Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review

Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.

Obstructive sleep apnoea syndrome and left ventricular hypertrophy: a meta-analysis of echocardiographic studies

AIM

We investigated the association between obstructive sleep apnoea (OSA) and subclinical cardiac organ damage through a meta-analysis of echocardiographic studies that provided data on left ventricular hypertrophy (LVH), assessed as a categorical or continuous variable.

DESIGN

The PubMed, OVID-MEDLINE, and Cochrane library databases were systematically analyzed to search English-language articles published from 1 January 2000 to 15 August 2019. Studies were detected by using the following terms: 'obstructive sleep apnea', 'sleep quality', 'sleep disordered breathing', 'cardiac damage', 'left ventricular mass', 'left ventricular hypertrophy', and 'echocardiography'.

RESULTS

Meta-analysis included 5550 patients with OSA and 2329 non-OSA controls from 39 studies. The prevalence of LVH in the pooled OSA population was 45% (CI 35--55%). Meta-analysis of studies comparing the prevalence of LVH in participants with OSA and controls showed that OSA was associated with an increased risk of LVH (OR = 1.70, CI 1.44-2.00, P < 0.001). LV mass was significantly increased in patients with severe OSA as compared with controls (SMD 0.46 ± 0.08, CI 0.29-0.62, P < 0.001) or with mild OSA. This was not the case for studies comparing patients with unselected or predominantly mild OSA and controls (0.33 ± 0.17, CI -0.01 to 0.67, P = 0.057).

CONCLUSION

The present meta-analysis expands previous information on the relationship between OSA and echocardiographic LVH, so far based on individual studies. The overall evidence strongly suggests that the likelihood of LVH increases with the severity of OSA, thus exhibiting a continuous relationship.

Targeting subclinical organ damage in obstructive sleep apnea: a narrative review

Subclinical abnormalities in cardiac and vascular structure reflect the adverse effects triggered by a variety of risk factors on the cardiovascular (CV) system thereby representing an intermediate step in the cardiovascular continuum; such alterations are recognized as reliable markers of increased cardiovascular risk in different clinical settings including obstructive sleep apnea (OSA). The mechanisms underlying subclinical organ damage (OD) in the OSA setting are multifactorial. Hypoxemia and hypercapnia, induced by repeated collapses of upper airways, have been suggested to trigger a cascade of events such as activation of the sympathetic tone, renin-angiotensin-aldosterone system leading to endothelial dysfunction, vasoconstriction, myocardial and vascular remodeling, and hypertension. Furthermore, coexisting non-haemodynamic alterations such as increased oxidative stress, release of inflammatory substances, enhanced lipolysis and insulin resistance have been reported to play a role in the pathogenesis of both cardiac and extra-cardiac OD. In this article we reviewed available evidence on the association between OSA and subclinical cardiac (i.e., left and right ventricular hypertrophy, left atrial dilatation) and extra-cardiac organ damage (i.e., carotid atherosclerosis, arterial stiffness, microvascular retinal changes, and microalbuminuria). This association is apparently stronger for cardiac and carotid subclinical damage than for other markers (i.e., arterial stiffness and retinal changes) and mostly evident in the setting of severe OSA.

High prevalence of occult heart disease in normotensive patients with rheumatoid arthritis

BACKGROUND

Due to chronic inflammatory status, rheumatoid arthritis (RA) patients are exposed to changes in left ventricular (LV) geometry and function. We assessed prevalence, factors associated with, and prognostic role of concentric LV geometry and systolic dysfunction (LVSD) detected by echocardiography in a large cohort of patients with RA and normal blood pressure.

HYPOTHESIS

Changes in LV geometry and function are widely detectable in normotensive patients with RA analyzed in primary prevention.

METHODS

We prospectively analyzed 194 normotensive RA patients without overt cardiac disease recruited between March 2014 and May 2016, compared with 194 non-RA matched controls. Relative wall thickness >0.43 defined concentric LV geometry. LVSD was defined as impaired global longitudinal strain (GLS). The prespecified study endpoints were all-cause hospitalization and hospitalization for cardiovascular cause.

RESULTS

The 194 normotensive subjects (mean age, 54 years; 63% female; RA duration 13 years) had a prevalence of LV concentric geometry 5-fold higher and LVSD 5-fold higher than non-RA matched controls. Body mass index, LVSD, and diastolic dysfunction were associated with concentric LV geometry, while worsening renal function and older age were associated with LVSD. LVSD was independently related to the study endpoints (HR 2.37 [1.24-4.53], p = 0.009, for all-causes hospitalization and HR 6.60 [1.47-29.72], p = 0.01 for cardiovascular hospitalization).

