Analysis of transmural trends in myocardial integrated backscatter in patients with progressive systemic sclerosis

Systemic Sclerosis Portends Increased Risk of Conduction and Rhythm Abnormalities at Diagnosis and During Disease Course: A US Population-Based Cohort

Objectives

To study the incidence, risk factors and outcomes of conduction and rhythm disorders in a population-based cohort of patients with systemic sclerosis (SSc) vs. non-SSc comparators.

Methods

An incident cohort of patients with SSc (1980-2016) from Olmsted County, MN was compared to age- and sex-matched non-SSc subjects (1:2). Electrocardiograms (ECGs), Holter ECGs, and need for cardiac interventions were reviewed to determine the occurrence of any conduction or rhythm abnormalities.

Results

78 incident SSc cases and 156 comparators were identified (mean age 56 y, 91% female). The prevalence of any conduction disorder prior to SSc diagnosis compared to non-SSc subjects was 15% vs. 7% (p=0.06), and any rhythm disorder was 18% vs. 13% (p=0.33). During a median follow-up of 10.5 years in patients with SSc and 13.0 years in non-SSc comparators, conduction disorders developed in 25 patients with SSc with cumulative incidence of 20.5% (95% CI: 12.4-34.1%) vs. 28 non-SSc patients with cumulative incidence of 10.4% (95% CI: 6.2-17.4%) (HR: 2.57; 95% CI: 1.48-4.45), while rhythm disorders developed in 27 patients with SSc with cumulative incidence of 27.3% (95% CI: 17.9-41.6%) vs. 43 non-SSc patients with cumulative incidence of 18.0% (95% CI: 12.3-26.4%) (HR: 1.62; 95% CI: 1.00-2.64). Age, pulmonary hypertension and smoking were identified as risk factors.

Conclusion

Patients with SSc have an increased risk of conduction and rhythm disorders both at disease onset and over time, compared to non-SSc patients. These findings warrant increased vigilance and screening for ECG abnormalities in SSc patients with pulmonary hypertension.

Impact of Pulmonary Arterial Hypertension on Left Ventricular Function – a Comparative Study between Scleroderma and Coronary Artery Disease

Background: The impact of pulmonary arterial hypertension (PAH) on left ventricular performance in patients with scleroderma is still unknown. This study aims to perform a comparative echocardiographic analysis of left ventricular function between two different etiological varieties of PAH, namely PAH caused by systemic sclerosis as a representative of systemic inflammatory diseases and PAH caused by myocardial ischemia.

Material and method: We conducted a prospective observational study on 82 patients, of which 36 were with documented PAH, with the systolic pressure in the pulmonary artery above 35 mmHg, and 46 were patients with normal pulmonary artery pressure. The study population was divided into two groups, based on the etiology of PAH: group 1 included patients diagnosed with scleroderma (n = 48); group 2 included patients with coronary artery disease (n = 35). Patients from each group were divided into two subgroups based on the diagnosis of PAH: subgroup 1A – subjects with scleroderma and associated PAH (n = 20); subgroup 1B – subjects with scleroderma without PAH (n = 28); subgroup 2A – ischemic patients with associated PAH (n = 16); and subgroup 2B – patients with ischemic disease without PAH (n = 19).

Results: A significant difference between LVEF values in patients with PAH versus those without PAH in the ischemic group (p = 0.023) was recorded. Compared to scleroderma subjects, ischemic patients presented significantly lower values of LVEF in both PAH and non-PAH subgroups (p <0.0001 and p <0.0001, respectively). Linear regression analysis between sPAP and LVEF revealed a significant negative correlation only for the ischemia group (r = −0.52, p = 0.001) and the scleroderma 2B subgroup (r = −0.51, p = 0.04). Tissue Doppler analysis of left ventricular function revealed a significant impact of PAH on left ventricular diastolic performance in the ischemic group.

Conclusions: Compared to patients with coronary artery disease, those with scleroderma present a less pronounced deterioration of LVEF in response to pulmonary arterial hypertension.

