ali A Alhijji
- Department of Medicine, Division of Rheumatology, King Saud University, Riyadh, Saudi Arabia
| | | | - Mohammed A Omair
- Department of Medicine, Division of Rheumatology, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
10
|
A Randomized Controlled Trial of Acupressure for the Treatment of Raynaud's Phenomenon: The difficulty of conducting a trial in Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016; 1:226-233. [PMID: 27840853 DOI: 10.5301/jsrd.5000206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of acupressure on Raynaud's phenomenon (RP) in a randomized controlled clinical trial (RCT) and to evaluate the difficulties of conducting a RP RCT. METHODS A pilot single center RCT of acupressure vs. targeted patient education was conducted for the treatment of RP. Patients with either primary (N = 15) or secondary (N = 8) RP were randomized in an 8-week study. The primary endpoints included a decrease in the frequency and duration of RP. Secondary endpoints included several serum biomarkers including endothelial dysfunction, Raynaud's attack symptoms, Raynaud's Condition Score, and patient and physician global assessments of RP. Primary data analysis was conducted using the last observation carried forward and t-tests or a Wilcoxon rank test was used to compare the two groups. RESULTS 23 patients were randomized and 7 discontinued prematurely. 78% of patients were female, 96% were Caucasian, and the mean age was 49.8 (SD=16) years. No statistically significant differences were detected between the acupressure vs. education groups in primary and secondary outcomes (p> 0.05). Frequency of attacks decreased by 6.7 attacks (SD=8.8) in the acupressure group vs. 7.2 (SD=12.8) in the education group (p=0.96), and the duration of attacks decreased by 11.4 (SD=19.9) minutes in the acupressure group vs. an increase of 0.8 minutes (SD=11.2) in the education group (p=0.14). There were no adverse events noted in the RCT. CONCLUSION This pilot study does not support efficacy of acupressure for RP.
Collapse
|
11
|
Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. The Sphinx's riddle: cardiovascular involvement in autoimmune rheumatic disease. BMC Cardiovasc Disord 2016; 16:204. [PMID: 27793103 PMCID: PMC5084462 DOI: 10.1186/s12872-016-0381-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 10/22/2016] [Indexed: 02/03/2023] Open
Abstract
Factors leading to Cardiovascular Disease (CVD) in Autoimmune Rheumatic Diseases (ARD) include: a) atherosclerosis and macro-microvascular coronary artery disease b) pericardial, myocardial and vascular inflammation c) heart valve disease d) heart failure and e) pulmonary hypertension. Cardiology utilizes various non-invasive imaging modalities, such as rest/stress Electrocardiogram (ECG), echocardiography, nuclear imaging and more recently Cardiovascular Magnetic Resonance (CMR) to detect ischemic or inflammatory disease in ARD. Exercise ECG is a reliable prognostic test for identification of patients either very unlikely or very likely to have cardiac events. However, this is not the case for intermediate risk patients. In stress echocardiography the diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. It provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion, but at a lower cost and without radiation exposure. Stress Myocardial Perfusion Scintigraphy (MPS) is a non-invasive imaging modality for patients with suspected coronary artery disease, but has important limitations including radiation exposure, imaging artefacts and low spatial resolution, which preclude detection of small myocardial scars commonly found in ARD. By identifying early stages of inflammation and perfusion defects, CMR can shed light on the exact pathophysiologic background of myocardial lesions, even if the underlying ARD seems stable. However, high cost and lack of availability and expertise limit wider adoption. Hopefully, CMR will not have the same fate as Oedipous, who despite answering the Sphinx’s riddle successfully, finally came to a bitter end; for in the case of CMR overcoming fate is, in fact, in our hands.
Collapse
Affiliation(s)
- Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, P. Faliro, Athens, Greece.
