A right ventricular diastolic impairment is common in systemic sclerosis and is associated with other target-organ damage

Pulmonary arterial hypertension associated with connective tissue diseases (CTD-PAH): Recent and advanced data

Pulmonary arterial hypertension (PAH), corresponding to group 1 of pulmonary hypertension classification, is a rare disease with a major prognostic impact on morbidity and mortality. PAH can be either primary in idiopathic and heritable forms or secondary to other conditions including connective tissue diseases (CTD-PAH). Within CTD-PAH, the leading cause of PAH is systemic sclerosis (SSc) in Western countries, whereas systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD) are predominantly associated with PAH in Asia. Although many advances have been made during the last two decades regarding classification, definition early screening and risk stratification and therapeutic aspects with initial combination treatment, the specificities of CTD-PAH are not yet clear. In this manuscript, we review recent literature data regarding the updated definition and classification of PAH, pathogenesis, epidemiology, detection, prognosis and treatment of CTD-PAH.

Digital Ulcers and Ventricular Arrhythmias as Red Flags to Predict Replacement Myocardial Fibrosis in Systemic Sclerosis

BACKGROUND

Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Echocardiography is the first line imaging tool to detect cardiac involvement, but it is not able to routinely detect myocardial fibrosis. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for replacement myocardial fibrosis assessment, but its availability is currently limited.

AIM

We aimed to assess the clinical and instrumental parameters that would be useful for predicting the presence of LGE-CMR, to achieve a better selection of patients with SSc that could benefit from third-level CMR imaging.

METHODS

344 SSc patients underwent a comprehensive echocardiogram and LGE-CMR on the same day; for 189 patients, a 24 h ECG Holter monitoring was available.

RESULTS

CMR showed non-junctional replacement myocardial fibrosis via LGE in 25.1% patients. A history of digital ulcers (OR 2.188; 95% C.I. 1.069-4.481) and ventricular arrhythmias at ECG Holter monitoring (OR 3.086; 95% C.I. 1.191-7.998) were independent predictors of replacement myocardial fibrosis.

CONCLUSIONS

CMR can detect patterns of clinical and subclinical cardiac involvement, which are frequent in SSc. A history of digital ulcers and evidence of ventricular arrhythmias at ECG Holter monitoring are red flags for the presence of replacement myocardial fibrosis in CMR. The association between digital ulcers and myocardial fibrosis suggests that a similar pathological substrate of abnormal vascular function may underlie peripheral vascular and cardiac complications.

A Multidisciplinary Approach as a Goal for the Management of Complications in Systemic Scleroderma: A Literature Review and Case Scenario

Systemic sclerosis (also known as scleroderma) is a chronic fibrosing autoimmune disease with both skin and multisystem organ involvement. Scleroderma has the highest mortality among all rheumatic diseases. The pathophysiology mechanism of systemic sclerosis is a progressive self-amplifying process, which involves widespread microvascular damage, followed by a dysregulation of innate and adaptive immunity and inflammation and diffuse fibrosis of the skin and visceral organs. Fibrosis of internal organs is a hint for systemic sclerosis, moreover associated with interstitial lung disease (SSc-ILD) is a complex process. In order to correlate scientific data from the literature with clinical experience, we present the case of a 56-year-old woman who was diagnosed with systemic sclerosis 16 years ago. The association of numerous comorbidities characterized by a considerable level of seriousness characterizes this case: the highly extensive systemic damage, the cardiovascular impact of the illness, and the existence of severe pulmonary arterial hypertension. The systemic and clinical manifestations, respiratory functional tests, radiological features, and specific therapy are discussed.

Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management

Systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations. SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis. While cardiac involvement is the second leading SSc-related cause of death, it is frequently clinically silent in early disease and often missed with routine screening. To facilitate identification of cardiac disease in this susceptible population, we present here a review of cardiac imaging modalities and potential uses in the SSc patient population. We describe well-characterized techniques including electrocardiography and 2D echocardiography with Doppler, but also discuss more advanced imaging approaches, such as speckle-tracking echocardiography, cardiovascular magnetic resonance imaging (CMR), and stress imaging, among others. We also suggest an algorithm for the appropriate application of these modalities in the workup and management of patients with SSc. Finally, we discuss future opportunities for cardiac imaging in SSc research to achieve early detection and to optimize treatment.