Early assessment of sub-clinical cardiac involvement in systemic sclerosis (SSc) using delayed enhancement cardiac magnetic resonance (CE-MRI)

OBJECTIVES

Systemic sclerosis heart involvement (SHI) is one of systemic sclerosis (SSc) most frequent complications, both in diffuse (dcSSc) and limited (lcSSc) cutaneous forms of disease. Nowadays, SHI is a major factor decreasing SSc survival rate because, when clinically evident, is associated with 70% of mortality at 5 years. SHI shows different forms, primary and/or secondary. Primary myocardial SHI is characterized by fibrosis. Aim of our study is to assess the presence and pattern of fibrosis as detected by cardiac magnetic resonance (CMR) in systemic sclerosis.

METHODS

In this study, we used CE-MRI (contrast enhanced-MRI) in 58 female SSc patients. Images were evaluated to obtain functional parameters and to see presence, location and pattern (nodular, linear or diffuse) of myocardial LE, sign of fibrosis. CE-MRI findings were correlated with patients clinical setting.

RESULTS

Myocardial fibrosis was detected in 25 of 58 patients (43%). The main finding observed in 16 of these 25 patients was a late enhancement showing a linear pattern, without coronary distribution and sparing the sub-endocardial myocardial layers. A patchy nodular enhancement pattern was observed in 9 patients (36%). Patients with linear pattern presented dcSSc, on the contrary patients with nodular LE displayed the lcSSc form.

CONCLUSIONS

This study shows that CE-MRI is a reliable technique to detect SHI earlier than other methods. SHI increase passive myocardial stiffness, proportional to collagen deposition degree, leading to cardiac remodelling with possible development of heart failure, even with normal ejection fraction. An early treatment of SHI might improve SSc patients outcome.

Echocardiographic tissue characterization demonstrates differences in the left and right sides of the ventricular septum

The left and right ventricular function of the heart are influenced by the complex structure of the ventricular septum. The cyclic variation of ultrasonic backscatter over the cardiac cycle is known to be sensitive to both structural and functional characteristics of the myocardium. The objective of this study was to investigate differences in the measured magnitude and normalized delay of cyclic variation between the left and right sides of the ventricular septum in normal adult subjects (N = 31). The measured mean magnitudes of cyclic variation were found to be 4.9 ± 0.4 dB and 2.4 ± 0.3 dB (mean ± SE; p < 0.0001) and the corresponding normalized delay values were found to be 0.94 ± 0.05 and 1.59 ± 0.12 (mean ± SE; p < 0.0001) for the left and right sides, respectively. These results show significant differences in the measured magnitude and normalized delay of cyclic variation between the left and right sides of the ventricular septum in normal subjects that appear consistent with predictions based on previously described models of cyclic variation of backscatter and reported measurements of transmural differences in strain properties of the septum.

Detection of subclinical cardiac involvement in systemic sclerosis by echocardiographic strain imaging

BACKGROUND

Cardiac involvement is one of the major problems in systemic sclerosis (SSc). Subclinical cardiac involvement has a higher frequency than thought previously. In this study we investigated whether subclinical cardiac involvement can be detected by using echocardiographic strain imaging in SSc patients without pulmonary hypertension.

METHODS

Echocardiographic examinations were performed to 27 SSc patients and 26 healthy controls. Left ventricular strain parameters were obtained from apical views and average strain value was calculated from these measurements.

RESULTS

There were no significant differences between patients and controls regarding two-dimensional (2D), conventional Doppler and tissue Doppler velocity measurements. Strain was reduced in 6 of 12 segments of the left ventricle (LV) and in 1 of 2 segments of the right ventricle (RV). Strain rate (SR) was reduced in 2 of 12 segments of the LV and 1 of 2 segments of the RV in SSc patients as compared to controls (P < 0.05 for all). These involvements did not match any particular coronary artery distribution. More important differences were detected by average strain and SR values of the LV between patients and controls (19.78 +/- 3.00% vs 23.41 +/- 2.73%, P < 0.001; 2.01 +/- 0.41 vs 2.23 +/- 0.27/sec, P = 0.026, respectively). Furthermore, carbon monoxide diffusion capacity (DLCO) in scleroderma patients significantly correlated with LV average strain (r = 0.59; P = 0.001).