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, P. Faliro, Athens, Greece
| |
Collapse
|
12
|
Baptista R, Serra S, Martins R, Teixeira R, Castro G, Salvador MJ, Pereira da Silva JA, Santos L, Monteiro P, Pêgo M. Exercise echocardiography for the assessment of pulmonary hypertension in systemic sclerosis: a systematic review. Arthritis Res Ther 2016; 18:153. [PMID: 27368695 PMCID: PMC4930605 DOI: 10.1186/s13075-016-1051-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/20/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) complicates the course of systemic sclerosis (SSc) and is associated with poor prognosis. The elevation of systolic pulmonary arterial pressure (sPAP) during exercise in patients with SSc with normal resting haemodynamics may anticipate the development of PAH. Exercise echocardiography (ExEcho) has been proposed as a useful technique to identify exercise-induced increases in sPAP, but it is unclear how to clinically interpret these findings. In this systematic review, we summarize the available evidence on the role of exercise echocardiography to estimate exercise-induced elevations in pulmonary and left heart filling pressures in patients with systemic sclerosis. METHODS We conducted a systematic review of the literature using MEDLINE, Cochrane Library and Web of Knowledge, using the vocabulary terms: ('systemic sclerosis' OR 'scleroderma') AND ('exercise echocardiography') AND ('pulmonary hypertension'). Studies including patients with SSc without a prior diagnosis of PAH, and subjected to exercise echocardiography were included. All searches were limited to English and were augmented by review of bibliographic references from the included studies. The quality of evidence was assessed by the Effective Public Health Practice Project system. RESULTS We identified 15 studies enrolling 1242 patients, who were mostly middle-aged and female. Several exercise methods were used (cycloergometer, treadmill and Master's two step), with different protocols and positions (supine, semi-supine, upright); definition of a positive test also varied widely. Resting estimated sPAP levels varied from 18 to 35 mm Hg, all in the normal range. The weighted means for estimated sPAP were 22.2 ± 2.9 mmHg at rest and 43.0 ± 4.3 mmHg on exercise; more than half of the studies reported mean exercise sPAP ≥40 mmHg. The assessment of left ventricular diastolic function on peak exercise was reported in a minority of studies; however, when assessed, surrogate variables of left ventricular (LV) diastolic dysfunction were associated with higher sPAP on exercise. CONCLUSIONS We found very high heterogeneity in the methods, the protocols and the estimated sPAP response to exercise. LV diastolic dysfunction was common and was associated with greater elevation of sPAP on exercise.
Collapse
Affiliation(s)
- Rui Baptista
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Sara Serra
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rui Martins
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
| | - Rogério Teixeira
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Graça Castro
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
| | - Maria João Salvador
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José António Pereira da Silva
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lèlita Santos
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Mariano Pêgo
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-001, Coimbra, Portugal
| |
Collapse
|
13
|
Rhee RL, Gabler NB, Sangani S, Praestgaard A, Merkel PA, Kawut SM. Comparison of Treatment Response in Idiopathic and Connective Tissue Disease-associated Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2016; 192:1111-7. [PMID: 26291092 DOI: 10.1164/rccm.201507-1456oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Studies suggest that patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) have a poorer treatment response to therapies for PAH compared with patients with idiopathic PAH (IPAH), but individual randomized controlled trials (RCTs) have been underpowered to examine differences within these subgroups. OBJECTIVES To compare the effect of therapy for PAH in CTD-PAH versus IPAH. METHODS We obtained individual participant data from phase III placebo-controlled RCTs of therapies for PAH submitted to the U.S. Food and Drug Administration for drug approval. A treatment-by-diagnosis interaction term evaluated differences in treatment response between CTD-PAH and IPAH. Outcomes included change in 6-minute-walk distance (∆6MWD) from baseline to 12 weeks, clinical worsening, and all-cause mortality. MEASUREMENTS AND MAIN RESULTS The study sample included 827 participants with CTD-PAH and 1,935 with IPAH from 11 RCTs. Patients with CTD-PAH had less improvement in 6MWD when assigned to active treatment versus placebo compared with patients with IPAH (difference in treatment effect on ∆6MWD in CTD-PAH vs. IPAH, -17.3 m; 90% confidence interval, -31.3 to -3.3; P for interaction = 0.043). Treatment was less effective in reducing the occurrence of clinical worsening in CTD-PAH versus IPAH (P for interaction = 0.012), but there was no difference in the placebo-adjusted effect of treatment on mortality (P for interaction = 0.65). CONCLUSIONS Treatment for PAH was less effective in CTD-PAH compared with IPAH in terms of increasing 6MWD and preventing clinical worsening. The heterogeneity of treatment response supports the need for identifying therapies that are more effective for CTD-PAH.