Management of systemic sclerosis: the first five years

PURPOSE OF REVIEW

This review provides a risk-stratified and evidence-based management for subsets of systemic sclerosis (SSc) patients in the first five years from disease onset.

RECENT FINDINGS

Cardiopulmonary disease remains the primary cause of mortality in SSc patients. Morbidity and mortality in SSc-associated pulmonary arterial hypertension have improved with combination treatment, in either an upfront or sequential treatment pattern. Traditional therapies for interstitial lung disease (SSc-ILD) have targeted those with clinically significant and progressive ILD with immunosuppression. New data suggest a possible paradigm shift, introducing immunosuppressive therapy to patients before they develop clinically significant or progressive ILD. The year 2019 saw the approval of the first FDA-approved therapy for SSc-associated interstitial lung disease, using an antifibrotic agent previously approved for idiopathic pulmonary fibrosis. To date, only autologous hematopoietic stem cell transplant has demonstrated a mortality benefit for SSc-ILD, albeit in a narrow spectrum of SSc-ILD patients.

SUMMARY

SSc is a highly heterogeneous autoimmune disease typified by varying clinical trajectories. Its management may be stratified within the first five years by subclassifying patients based on factors that have important prognostic significance: skin distribution and autoantibody status.

Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis

PURPOSE OF THE REVIEW

Systemic sclerosis (scleroderma) is a complex autoimmune disease that commonly involves the cardiovascular system. Even if often subclinical, cardiac involvement is considered a poor prognostic factor as it is a leading cause of death in scleroderma patients. We review the cardiac manifestations of scleroderma, the diagnostic methods useful in detection, and current advances in therapeutic management.

RECENT FINDINGS

Beside the routine exams for the assessment of cardiac status (including EKG, standard echocardiography, provocative tests) novel techniques such as myocardial strain imaging on echocardiography, cardiac magnetic resonance imaging, invasive hemodynamic assessment, and endomyocardial biopsy have been demonstrated to be useful in understanding the cardiac alterations that typically affect scleroderma patients. Recent application of novel cardiac detection strategies is providing increased insight into the breadth and pathogenesis of cardiac complications of scleroderma. Further studies coupling exercise provocation, invasive and imaging assessment, and mechanistic studies in scleroderma cardiac tissue are needed to develop the optimal approach to early detection of cardiac disease in scleroderma and targeted therapies.

Systolic Dysfunction in Systemic Sclerosis: Prevalence and Prognostic Implications

Objective

Primary cardiac involvement is presumed to account for a substantial part of disease-related mortality in systemic sclerosis (SSc). Still, there are knowledge gaps on the evolution and total burden of systolic dysfunction in SSc. Here we evaluated prospective left ventricular (LV) and right ventricular (RV) systolic function in an unselected SSc cohort and assessed the burden of systolic dysfunction on mortality.

Methods

From the Oslo University Hospital cohort, 277 SSc patients were included from 2003-2016 and compared with healthy controls. Serial echocardiographies were reevaluated in order to detect change in systolic function. Right heart catheterization was performed on patients suspected of pulmonary hypertension. Descriptive and regression analyses were conducted.

Results

At baseline, LV systolic dysfunction by ejection fraction less than 50%, or a global longitudinal strain greater than -17.0%, was found in 12% and 24%, respectively. RV systolic dysfunction measured by tricuspid annular plane systolic excursion (TAPSE) less than 17 mm was evident in 10%. Follow-up echocardiography was performed after a median of 3.3 years (interquartile range [IQR] 1.5-5.6). At follow-up, LV systolic function remained stable, whereas RV function evaluated by TAPSE deteriorated (mean 23.1 to 21.7 mm, P = 0.005) equaling a 15% prevalence of RV systolic dysfunction. RV systolic function predicted mortality in multivariable models (hazard ratio 0.41, 95% confidence interval [CI] 0.19-0.90, P value 0.027), whereas LV systolic function lost predictive significance when adjusted for TAPSE.

Conclusion

In this unselected and prospective study, systolic dysfunction of the LV and RV was a frequent complication of SSc. LV systolic function remained stable across the observation period, whereas RV function deteriorated and predicted mortality.

CT compared to MRI for functional evaluation of the right ventricle: a systematic review and meta-analysis

OBJECTIVE

Right ventricular function (RVF) is a strong predictor of adverse cardiac events; however, the reference standard for RVF assessment, MRI, is limited in some patients for whom accurate evaluation of RVF is essential, like those with COPD or non-MR compatible metal implants. We conducted this meta-analysis to evaluate whether CT was as accurate as MRI for the assessment of RVF.