CONCLUSION

Evaluation of ventricular function by using echocardiographic strain imaging appears to be useful to detect subclinical cardiac involvement in SSc patients with normal standard echocardiographic and tissue Doppler velocity findings.

Associations between left ventricular myocardial involvement and endothelial dysfunction in systemic sclerosis: noninvasive assessment in asymptomatic patients

OBJECTIVES

Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult.

AIM OF THE STUDY

To analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc.

METHODS

30 healthy patients and 33 age- and sex-comparable asymptomatic patients classified as having either diffuse (18 patients) or limited form (15 patients) of SSc underwent standard Doppler Echo, Doppler myocardial imaging, Strain rate imaging of interventricular septum and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel (after dipyridamole infusion), and brachial artery vasodilatation measurement (Vivid 7, GE Medical Systems Inc).

RESULTS

LV diameters and ejection fraction were comparable between the two groups, while systolic pulmonary pressure (P < 0.001) was increased in SSc. By chest-CT, 15 SSc patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 14 SSc patients, and anti Scl-70 in 19 patients. In SSc, LV myocardial early diastolic peak velocity, peak systolic strain rate and strain were both reduced in basal and middle interventricular septum, and in basal and middle LV lateral wall. Both CFR (P < 0.0001) and endothelial flow-mediated dilatation (P < 0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (P < 0.001) and endothelial function (P < 0.001) were powerful independent determinants of middle LV strain.

CONCLUSIONS

Strain rate imaging, transthoracic CFR, and brachial artery flow-mediated dilatation are valuable noninvasive and easily repeatable tools for detecting LV myocardial and vascular involvement caused by SSc. Their combined use may be therefore useful for early identifying patients with more diffused and severe form of SSc, ideally in asymptomatic cases prior to the development of severe vasculopathy, when it may be most feasible to modify the disease process by new potential therapies.

Myocardial and vascular dysfunction in systemic sclerosis: The potential role of noninvasive assessment in asymptomatic patients

Systemic sclerosis (SSc) is a multi-system disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. The aim of the present study was to analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc. Thirty healthy subjects and 33 age- and sex-comparable asymptomatic SSc patients underwent standard Doppler Myocardial Imaging, Strain Rate (SR) Imaging of interventricular septum (IVS) and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel, and brachial artery vasodilatation measurement. In SSc patients, LV myocardial early diastolic peak velocity, peak systolic SR and strain were both reduced in basal and middle IVS, and in basal and middle LV lateral wall (p<0.001). In addition, both CFR (p<0.0001) and endothelial flow-mediated dilatation (p<0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (p<0.001) and endothelial function (p<0.001) were powerful independent determinants of middle LV strain of SSc patients. In conclusion, SR Imaging, transthoracic CFR and brachial artery flow-mediated dilatation are valuable non-invasive and easy-repeatable tools for detecting early LV myocardial and vascular involvement caused by SSc.

The heart in systemic sclerosis

The heart is one of the major organs involved in scleroderma. Cardiac involvement can be manifested by myocardial disease, conduction system abnormalities, arrhythmias, or pericardial disease. Additionally, scleroderma renal crisis and pulmonary hypertension lead to significant cardiac dysfunction secondary to damage in the kidney and lung. This report summarizes the recent advances to further understand the types and mechanism of abnormalities in the heart in scleroderma. New cardiac technology shows significant frequencies of asymptomatic cardiac abnormalities. Further long-term studies are necessary to determine the outcome and the best approach to treatment of such abnormalities. Diastolic dysfunction has been carefully evaluated in scleroderma in recent years and appears to be more common than once realized. There is controversy as to whether this is a significant finding independent to other cardiopulmonary problems. More extensive evaluation of the conduction and the arrhythmia ablative therapy has helped manage these life-threatening complications.