Survival in rheumatoid arthritis-associated pulmonary arterial hypertension compared with idiopathic pulmonary arterial hypertension

Echocardiography Coupled with Strain Method in the Screening for Cardiac Involvement in Rheumatoid Arthritis

OBJECTIVE

In this study, the usefulness of transthoracic echocardiography (TTE) in systematic screening was assessed for various cardiac abnormalities in patients with rheumatoid arthritis (RA).

METHODS

We performed a comparative cross-sectional study from July 2020 to February 2021. Each patient underwent a TTE coupled with the strain technique.

RESULTS

Seventy-two RA patients and 72 controls were included. Abnormalities detected by TTE were more frequent in RA patients (80.6% vs. 36.1%; p < 0.01), and they were asymptomatic in 65.5% of cases. Valvular involvement was found in 45.8% of RA patients, with a significant difference (p < 0.01). Left ventricular diastolic dysfunction was also more frequent in the RA group (36.1% vs. 13.9%; p < 0.01). Left ventricular systolic dysfunction was absent in our study, but subclinical left ventricular myocardial damage assessed by Global Longitudinal Strain (GLS) method was found in 37.5% of RA patients and 16.6% of controls (p < 0.01). The mean GLS in RA patients was -17.8 ± 2.9 (-22 to -10.7) vs. -19.4 ± 1.9 (-24.7 to -15.7) in controls. Left ventricular hypertrophy was detected in 22.2% of RA patients and in 6.9% of controls (p < 0.01). Pericardial effusion and pulmonary arterial hypertension were present only in the RA group (2.8% of cases). We found a significant relationship between echocardiographic damage and disease activity (p < 0.01), number of painful joints (p < 0.01), functional impact (HAQ) (p = 0.01), CRP level (p < 0.01) and the use and dose of Corticosteroids (p = 0.02; p = 0.01).

CONCLUSION

Echocardiographic damage in RA is frequent and often asymptomatic, hence there has been an increased interest in systematic screening in order to improve the quality of life and vital prognosis of patients. Early management of RA can reduce the risk of occurrence of cardiac involvement.

Pulmonary hypertension in connective tissue diseases: epidemiology, pathogenesis, and treatment

Pulmonary hypertension (PH) is a clinical condition characterized by increased pulmonary arterial pressure arising from a heterogeneous range of diseases that has a deteriorating effect on the quality of life and may cause early mortality if left untreated. Connective tissue disorders (CTD)-associated PH is the second most common cause of pulmonary arterial hypertension (PAH), after the idiopathic form, categorized as group I. Systemic scleroderma (SSc) accounts for 75% of CTD-associated PH cases. Although SSc ranks first place for CTD-associated PH, SSc is followed by systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD), having a lesser frequency of PH occurrence, while it occurs as a rare complication in cases with rheumatoid arthritis (RA) and inflammatory myositis. PH may also occur during non-SSc CTDs and even other rheumatic diseases, including Behcet's disease and adult-onset Still's disease, albeit to a lesser extent. The prognosis of CTD-associated PH is worse than the other forms of PH. Although, as in idiopathic pulmonary arterial hypertension (IPAH), the mechanism of CTD-related PH is associated with an increase in vasoconstrictors like endothelin-1 and a decrease in vasodilators like prostacyclin and nitric oxide production, inflammation, and autoimmune mechanisms also play a role in the development and progression of PH. This may lead to the involvement of more than one mechanism in CTD-associated PH. Knowing which mechanism is dominant is very important in determining the treatment option. This review will primarily focus on the epidemiology, risk factors, and prognosis of PH that develops during rheumatic diseases; the pathogenesis and treatment will be briefly mentioned in light of the newly published guidelines. Key Points • Pulmonary arterial hypertension (PAH) associated with connective tissue disease (CTD) in Western countries is the second most common type of PAH after idiopathic PAH (IPAH). • CTD-PH can be seen most often in systemic scleroderma (SSc), less in systemic lupus erythematosus (SLE), mixed CTD (MCTD), and rarely in other CTDs. • While current guidelines recommend annual transthoracic echocardiography as a screening test for asymptomatic SSc patients, screening for PH is not advised in the absence of symptoms suggestive of PH in other CTDs. • CTD-PH treatment can be divided into specific vasodilator PH treatments and immunosuppressive therapy. Current treatment guidelines recommend the same treatment algorithm for patients with CTD-associated PH as for patients with IPAH. Several case series have shown the beneficial effect of immunosuppressive agents in patients with SLE-PH and MCTD-PH.

