Sex-specific difference in cardiac function in patients with systemic sclerosis: association with cardiovascular outcomes

BACKGROUND

Cardiovascular involvement is one of the leading causes of mortality in systemic sclerosis (SSc) and is reported to be higher in men as compared with women. However, the cause of this difference is largely unknown. The objective of this study was to assess sex differences in echocardiographic characteristics, including left ventricular global longitudinal strain (LV GLS), as a potential explanation of sex differences in outcomes.

METHODS

A total of 746 patients with SSc from four centres, including 628 (84%, 54±13 years) women and 118 (16%, 55±15 years) men, were evaluated with standard and advanced echocardiographic examinations. The independent association of the echocardiographic parameters with the combined endpoint of cardiovascular events-hospitalisation/death was evaluated.

RESULTS

Men and women with SSc showed significant differences in disease characteristics and cardiac function. After adjusting for the most important clinical characteristics, while LV ejection fraction and diastolic function were not significantly different anymore, men still presented with more impaired LV GLS as compared with women (-19% (IQR -20% to -17%) vs -21% (IQR: -22% to -19%), p<0.001). After a median follow-up of 48 months (IQR: 26-80), the combined endpoint occurred in 182 patients. Men with SSc experienced higher cumulative rates of cardiovascular events-hospitalisation/mortality (χ2=8.648; Log-rank=0.003), and sex differences were maintained after adjusting for clinical confounders, but neutralised when matching the groups for LV GLS.

CONCLUSION

In patients with SSc, male sex is associated with worse cardiovascular outcomes even after adjusting for important clinical characteristics. LV GLS was more impaired in men as compared with women and potentially explains the sex difference in cardiovascular outcomes.

Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis

OBJECTIVES

Cardiac involvement in patients with systemic sclerosis (SSc) is associated with poor prognosis. Early detection of myocardial impairment is essential for treatment. The present study aimed to systematically review the value of detecting subclinical myocardial impairment in SSc patients using myocardial strain obtained from speckle tracking echocardiography (STE).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase and Cochrane library databases were searched in the period from the earliest available indexing date to 30 September 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies evaluating myocardial function in SSc patients comparison with healthy controls based on myocardial strain data obtained from STE were included.

DATA EXTRACTION AND SYNTHESIS

Ventricle and atrium data on myocardial strain were extracted to assessing the mean difference (MD).

RESULTS

A total of 31 studies were included in the analysis. Left ventricular global longitudinal strain (MD: -2.31, 95% CI -2.85 to -1.76), left ventricular global circumferential strain (MD: -2.93, 95% CI -4.02 to -1.84) and left ventricular global radial strain (MD: -3.80, 95% CI -5.83 to -1.77) was significantly lower in SSc patients than in healthy controls. Right ventricular global wall strain (MD: -2.75, 95% CI -3.25 to -2.25) was also decreased in SSc patients. STE revealed significant differences in several atrial parameters including left atrial reservoir strain (MD: -6.72, 95% CI -10.09 to -3.34) and left atrial conduit strain (MD: -3.26, 95% CI -6.50 to -0.03), as well as right atrial reservoir strain (MD: -7.37, 95% CI -11.20 to -3.53) and right atrial conduit strain (MD: -5.44, 95% CI -9.15 to -1.73). There were no differences in left atrial contractile strain (MD: -1.51, 95% CI -5.34 to 2.33).

CONCLUSION

SSc patients have a lower strain than healthy controls for the majority of STE parameters, indicating the presence of an impaired myocardium involving both the ventricle and atrium.

Progression of Left Ventricular Myocardial Dysfunction in Systemic Sclerosis: A Speckle-tracking Strain Echocardiography Study

OBJECTIVE

Cardiac involvement is a main cause of mortality in systemic sclerosis (SSc). Its detection remains challenging using conventional echocardiography and little is known about its potential progression. This study assessed changes in cardiac performance over time in a prospective cohort of patients with SSc, including echocardiographic speckle-tracking strain analysis.

METHODS

The study included 234 patients with SSc [196 women, age 52 ± 14 yrs, 165 limited SSc, time since diagnosis 5.2 yrs, interquartile range (IQR) 2.9-11.3]. Clinical variables, laboratory tests, pulmonary function tests, and echocardiographic measures were recorded at baseline and followup (median 2.3 yrs, IQR 1.3-3.9). Additionally, left ventricular (LV) systolic function was assessed with global longitudinal strain (GLS) by echocardiographic speckle-tracking analysis.

RESULTS

At followup, GLS had significantly worsened (-21% ± 2 vs -19% ± 2, p < 0.001) while LV ejection fraction had not changed (62% ± 7 vs 61% ± 8, p = 0.124). In particular, 39 patients showed a significant deterioration of GLS as defined by a ≥ 15% decrease, which was accompanied by a concomitant worsening of proximal muscle weakness, lung fibrosis, renal function, LV diastolic function, and right ventricular systolic function. Baseline variables associated with ≥ 15% deterioration in GLS were proximal muscle weakness (OR 3.437, 95% CI 1.13-10.43, p = 0.020), decreased DLCO (OR 3.621, 95% CI 1.25-10.51, p = 0.049), and LV diastolic dysfunction (OR 2.378, 95% CI 1.07-5.27, p = 0.033).

CONCLUSION

In patients with SSc, progression of LV systolic dysfunction was demonstrated by GLS but not by LV ejection fraction. Proximal muscle weakness, DLCO, and LV diastolic dysfunction may identify patients at risk for progressive LV systolic dysfunction and in need of closer cardiac monitoring.