METHOD

We conducted a meta-analysis of studies retrieved from PubMed, Embase, and Cochrane Central searches to evaluate the differences and correlations between the following RVF parameters as measured by CT and MRI: end diastole volume (EDV), end systole volume (ESV), right ventricular ejection fraction (RVEF), and stroke volume (SV).

RESULTS

Sixteen studies that used disk summation (637 subjects) and three studies that used three-dimensional reconstruction were included. For the 16 studies, the pooled standard mean differences (95% confidence interval) were 1.04 (- 2.59, 4.67) for EDV, 1.22 (1.50, 3.95) for ESV, - 0.65 (- 2.60, 1.29) for RVEF, and - 0.37 (- 3.64, 2.90) for SV. The overall correlation coefficient (r) values were 0.98 for EDV, 0.95 for ESV, 0.98 for RVEF, and 0.97 for SV. The mean difference between the two methods was not statistically significant (overall effect Z test, p > 0.1).

CONCLUSION

CT can assess RVF with accuracy comparable to that of MRI. Thus, CT is a valid alternative to MRI.

KEY POINTS

• CT could help clinicians to assess RVF as accurately as MRI can, with satisfactory repeatability.

Update of screening and diagnostic modalities for connective tissue disease-associated pulmonary arterial hypertension

OBJECTIVE

Pulmonary arterial hypertension (PAH) has high morbidity and mortality in connective tissue diseases (CTDs), especially systemic sclerosis (SSc). In this systematic review, we provide an update on screening measures for early detection of PAH in CTD.

METHODS

Manuscripts published between July 2012 and October 2017, which incorporated screening measures to identify patients with PAH by right heart catheterization, were identified. Risk of bias was assessed using the QUADAS-2 tool.

RESULTS

The systematic review resulted in 1514 unique citations and 22 manuscripts were included for final review; the majority of manuscripts had a lower risk of bias based on the QUADAS-2 tool. There were 16 SSc cohort studies and 6 case-control studies (SSc 4, SLE 2). Four SSc cohort studies evaluated transthoracic echocardiography (TTE) only. Eight SSc cohort studies evaluated composite measures including ASIG, DETECT, and a combination of tricuspid regurgitation velocity (TRV) and PFT variables. DETECT and ASIG had greater sensitivity and negative predictive value (NPV) compared to the 2009 ESC/ERS guidelines in different cohorts. The addition of PFT variables, such as DLCO or FVC/ DLCO ratio, to TRV, resulted in greater sensitivity and NPV compared to TRV alone.

CONCLUSION

Current screening for PAH in CTDs is centered on SSc. Data continues to support the use of TTE and provides additional evidence for use of composite measures.

A normal diffusing capacity of the lungs for carbon monoxide is rare in incidental pulmonary arterial hypertension in systemic sclerosis: Data from the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma cohort

Objective:

Our purpose was to determine the frequency of normal diffusing capacity for carbon monoxide defined as ⩾70% predicted, in those diagnosed with pulmonary arterial hypertension in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma cohort. We compared those with normal diffusing capacity for carbon monoxide to those with reduced diffusing capacity for carbon monoxide <70% in order to better clarify the role of pulmonary function testing as a screening test for pulmonary arterial hypertension and to better understand this population.

Methods:

Entry criteria included a right heart catheterization with mean pulmonary artery pressure ⩾25 mm Hg and pulmonary capillary wedge pressure ⩽15 mm Hg. Demographics, echocardiogram variables, B-type natriuretic peptide levels, right heart catheterization findings, and survival were described for both groups.

Results:

Of (n = 202), 11 (5.4%) had a diffusing capacity for carbon monoxide of ⩾70% versus 191 (94.6%) who had a diffusing capacity for carbon monoxide <70%. There were no identified statistical differences between the groups. Left atrium size was 4.1 cm in the normal diffusing capacity for carbon monoxide patients compared to 3.7 cm in the low diffusing capacity for carbon monoxide group but did not reach statistical significance. There were no statistically significant differences in survival. On repeat testing, seven patients subsequently developed a diffusing capacity for carbon monoxide <70%.