Outcomes of pregnancy in women with different types of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) is considered to increase maternal and fetal risk, and we attempt to explore pregnancy outcomes in women with different types of PH.

METHODS

We retrospectively analyzed the clinical data of pregnant women with PH who were admitted to Anzhen Hospital from January 2010 to December 2019, and followed up on these parturients and their offspring.

RESULTS

Three hundred and sixty-six pregnant women with PH were collected, including 265 pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD), 65 PH caused by left heart disease, 12 idiopathic PH, and 24 PH associated with other diseases. Maternal mean age was 28.4 ± 4.4 years and 72.1% were nulliparous. The estimated systolic pulmonary artery pressure was < 50 mmHg in 40.2% of patients, 50-70 mmHg in 23.2%, and > 70 mmHg in 36.6%. In more than 94% of women, a diagnosis of PH was made before pregnancy. During pregnancy, heart failure occurred in 15% of patients. Cesarean section was performed in 90.5% (20.4% emergency). Complications included fetal mortality (0.5%), preterm delivery (40.4%), and low birth weight (37.7%). A total of 20 mothers died (5.5%). The highest mortality rate was found in patients with idiopathic PH (4/12, 33.3%). A total of 12 children died (3.3%), 5 (1.4%) of them after discharge from the hospital, and 7 (1.9%) were in hospital.

CONCLUSIONS

Although most of these women are fertile, PH does increase maternal and fetal risk. Women with idiopathic PH and Eisenmenger syndrome are not recommended to have children.

Association between Leflunomide and Pulmonary Hypertension

Rationale: Pulmonary hypertension (PH) has been described in patients treated with leflunomide. Objectives: To assess the association between leflunomide and PH. Methods: We identified incident cases of PH in patients treated with leflunomide from the French PH Registry and through the pharmacoVIGIlAnce in Pulmonary ArTerial Hypertension (VIGIAPATH) program between September 1999 to December 2019. PH etiology, clinical, functional, radiologic, and hemodynamic characteristics were reviewed at baseline and follow-up. A pharmacovigilance disproportionality analysis using the World Health Organization's global database was conducted. We then investigated the effect of leflunomide on human pulmonary endothelial cells. Data are expressed as median (min-max). Results: Twenty-eight patients treated with leflunomide before PH diagnosis was identified. A total of 21 (75%) had another risk factor for PH and 2 had two risk factors. The median time between leflunomide initiation and PH diagnosis was 32 months (1-120). Right heart catheterization confirmed precapillary PH with a cardiac index of 2.37 L⋅min^-1 ⋅m^-2 (1.19-3.1) and elevated pulmonary vascular resistance at 9.63 Wood Units (3.6-22.1) without nitric oxide reversibility. Five patients (17.9%) had no other risk factor for PH besides exposure to leflunomide. No significant hemodynamic improvement was observed after leflunomide withdrawal. The pharmacovigilance disproportionality analysis using the World Health Organization's database revealed a significant overrepresentation of leflunomide among reported pulmonary arterial hypertension-adverse drug reactions. In vitro studies showed the dose-dependent toxicity of leflunomide on human pulmonary endothelial cells. Conclusions: PH associated with leflunomide is rare and usually associated with other risk factors. The pharmacovigilance analysis suggests an association reinforced by experimental data.