CONCLUSIONS

Despite normotensive status, a consistent proportion of RA patients analyzed in primary prevention have cardiac abnormalities detectable by echocardiography. LVSD is a strong prognosticator of adverse outcome at midterm period in these patients.

Prognostic Role of Subclinical Left Ventricular Systolic Dysfunction Evaluated by Speckle-Tracking Echocardiography in Rheumatoid Arthritis

BACKGROUND

Speckle-tracking echocardiography allows early detection of subclinical left ventricular systolic dysfunction (LVSD) in patients with rheumatoid arthritis (RA). In this prospective study, we assessed the prevalence and the prognostic role of subclinical LVSD detected by speckle-tracking echocardiography in RA patients.

METHODS

Two-dimensional global longitudinal strain (GLS) and global circumferential strain (GCS) were measured in 209 RA patients without overt cardiac disease. LVSD was defined as low GLS (> -16.0%), low GCS (> -17.8%), or both. The primary end point was all-causes hospitalization; the coprimary end point was hospitalization for cardiovascular causes.

RESULTS

The study population had a mean age of 58 ± 11 years; 67% were female, 52% had hypertension, and the RA duration was 14 ± 10 years. Low GLS was detected in 51 patients (24%), low GCS in 42 patients (20%), and combined low GLS and GCS in 18 patients (9%). During a median follow-up time of 16 months (range, 10-21 months), a primary end point occurred in 50 patients (24%), and 25 patients were hospitalized for a cardiovascular event. Multiple Cox regression analyses revealed that combined low GLS and GCS was independently associated with the end point defined as all-causes hospitalization together with higher aortic stiffness. Examined individually, neither low GCS nor low GLS showed an independent association with this typology of clinical outcome. Conversely, both low GCS and low GLS (examined individually or as combined low GLS and GCS) emerged as strong independent prognosticators of cardiovascular events.

CONCLUSIONS

Subclinical LVSD defined as low GLS, GCS, or both is common in RA patients without overt cardiac disease and provides additional prognostic information in these individuals.

Sleep-disordered breathing and echocardiographic measures of function and dyssynchrony: a complex approach to cardiac resynchronization therapy

INTRODUCTION

We investigated the relationship between sleep-disordered breathing (SDB), cardiac function, and cardiac resynchronization therapy (CRT).

METHODS

Fifty-five CRT patients with SDB diagnosed by Holter ECG (apnea/hypopnea index - AHI) were included in the study. We sought to determine right ventricle (RV) predictors of short-term SDB improvement and long-term outcome in patients with (AHI dippers) and without (AHI nondippers) 25% AHI improvement, markers of CRT response, and SDB influence on survival.

RESULTS

Baseline tricuspid E-wave (AUC - 0.925, cut-off value > 0.336 m/s; sensitivity - 90%, specificity - 100%) and RV E/E' - 0.864, ≤16.25; 73%, 100%, respectively) were found as predictors of 25% AHI reduction. Spiroergometric tests, mitral regurgitation, and LVEF results improved significantly in AHI dippers. Regression analysis identified the absence of 25% AHI reduction (OR-7.67, 95% CI 1.52-38.6 and OR-9.92, 95%CI 6.02-15.3) and septal-lateral atrial velocities delay (OR-1.09, 95% CI 0.99-1.2 and 1.07, 95% CI 0.99-1.16) as independent predictors of both clinical and echocardiographic nonresponse. During median follow-up of 6.8 years, mortality was significantly reduced in patients with both AHI 25% reduction and 10% absolute LVEF increase in the first 3 months of CRT, compared with the subjects with only one or none of those criteria.

CONCLUSION

The baseline RV diastolic indices were found as independent predictors of SDB improvement during CRT. Both clinical and echocardiographic long-term response can be independently predicted by SDB and intraatrial dyssynchrony. The best survival rate was observed in patients with SDB and LVEF improvement noted in the first 3 months of CRT.