Collapse
Affiliation(s)
| | | | | | | | - Peter A Merkel
- 1 Division of Rheumatology.,2 Center for Clinical Epidemiology and Biostatistics, and
| | - Steven M Kawut
- 2 Center for Clinical Epidemiology and Biostatistics, and.,3 Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
14
|
Cardiovascular magnetic resonance in rheumatology: Current status and recommendations for use. Int J Cardiol 2016; 217:135-48. [PMID: 27179903 DOI: 10.1016/j.ijcard.2016.04.158] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/25/2016] [Indexed: 01/14/2023]
Abstract
Targeted therapies in connective tissue diseases (CTDs) have led to improvements of disease-associated outcomes, but life expectancy remains lower compared to general population due to emerging co-morbidities, particularly due to excess cardiovascular risk. Cardiovascular magnetic resonance (CMR) is a noninvasive imaging technique which can provide detailed information about multiple cardiovascular pathologies without using ionizing radiation. CMR is considered the reference standard for quantitative evaluation of left and right ventricular volumes, mass and function, cardiac tissue characterization and assessment of thoracic vessels; it may also be used for the quantitative assessment of myocardial blood flow with high spatial resolution and for the evaluation of the proximal coronary arteries. These applications are of particular interest in CTDs, because of the potential of serious and variable involvement of the cardiovascular system during their course. The International Consensus Group on CMR in Rheumatology was formed in January 2012 aiming to achieve consensus among CMR and rheumatology experts in developing initial recommendations on the current state-of-the-art use of CMR in CTDs. The present report outlines the recommendations of the participating CMR and rheumatology experts with regards to: (a) indications for use of CMR in rheumatoid arthritis, the spondyloarthropathies, systemic lupus erythematosus, vasculitis of small, medium and large vessels, myositis, sarcoidosis (SRC), and scleroderma (SSc); (b) CMR protocols, terminology for reporting CMR and diagnostic CMR criteria for assessment and quantification of cardiovascular involvement in CTDs; and (c) a research agenda for the further development of this evolving field.
Collapse
|
15
|
Vascular Remodelling and Mesenchymal Transition in Systemic Sclerosis. Stem Cells Int 2016; 2016:4636859. [PMID: 27069480 PMCID: PMC4812480 DOI: 10.1155/2016/4636859] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 12/22/2022] Open
Abstract
Fibrosis of the skin and of internal organs, autoimmunity, and vascular inflammation are hallmarks of Systemic Sclerosis (SSc). The injury and activation of endothelial cells, with hyperplasia of the intima and eventual obliteration of the vascular lumen, are early features of SSc. Reduced capillary blood flow coupled with deficient angiogenesis leads to chronic hypoxia and tissue ischemia, enforcing a positive feed-forward loop sustaining vascular remodelling, further exacerbated by extracellular matrix accumulation due to fibrosis. Despite numerous developments and a growing number of controlled clinical trials no treatment has been shown so far to alter SSc natural history, outlining the need of further investigation in the molecular pathways involved in the pathogenesis of the disease. We review some processes potentially involved in SSc vasculopathy, with attention to the possible effect of sustained vascular inflammation on the plasticity of vascular cells. Specifically we focus on mesenchymal transition, a key phenomenon in the cardiac and vascular development as well as in the remodelling of injured vessels. Recent work supports the role of transforming growth factor-beta, Wnt, and Notch signaling in these processes. Importantly, endothelial-mesenchymal transition may be reversible, possibly offering novel cues for treatment.
Collapse
|
16
|
Reiseter S, Molberg Ø, Gunnarsson R, Lund MB, Aalokken TM, Aukrust P, Ueland T, Garen T, Brunborg C, Michelsen A, Abraityte A, Hoffmann-Vold AM. Associations between circulating endostatin levels and vascular organ damage in systemic sclerosis and mixed connective tissue disease: an observational study. Arthritis Res Ther 2015; 17:231. [PMID: 26315510 PMCID: PMC4551562 DOI: 10.1186/s13075-015-0756-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction Systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) are chronic immune-mediated disorders complicated by vascular organ damage. The aim of this study was to examine the serum levels of the markers of neoangiogenesis: endostatin and vascular endothelial growth factor (VEGF), in our unselected cohorts of SSc and MCTD. Methods Sera of SSc patients (N = 298) and MCTD patients (N = 162) from two longitudinal Norwegian cohorts were included. Blood donors were included as controls (N = 100). Circulating VEGF and endostatin were analyzed by enzyme immunoassay. Results Mean endostatin levels were increased in SSc patients 93.7 (37) ng/ml (P < .001) and MCTD patients 83.2 (25) ng/ml (P < .001) compared to controls 65.1 (12) ng/ml. Median VEGF levels were elevated in SSc patients 209.0 (202) pg/ml compared to MCTD patients 181.3 (175) pg/ml (P = .017) and controls 150.0 (145) pg/ml (P < .001). Multivariable analysis of SSc subsets showed that pulmonary arterial hypertension (coefficient 15.7, 95 % CI: 2.2–29.2, P = .023) and scleroderma renal crisis (coefficient 77.6, 95 % CI: 59.3–100.0, P < .001) were associated with elevated endostatin levels. Multivariable analyses of MCTD subsets showed that digital ulcers were associated with elevated endostatin levels (coefficient 10.5, 95 % CI: 3.2–17.8, P = .005). The risk of death increased by 1.6 per SD endostatin increase (95 % CI: 1.2–2.1, P = .001) in the SSc cohort and by 1.6 per SD endostatin increase (95 % CI: 1.0–2.4, P = .041) in the MCTD cohort after adjustments to known risk factors. Conclusions Endostatin levels were elevated in patients with SSc and MCTD, particularly SSc patients with pulmonary arterial hypertension and scleroderma renal crisis, and MCTD patients with digital ulcers. Elevated endostatin levels were also associated with increased all-cause mortality during follow-up in both groups of patients. We propose that endostatin might indicate the degree of vascular injury in SSc and MCTD patients. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0756-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Silje Reiseter
- Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway.