Factors Associated with Incident Severe Pulmonary Arterial Hypertension in Systemic Autoimmune Rheumatic Diseases: a Nationwide Study

OBJECTIVES

To assess the association of severe pulmonary arterial hypertension (PAH) with particulate matter <2.5 μm (PM2.5) and clinical data in patients with systemic autoimmune rheumatic diseases (SARDs).

METHODS

We used the 2003-2017 nationwide data in Taiwan to identify patients with SARDs, including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis/polymyositis and primary Sjögren's syndrome. We identified 479 cases with severe PAH and selected controls matched (1:4) for age, sex, and index-year. We used conditional logistic regression analysis to determine factors associated with risks for severe PAH shown as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We found that severe PAH was highly associated with interstitial lung disease (OR, 8.57; 95% CI, 5.52-13.32), congestive heart failure (OR, 7.62; 95% CI, 5.02-11.55), valvular heart disease (OR, 3.34; 95% CI, 2.03-5.50) and slightly associated with thyroid diseases (OR, 1.88; 95% CI, 1.18-3.00), but not the level of exposure to PM2.5. Increased risk for PAH was found in patients receiving corticosteroid (prednisolone equivalent dosage, mg/day, OR, 1.03; 95% CI, 1.01-1.05), biologics (OR, 2.18; 95% CI, 1.15-4.12) as well as immunosuppressants, including cyclosporin (OR, 2.17; 95% CI, 1.31-3.59), azathioprine (OR, 1.96; 95% CI, 1.48-2.61), cyclophosphamide (OR, 2.01; 95% CI, 1.30-3.11) and mycophenolate mofetil/mycophenolic acid (OR, 2.42; 95% CI, 1.37-4.27), and those with the highest level of insured amount (reference, lowest level; OR, 0.53; 95% CI, 0.34-0.83).

CONCLUSION

The population-based study identified risks for severe PAH in patients with SARDs, and these findings provide evidence for PAH risk stratification in patients with SARDs.

Triptolide protects against TGF-β1-induced pulmonary fibrosis by regulating FAK/calpain signaling

The present study aimed to investigate the mechanism of anti-proliferative, anti-inflammatory and anti-fibrotic effects of triptolide (TPL) on activated lung fibroblasts by regulating the focal adhesion kinase (FAK) and calpain signaling pathways. The HFL-1 human foetal lung fibroblast cell line was cultured in vitro and treated with 50 ng/ml transforming growth factor (TGF)-β1 for 48 h to establish the model of pulmonary fibrosis. Subsequently, the cells were divided into five groups, including a control, model, TPL, FAK inhibitor and calpeptin group. Subsequently, the proliferation of lung fibroblasts was detected using the Cell Counting Kit-8 assay. The concentration of interleukin (IL)-6 in the cell culture supernatant was examined by ELISA and the mRNA expression levels of collagen type I (ColI)α and ColIII in lung fibroblasts were quantified by reverse transcription-quantitative PCR. The protein levels of FAK, phosphorylated (p)-FAK, calpain 1 and calpain 2 were detected by western blot analysis. TGF-β1 induced the proliferation of lung fibroblasts, whereas TPL inhibited this proliferation in a dose-dependent manner. TPL also decreased the TGF-β1-induced production of IL-6 and reduced the upregulation of ColIα, ColIII, FAK, p-FAK, and inhibited the decrease of calpain 1 and calpain 2 induced by TGF-β1. In addition, the FAK inhibitor acted synergistically with TPL to decrease TGF-β1-induced production of IL-6 and attenuate TGF-β1-induced synthesis of ColIα and ColIII, while calpeptin had an antagonistic effect on the function of TPL. Furthermore, treatment with the FAK inhibitor and TPL markedly decreased the protein levels of FAK and p-FAK, and increased the protein expression of calpain 1 and calpain 2 in lung fibroblasts stimulated by TGF-β1 to a greater extent than TPL alone, while calpeptin had an antagonistic effect on the action of TPL. In conclusion, the present study indicated that TPL protected against TGF-β1-induced proliferation, inflammation and fibrosis by regulating the FAK and calpain signaling pathways.