Does metabolic syndrome worsen systolic dysfunction in diabetes? The shortwave study

Patients with metabolic syndrome (MetS) have high cardiovascular event rates. The additional effect of MetS on left ventricular (LV) systolic function in patients with type 2 diabetes mellitus (T2DM) is unknown. We studied the relation between MetS and LV systolic function in T2DM patients without coronary artery disease (CAD). Clinical and echocardiographic data from 331 T2DM patients were analyzed. Prevalence of MetS was assessed based on NCEP ATPIII definition. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were analyzed as indexes of circumferential and longitudinal shortening, respectively. Sc-MS was impaired if <89 %, S' if <8.5 cm/s (10th percentile of healthy controls). MetS was diagnosed in 172 patients. Sc-MS and S' were similar in T2DM patients with and without MetS (91 ± 14 vs 92 ± 15 %; 9.8 ± 2.0 vs 9.5 ± 2.1 cm/s, respectively; p = ns) but significantly reduced comparing to controls (102 ± 11 % and 10.8 cm/s; p < 0.0001). Impairment of sc-MS and S' were detected in 37 vs 40 % and in 29 vs 32 % of T2DM patients with and without MetS (p = ns), respectively. LV systolic function measured as sc-MS and S' is frequently impaired in T2DM patients without CAD; however, the coexistence of MetS is not associated with more severe LV systolic dysfunction. Further pathological mechanisms have to be considered to explain the negative prognostic impact of MetS in T2DM patients.

Independent association of obstructive sleep apnea with left ventricular geometry and systolic function in resistant hypertension: the RESIST-POL study

OBJECTIVE

We investigated the impact of obstructive sleep apnea (OSA) and night blood pressure (BP) on left ventricular geometry and systolic function in patients with resistant hypertension (RHTN).

METHODS AND RESULTS

Data from 155 patients with RHTN were analyzed. All patients underwent biochemical evaluations, ambulatory blood pressure monitoring (ABPM), and polysomnography. Left ventricular mass index (LVMI), relative wall thickness (RWT), left ventricular ejection fraction (LVEF), midwall fractional shortening (mwFS) and global longitudinal strain (GLS) were measured. Patients were divided into four groups based on the presence of metabolic syndrome (MS) and OSA: group 1: OSA(-), MS(-) [n = 42]; group 2: OSA(+), MS(-) [n = 14]; group 3: OSA(-), MS(+) [n = 46]; and group 4: OSA(+), MS(+) [n = 53]. In group 3 and 4 concentric geometry was present in 53.2% and 79.6% respectively (P = 0.004). There were no differences in LVEF between groups. Group 3 and 4 had lower mwFS as compared with group 1 (16.40 ± 1.9 and 15.38 ± 2.2 vs 17.44 ± 1.9; P < 0.049 and P < 0.0001 respectively). Group 4 had significantly lower GLS as compared with group 1 (-12.64 ± 3.3 vs -15.59 ± 4.0; P < 0.001). In the multivariable analysis, factors independently associated with concentric geometry were age, nighttime SBP (OR -1.04; 95%Cl 1.019-1.082; P < 0.0001) and OSA (OR -3.97; 95%Cl 1.835-8.590; P < 0.0001). In the other multivariable analysis, factors independently associated with GLS were OSA (beta = 0.279; P = 0.001), and nighttime DBP (beta = 0.168; P = 0.048) whereas factors independently associated with mwFS were age, gender, nighttime SBP, concentric geometry, and metabolic syndrome.

CONCLUSIONS

In patients with true RHTN without diabetes concentric geometry and systolic dysfunction are independently associated with moderate and severe OSA and nighttime BP levels.

Assessment of subclinical left ventricular dysfunction in obstructive sleep apnea patients with speckle tracking echocardiography

In this study, our aim was to evaluate the LV (left ventricle) subclinical myocardial dysfunction using the two-dimensional speckle tracking echocardiography (2D-STE) method on obstructive sleep apnea (OSA) patients with preserved left ventricular ejection fraction (LVEF) and without any confounding disease that may result myocardial dysfunction. Twenty-one healthy individuals and 58 OSA patients were enrolled in the study. The patients were categorized into mild, moderate and severe OSA groups according to the apnea-hypopnea index (AHI). Conventional- and tissue Doppler echocardiography imagings were performed in all the individuals besides the 2D-STE. The longitudinal strain (S) and systolic strain rate (SR(S)) values decreased as the severity of disease increased from moderate towards severe OSA. The circumferential S and SR(S) values were observed to be lower in the severe OSA patients. Despite the increase in the radial S and SR(S) in moderate and mild OSA patients, these measurements decreased in those with severe OSA. Although the longitudinal, circumferential and radial early diastolic strain rates (SR(E)) decreased as the severity of disease increased form moderate to severe, the late diastolic strain rates (SR(A)) were observed to increase. In the early stages of OSA, longitudinal systolic LV dysfunction is detected in addition to the diastolic dysfunction. The circumferential mechanics of the LV deteriorate in the later stages of the OSA. Despite a compensatory increase in the radial LV function in the early stages of OSA, in later stages, the LV radial function also deteriorates. The assessment of the myocardial functions using the STE method in patients with OSA with preserved LVEF has the potential to detect the subclinical LV dysfunction and might provide useful information for risk stratification.