| | - Øyvind Molberg
- Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,Department of Rheumatology, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| | - Ragnar Gunnarsson
- Department of Rheumatology, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| | - May Brit Lund
- Department of Respiratory Medicine, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| | - Trond Mogens Aalokken
- Department of Radiology, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| | - Pål Aukrust
- Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,Department of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway. .,Research Institute of Clinical Medicine, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway. .,K. G. Jebsen Inflammation Research Centre, Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,K. G. Jebsen Thrombosis Research and Expertise Centre, The Arctic University of Norway, Langnes, 9037, Tromsø, Norway.
| | - Thor Ueland
- Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,Research Institute of Clinical Medicine, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway. .,K. G. Jebsen Inflammation Research Centre, Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,K. G. Jebsen Thrombosis Research and Expertise Centre, The Arctic University of Norway, Langnes, 9037, Tromsø, Norway.
| | - Torhild Garen
- Department of Rheumatology, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Ullevål, 0424, Oslo, Norway.
| | - Annika Michelsen
- Research Institute of Clinical Medicine, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway. .,K. G. Jebsen Thrombosis Research and Expertise Centre, The Arctic University of Norway, Langnes, 9037, Tromsø, Norway.
| | - Aurelija Abraityte
- Research Institute of Clinical Medicine, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway. .,K. G. Jebsen Thrombosis Research and Expertise Centre, The Arctic University of Norway, Langnes, 9037, Tromsø, Norway.
| | - Anna-Maria Hoffmann-Vold
- Institute of Clinical Medicine, University of Oslo, 0318, Oslo, Norway. .,Department of Rheumatology, Oslo University Hospital Rikshospitalet, 0424, Oslo, Norway.
| |
Collapse
|
17
|
Park JS, Park MC, Song JJ, Park YB, Lee SK, Lee SW. Application of the 2013 ACR/EULAR classification criteria for systemic sclerosis to patients with Raynaud's phenomenon. Arthritis Res Ther 2015; 17:77. [PMID: 25889905 PMCID: PMC4384278 DOI: 10.1186/s13075-015-0594-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 03/11/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction We investigated how many patients, who presented with Raynaud’s phenomenon (RP) and who had not been classified as systemic sclerosis (SSc), would be reclassified as SSc, if the 2013 American College of Rheumatology (ACR)/the European League Against Rheumatism (EULAR) classification criteria were used. We also analyzed the predictive values of the reclassification as SSc in those patients. Methods We consecutively enrolled 64 patients with RP and 60 patients with SSc. We applied the new classification criteria to them, reclassified them, and compared variables between those who were newly classified as SSc and those who were not or previously classified as SSc. Results Seventeen of 64 patients (26.5%), who presented with RP, but did not fulfill the 1980 ACR classification criteria, were newly classified as SSc by the 2013 ACR/EULAR classification criteria. The newly classified patients as SSc showed increased frequencies of sclerodactyly, digital tip ulcer, telangiectasia, abnormal nailfold capillaries and the presence of anti-centromere antibody, compared to those not and telangiectasia and anti-centromere antibody, compared to the previously classified patients. For the reclassification as SSc, the variables with independent predictive value were sclerodactyly (odds ratio (OR) 60.025), telangiectasia (OR 13.353) and the presence of anti-centromere antibody (OR 11.168). Conclusions Overall, 26.5% of the patients, who presented with RP, but who did not fulfill the 1980 ACR classification criteria, were newly classified as SSc according to the 2013 ACR/EULAR classification criteria. Sclerodactyly, telangiectasia, and the presence of anti-centromere antibody had independent predictive value for reclassifying patients with RP as SSc.