Conclusion:

Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma data suggest that it is very rare for a patient to develop pulmonary arterial hypertension with a preserved diffusing capacity for carbon monoxide. The data support the importance of obtaining diffusing capacity for carbon monoxide and that a patient with a normal diffusing capacity for carbon monoxide while suspected to have systemic sclerosis-pulmonary arterial hypertension should be considered critically. Diffusing capacity for carbon monoxide >70% was present in too few patients to find significant differences in B-type natriuretic peptide and atrium size. Future research should seek to confirm abnormal B-type natriuretic peptide, increased left atrium size, and other evidence of myocardial involvement on diffusing capacity for carbon monoxide.

Systemic sclerosis impacts right heart and cardiac autonomic nervous system

AIM

To evaluate the influence of systemic sclerosis (SSc) on right ventricular (RV) remodeling by two- and three-dimensional echocardiography (2DE and 3DE) and heart rate variability (HRV).

METHODS

Forty-five SSc patients and 35 age- and gender-matched healthy controls underwent clinical examination, 24-h Holter monitoring, and comprehensive 2DE and 3DE.

RESULTS

2DE RV global and RV free wall longitudinal strains, as well as 2DE RV endocardial, mid-myocardial, and epicardial longitudinal strains were lower in SSc subjects, who exhibited greater 3DE RV volumes but lower 3DE RV ejection fraction than controls. HRV indices were impaired in SSc subjects. These differences in RV global and free wall longitudinal strain, layer-specific strains, and ejection fraction, were associated with HRV indices independently of demographic, clinical, and echocardiographic parameters. Modified Rodnan Skin Score, clinical indicator of skin involvement in SSc, was associated with HRV parameters, RV layer-specific mechanics, and RV ejection fraction.

CONCLUSION

SSc affects RV function and mechanics of all myocardial layers, as well as cardiac autonomic nervous function. HRV indices are significantly associated with RV function, RV deformation, and skin involvement in SSc patients.

Update on assessment and management of primary cardiac involvement in systemic sclerosis

Primary cardiac involvement is a common and severe complication of systemic sclerosis, which may affect all of the hearts' structural components, including pericardium, myocardium, endocardium, cardiac valves, and conduction system. While cardiac disease can be clinically silent and only diagnosed in autopsy, new imaging modalities such as speckle-tracking echocardiography and cardiovascular magnetic resonance may reveal various abnormal findings in the majority of patients. Cardiovascular magnetic resonance evaluation should include assessment of left and right ventricular function, inflammation (STIR T2-weighted sequences (T2-W) for edema detection), and fibrosis (T1-weighted sequences 15 min after Gd-DTPA contrast medium injection (late-gadolinium enhancement). Notably, cardiac disease is responsible for about one-fourth of systemic sclerosis-related deaths. Systematic studies for the assessment and therapy of systemic sclerosis-related cardiac complications, as well as relevant guidelines from the European League Against Rheumatism and the American College of Rheumatology, are currently lacking. However, research advances reviewed herein allow for a better understanding of the mechanisms that alter cardiac function. Implementation of such knowledge should reduce cardiac morbidity and mortality in systemic sclerosis patients.

Complex Pathophysiology of Pulmonary Hypertension Associated with Systemic Sclerosis: Potential Unfavorable Effects of Vasodilators

Therapeutic advance by pulmonary vasodilators has provided huge impacts on prognosis in patients with pulmonary arterial hypertension (PAH), but outcomes of systemic sclerosis (SSc)-associated PAH still remain unsatisfactory. One of the major reasons is a series of potential unfavorable effects triggered by pulmonary vasodilators, which result from the complex pathophysiology of SSc-PAH. We herein present and discuss five representative conditions potentially induced by pulmonary vasodilators, including (i) emergence of latent pulmonary veno-occlusive disease, (ii) emergence of latent left-heart disease, (iii) worsening of pulmonary gas change in the presence of interstitial lung disease, (iv) ischemic limb gangrene by stealing of blood flow, and (v) uncontrolled hemorrhage from gastrointestinal telangiectasia. The former three conditions are common causes for worsening of dyspnea or oxygenation during treatment with pulmonary vasodilators, whereas the latter two are rare, but have significant negative impacts on patients’ quality of life and survival. These unfavorable conditions are pitfalls in clinical practice, and interfere with optimizing therapies in patients with SSc-PAH. Therefore, pre-assessment of pathophysiology of pulmonary hypertension and cautious monitoring during the treatment are necessary to achieve better outcomes in patients with SSc-PAH.