Collapse
Affiliation(s)
- Jin-Su Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Soo-Kon Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| |
Collapse
|
18
|
Tsuchida K, Yamada H, Yamasaki Y, Suzuki K, Kongoji K, Akashi Y, Ozaki S. Left heart abnormalities in connective tissue disease patients with pre-capillary pulmonary hypertension as well as borderline mean pulmonary arterial pressure. Mod Rheumatol 2015; 25:744-7. [PMID: 25736353 DOI: 10.3109/14397595.2015.1005871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe co-existence of left heart abnormalities among case series of connective tissue disease (CTD) patients who showed pre-capillary pulmonary hypertension (PH) as well as borderline mean pulmonary arterial pressure (mPAP). METHODS From 2010 through 2012, 49 CTD patients suspected to have PH by exercise Doppler echocardiography underwent right heart catheterization. We retrospectively searched for left heart diseases from the available data on Doppler echocardiography, cardiac magnetic resonance imaging (MRI), scintigraphy, and endomyocardial biopsy. RESULTS Among 49 patients, 11 and 2 had pre- and post-capillary PH, respectively, and another 10 had borderline mPAP. Six of 11 patients with pre-capillary PH showed low pulmonary vascular resistance (PVR) (≤ 240 dynes•sec•cm(- 5)) and low diastolic pulmonary gradient (< 7 mmHg). Seven of 10 patients with borderline mPAP had normal PVR (< 160) suggesting the presence of left heart abnormalities. Other abnormal findings included increased left atrial volume index and E/E' on Doppler echocardiography, delayed contrast enhancement by MRI, patchy area of hypoperfusion on thallium scintigraphy, and fibrosis in endomyocardial biopsy. CONCLUSION The present case series suggested some contribution of left heart abnormalities to the increase in mPAP among CTD patients with pre-capillary PH as well as borderline mPAP.
Collapse
Affiliation(s)
- Kosei Tsuchida
- a Division of Rheumatology and Allergology, Department of Internal Medicine , St. Marianna University School of Medicine , Miyamae-ku, Kawasaki , Japan
| | | | | | | | | | | | | |
Collapse
|
19
|
Deciphering Cardiovascular Disease in Systemic Inflammatory Diseases Using Advanced Magnetic Resonance Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
20
|
Teguh Ryanto GR, Nakayama K, Takaya T, Fujimoto D, Kinutani H, Shinkura Y, Mori S, Okada T, Nishii T, Kono A, Shinke T, Emoto N, Hirata KI. Use of Coils and a Pulmonary Vasodilator to Reduce Pulmonary Hypertension in a Patient with Interstitial Pneumonia and Scleroderma. Intern Med 2015; 54:2721-6. [PMID: 26521900 DOI: 10.2169/internalmedicine.54.4976] [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: 11/06/2022] Open
Abstract
Fistulas between systemic and pulmonary arteries are associated with various underlying etiologies and cause pulmonary hypertension (PH). Diagnosis of this condition requires several imaging studies and the exclusion of other possible causes of PH. We herein report a case of a patient with interstitial pneumonia and scleroderma. The imaging revealed multiple fistulas involving the inferior phrenic and left lower pulmonary arteries. The fistulas were closed using coils, but the PH remained presumably due to other undiagnosed fistulas. The improvement of symptoms following use of a supplementary pulmonary vasodilator provides the hope that the chosen treatment could be a viable alternative approach for other similar cases.
Collapse
Affiliation(s)
- Gusti Rizky Teguh Ryanto
- Division of Cardivascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Development of pulmonary hypertension in a high-risk population with systemic sclerosis in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) cohort study. Semin Arthritis Rheum 2014; 44:55-62. [DOI: 10.1016/j.semarthrit.2014.03.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/21/2014] [Accepted: 03/03/2014] [Indexed: 01/08/2023]
|
22
|
Abstract
Lung transplantation for scleroderma-related lung disease is controversial due to extra-pulmonary organ involvement that may threaten allograft and patient survival after transplant surgery. Despite concerns, several lung transplant programs do offer lung transplantation to patients with scleroderma-related lung disease. In this review, we evaluate the scleroderma-related extra-pulmonary organ involvement that may result in poorer outcomes after lung transplantation as well as the existing evidence on survival, freedom from bronchiolitis obliterans syndrome (BOS), and other important clinical outcomes after lung transplantation. Among the nine studies reviewed, comprising 226 subjects, survival and freedom from BOS appears to be similar for subjects undergoing lung transplantation for scleroderma compared to non-scleroderma lung diseases. Although scleroderma is a systemic disease with several unique potential threats to allograft and patient survival, lung transplantation appears to be a reasonable intervention for this patient population.
Collapse
|
23
|
Efthimiou P, Kadavath S, Mehta B. Life-threatening complications of adult-onset Still's disease. Clin Rheumatol 2014; 33:305-14. [PMID: 24435354 PMCID: PMC7102228 DOI: 10.1007/s10067-014-2487-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 12/27/2013] [Accepted: 01/03/2014] [Indexed: 12/28/2022]
Abstract
Adult-onset Still's Disease (AOSD) since its description in 1971 has proven to be a very complex and challenging disease entity. This rare auto-inflammatory disease is classically described by the "Still's triad" of fever, rash, and arthritis, although the atypical cases frequently outnumber the typical ones. The exact pathogenesis and etiologic factors responsible for the clinical features remain largely obscure, despite recent suggestive cytokine biology findings. Diagnosis is made on clinical grounds, following the exclusion of mimickers of infectious, autoimmune or neoplastic etiology, with the additional consideration of non-specific laboratory abnormalities such as peripheral leukocytosis and elevation of serum ferritin and other acute phase reactants. The disease manifestations are protean and can include diverse complications, affecting multiple organ systems. Moreover, the severity of the organ involvement can vary considerably, representing a wide spectrum from the self-limited to severe. The mainstay of therapy has evolved from the traditional use of corticosteroids and oral immunosupressants to the newer targeted treatments with biologic agents. The scope of this review is to alert the clinician to the existence of life-threatening AOSD complications, namely the macrophage activation syndrome, disseminated intravascular coagulopathy, thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, and pulmonary arterial hypertension. Such knowledge may lead in earlier recognition, prompt treatment, and, ideally, improved patient outcomes.
Collapse
Affiliation(s)
- Petros Efthimiou
- Rheumatology Division, Lincoln Medical and Mental Health Center, 234 E. 149th Street, New York, NY, 10451, USA,
| | | | | |
Collapse
|
24
|
Miller L, Chartrand S, Koenig M, Goulet JR, Rich É, Chin AS, Chartrand-Lefebvre C, Abrahamowicz M, Senécal JL, Grodzicky T. Left heart disease: a frequent cause of early pulmonary hypertension in systemic sclerosis, unrelated to elevated NT-proBNP levels or overt cardiac fibrosis but associated with increased levels of MR-proANP and MR-proADM: retrospective analysis of a French Canadian cohort. Scand J Rheumatol 2014; 43:314-23. [DOI: 10.3109/03009742.2013.854407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
25
|
Chaisson NF, Hassoun PM. Systemic sclerosis-associated pulmonary arterial hypertension. Chest 2014; 144:1346-1356. [PMID: 24081346 DOI: 10.1378/chest.12-2396] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc) and affects up to 12% of all patients with SSc, with a 50% mortality rate within 3 years of PAH diagnosis. Compared with the idiopathic form of PAH (IPAH), patients with SSc-associated PAH (SSc-PAH) have a threefold increased risk of death and may receive a diagnosis late in the course of disease because of insidious onset and the high prevalence of cardiac, musculoskeletal, and pulmonary parenchymal comorbidities. Treatment with conventional forms of PAH therapy often yield poor results compared with IPAH cohorts; unfortunately, the exact reasons behind this remain poorly understood but likely include variations in the pathologic mechanisms, differences in cardiovascular response to increasing afterload, and inadequate strategies to detect and treat SSc-PAH early in its course. Current methods for screening and longitudinal evaluation of SSc-PAH, such as the 6-min walk test, transthoracic echocardiography, and MRI, each have notable advantages and disadvantages. We provide an up-to-date, focused review of SSc-PAH and how it differs from IPAH, including pathogenesis, appropriate screening for disease onset, and new approaches to treatment and longitudinal assessment of this disease.
Collapse
Affiliation(s)
- Neal F Chaisson
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
26
|
Codullo V, Caporali R, Cuomo G, Ghio S, D'Alto M, Fusetti C, Borgogno E, Montecucco C, Valentini G. Stress Doppler echocardiography in systemic sclerosis: evidence for a role in the prediction of pulmonary hypertension. ACTA ACUST UNITED AC 2013; 65:2403-11. [PMID: 23754201 DOI: 10.1002/art.38043] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 05/28/2013] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Patients with systemic sclerosis (SSc) in whom pulmonary hypertension (PH) is not suspected have been reported to develop an inappropriate increase of pulmonary artery systolic pressure as estimated by Doppler echocardiography under conditions of exercise (pulmonary artery systolic pressure under exercise). We undertook this study to investigate whether this increase or any other parameter detectable by stress Doppler echocardiography has utility in predicting the development of PH in SSc. METHODS We enrolled a total of 170 patients with SSc previously investigated using standard and stress Doppler echocardiography and tissue Doppler imaging. Each patient was evaluated at baseline and yearly for skin and internal organ involvement. Right-sided heart catheterization was carried out when PH was suspected. The baseline Cochin Risk Prediction Score was calculated retrospectively. RESULTS During followup, 6 patients (3.5%) developed PH. Compared with patients without any feature suggesting PH, the Cochin Risk Prediction Score was higher in this group (mean ± SD 4.2 ± 0.9 versus 3.4 ± 0.9; P < 0.05), as was the difference between pulmonary artery systolic pressure under exercise and pulmonary artery systolic pressure (Δpulmonary artery systolic pressure) (18.2 ± 7 mm Hg versus 9.4 ± 6.5 mm Hg; P < 0.001), even when adjusted for cardiac index changes. In multivariate analysis, Δpulmonary artery systolic pressure (hazard ratio [HR] 3.4 [95% confidence interval 1.4-8], P < 0.01) and Cochin Risk Prediction Score within the fifth quintile of the values registered in our series (HR 9.3 [95% confidence interval 1.4-63.7], P < 0.05) were the only factors independently predictive of PH during followup. A Δpulmonary artery systolic pressure cutoff of >18 mm Hg, identified by receiver operating characteristic curve analysis, had a sensitivity of 50% and a specificity of 90% for the development of PH during followup. CONCLUSION An inappropriate response to exercise among patients with SSC is detectable by stress Doppler echocardiography. Independently of other clinical associations, increased Δpulmonary artery systolic pressure heralds PH. Stress Doppler echocardiography may represent an additional screening tool for this severe complication.
Collapse
|
27
|
Role of endothelial to mesenchymal transition in the pathogenesis of the vascular alterations in systemic sclerosis. ISRN RHEUMATOLOGY 2013; 2013:835948. [PMID: 24175099 PMCID: PMC3794556 DOI: 10.1155/2013/835948] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 08/09/2013] [Indexed: 12/13/2022]
Abstract
The pathogenesis of Systemic Sclerosis (SSc) is extremely complex, and despite extensive studies, the exact mechanisms involved are not well understood. Numerous recent studies of early events in SSc pathogenesis have suggested that unknown etiologic factors in a genetically receptive host trigger structural and functional microvascular endothelial cell abnormalities. These alterations result in the attraction, transmigration, and accumulation of immune and inflammatory cells in the perivascular tissues, which in turn induce the phenotypic conversion of endothelial cells and quiescent fibroblasts into activated myofibroblasts, a process known as endothelial to mesenchymal transition or EndoMT. The activated myofibroblasts are the effector cells responsible for the severe and frequently progressive fibrotic process and the fibroproliferative vasculopathy that are the hallmarks of SSc. Thus, according to this hypothesis the endothelial and vascular alterations, which include the phenotypic conversion of endothelial cells into activated myofibroblasts, play a crucial role in the development of the progressive fibrotic process affecting skin and multiple internal organs. The role of endothelial cell and vascular alterations, the potential contribution of endothelial to mesenchymal cell transition in the pathogenesis of the tissue fibrosis, and fibroproliferative vasculopathy in SSc will be reviewed here.
Collapse
|
28
|
Rapid progression to pulmonary arterial hypertension crisis associated with mixed connective tissue disease in an 11-year-old girl. Eur J Pediatr 2013; 172:1263-5. [PMID: 23686514 DOI: 10.1007/s00431-013-2034-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 05/06/2013] [Indexed: 10/26/2022]
Abstract
Mixed connective tissue disease (MCTD) is rare in pediatric rheumatic diseases. Pulmonary arterial hypertension (PAH) associated with MCTD usually progresses gradually and is difficult to note at the asymptomatic phase. We report a 11-year-old girl with MCTD complicated with rapidly progressive PAH. Although PAH was not detected by echocardiogram or chest CT scan at the initial examination, it became clear in 1 year and suddenly came to cardiac arrest during an invasive procedure. She was successfully treated with extracorporeal assist and both vasodilative and immunosuppressive medication. A combination of echocardiogram and plasma BNP levels could be a useful marker for the follow-up of such cases. PAH could develop early in the course of pediatric MCTD and needs attention to unexpected acute exacerbation, especially under emotional stress.
Collapse
|
29
|
Shahane A. Pulmonary hypertension in rheumatic diseases: epidemiology and pathogenesis. Rheumatol Int 2013; 33:1655-67. [PMID: 23334373 DOI: 10.1007/s00296-012-2659-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 12/28/2012] [Indexed: 11/26/2022]
Abstract
The focus of this review is to increase awareness of pulmonary arterial hypertension (PAH) in patients with rheumatic diseases. Epidemiology and pathogenesis of PAH in rheumatic diseases is reviewed, with recommendations for early screening and diagnosis and suggestion of possible role of immunosuppressive therapy in treatment for PAH in rheumatic diseases. A MEDLINE search for articles published between January 1970 and June 2012 was conducted using the following keywords: pulmonary hypertension, scleroderma, systemic sclerosis, pulmonary arterial hypertension, connective tissues disease, systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis, Sjogren's syndrome, vasculitis, sarcoidosis, inflammatory myopathies, dermatomyositis, ankylosing spondylitis, spondyloarthropathies, diagnosis and treatment. Pathogenesis and disease burden of PAH in rheumatic diseases was highlighted, with emphasis on early consideration and workup of PAH. Screening recommendations and treatment were touched upon. PAH is most commonly seen in systemic sclerosis and may be seen in isolation or in association with interstitial lung disease. Several pathophysiologic processes have been identified including an obliterative vasculopathy, veno-occlusive disease, formation of microthrombi and pulmonary fibrosis. PAH in systemic lupus erythematosus is associated with higher prevalence of antiphospholipid and anticardiolipin antibodies and the presence of Raynaud's phenomenon. Endothelial proliferation with vascular remodeling, abnormal coagulation with thrombus formation and immune-mediated vasculopathy are the postulated mechanisms. Improvement with immunosuppressive medications has been reported. Pulmonary fibrosis, extrinsic compression of pulmonary arteries and granulomatous vasculitis have been reported in patients with sarcoidosis. Intimal and medial hyperplasia with luminal narrowing has been observed in Sjogren's syndrome, mixed connective tissue disease and inflammatory myopathies. Pulmonary arterial hypertension (PAH) associated with rheumatic diseases carries a particularly grim prognosis with faster progression of disease and poor response to therapy. Though largely associated with systemic sclerosis, it is being increasingly recognized in other rheumatic diseases. An underlying inflammatory component may explain the poor response to therapy in patients with rheumatic diseases and is a rationale for consideration of immunosuppressive therapy in conjunction with vasodilator therapy in treatment for PAH. Further studies identifying pathogenetic pathways and possible targets of therapy, especially the role of immunomodulatory medications, are warranted.
Collapse
Affiliation(s)
- Anupama Shahane
- Division of Rheumatology, University of Pennsylvania, 8 Penn Tower, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
30
|
Dimitroulas T, Sandoo A, Kitas GD. Asymmetric dimethylarginine as a surrogate marker of endothelial dysfunction and cardiovascular risk in patients with systemic rheumatic diseases. Int J Mol Sci 2012. [PMID: 23202900 PMCID: PMC3497274 DOI: 10.3390/ijms131012315] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The last few decades have witnessed an increased life expectancy of patients suffering with systemic rheumatic diseases, mainly due to improved management, advanced therapies and preventative measures. However, autoimmune disorders are associated with significantly enhanced cardiovascular morbidity and mortality not fully explained by traditional cardiovascular disease (CVD) risk factors. It has been suggested that interactions between high-grade systemic inflammation and the vasculature lead to endothelial dysfunction and atherosclerosis, which may account for the excess risk for CVD events in this population. Diminished nitric oxide synthesis—due to down regulation of endothelial nitric oxide synthase—appears to play a prominent role in the imbalance between vasoactive factors, the consequent impairment of the endothelial hemostasis and the early development of atherosclerosis. Asymmetric dimethylarginine (ADMA) is one of the most potent endogenous inhibitors of the three isoforms of nitric oxide synthase and it is a newly discovered risk factor in the setting of diseases associated with endothelial dysfunction and adverse cardiovascular events. In the context of systemic inflammatory disorders there is increasing evidence that ADMA contributes to the vascular changes and to endothelial cell abnormalities, as several studies have revealed derangement of nitric oxide/ADMA pathway in different disease subsets. In this article we discuss the role of endothelial dysfunction in patients with rheumatic diseases, with a specific focus on the nitric oxide/ADMA system and we provide an overview on the literature pertaining to ADMA as a surrogate marker of subclinical vascular disease.
Collapse
Affiliation(s)
- Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands DY1 2HQ, UK; E-Mails: (A.S.); (G.D.K.)
- Author to whom correspondence should be addressed; E-Mail: or ; Tel.: +44-1384-244842; Fax: +44-1283-244272
| | - Aamer Sandoo
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands DY1 2HQ, UK; E-Mails: (A.S.); (G.D.K.)
| | - George D. Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands DY1 2HQ, UK; E-Mails: (A.S.); (G.D.K.)
- Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester M15 6SZ, UK
| |
Collapse
|
31
|
Koito H. Pulmonary arterial hypertension due to pulmonary veno-occlusive disease in systemic sclerosis: Importance of early diagnosis and cautious use of pulmonary vasodilator therapy. J Cardiol Cases 2012; 5:e175-e178. [PMID: 30532934 PMCID: PMC6265377 DOI: 10.1016/j.jccase.2012.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hitoshi Koito
- Misugikai Otokoyama Hospital, 2nd Department of Internal Medicine, Knasai Medical University, 19 Otokoyama-Izumi, Yawata, Kyoto 614-8366, Japan
| |
Collapse
|
32
|
Dimitroulas T, Mavrogeni S, Kitas GD. Imaging modalities for the diagnosis of pulmonary hypertension in systemic sclerosis. Nat Rev Rheumatol 2012; 8:203-13. [DOI: 10.1038/nrrheum.2012.2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|