Guideline implementation and early risk assessment in pulmonary arterial hypertension associated with congenital heart disease: A retrospective cohort study

INTRODUCTION

Current guidelines emphasize that accurate risk stratification is important for patients with pulmonary arterial hypertension (PAH), however, few suggestions have been specified for PAH associated with congenital heart disease (PAH-CHD).

OBJECTIVES

The aim of this study was to propose an accurate and simple system based on current guidelines for risk stratification in PAH-CHD patients during 12-month follow-up.

METHODS

We reviewed 288 Chinese PAH-CHD patients between January 2014 and December 2016 in this retrospective cohort study. The low-risk criteria according to 2015 European Society of Cardiology guidelines and the adverse events (AEs) during follow-up were collected. The association between low-risk criteria and AEs was assessed with Cox regression, and a simplified risk stratification system was proposed.

RESULTS

There were 105 PAH-CHD patients included in the final analysis. Twenty-nine patients had AEs defined as death, initiation of new or combined medication treatment, or re-hospitalisation because of the PAH worsening. Among the low-risk criteria, WHO/NYHA functional class, 6-minute walking distance (6MWD), NT-proBNP and SvO₂ were significantly different between AE and AE-free groups. However, 6MWD (HR = 0.08, 95% CI: 0.03-0.19, P < 0.001) and NT-proBNP (HR = 0.35, 95% CI: 0.16-0.78, P = 0.01) were the only independent predictors of AEs in multivariable model. When taking them into a simplified system for risk stratification, the number of low-risk criteria at diagnosis discriminated the risk of AEs (P < 0.001).

CONCLUSIONS

Among the low-risk criteria proposed by current guidelines, 6MWD and NT-proBNP predicted AEs independently for PAH-CHD patients. Simplified risk stratification system by taking these two parameters numerically provides accurate prognostic information in PAH-CHD patients.

Ethnic Variations in Systemic Sclerosis Disease Manifestations, Internal Organ Involvement, and Mortality

Objective.

A multiethnic systemic sclerosis (SSc) cohort study to evaluate ethnic variations in disease manifestations, internal organ involvement, and survival.

Methods.

Adults who fulfilled the American College of Rheumatology/European League Against Rheumatism classification criteria for SSc between 1970 and 2017 were included. Self-reported ethnicity was categorized as European-descent white, Afro-Caribbean, Hispanic, Arab, East Asian, South Asian, First Nations, or Persian. The primary outcome was the time from diagnosis to death from all causes. Survival probabilities and median survival times were determined using Kaplan-Meier survival curves.

Results.

There were 1005 subjects evaluated, the majority of whom were European-descent white (n = 745, 74%), Afro-Caribbean (n = 58, 6%), South Asian (n = 70, 7%), and East Asian (n = 80, 8%). Compared to European-descent white subjects, East Asians less frequently had calcinosis (29% vs 9%, p = 0.002) and esophageal dysmotility (88% vs 69%, p = 0.002); Afro-Caribbeans more frequently had interstitial lung disease (31% vs 53%, p = 0.007); and First Nations subjects more frequently had diffuse cutaneous disease (35% vs 56%, p = 0.02) and diabetes (5% vs 33%, p = 0.03). We found no difference in the short-term survival across ethnicities. Hispanic subjects have better longterm survival (81.3%, 95% CI 63–100) compared to European-descent white subjects (55%, 95% CI 51–60). East Asians appear to have the longest median survival time (43.3 yrs) and Arabs the shortest median survival time (15 yrs). There was no significant difference in median survival times between Afro-Caribbean and European-descent white subjects (22.2 vs 22.6 yrs).

Conclusion.

Ethnic variations in some SSc disease manifestations are observed. However, this does not result in significant differences in short-term survival but may affect longterm survival.

Acute Pulmonary Hypertension Crisis after Adalimumab Reduction in Rheumatoid Vasculitis

Rheumatoid vasculitis is a rare etiology for pulmonary hypertension (PH) in patients with connective tissue disease. We encountered a case of acute PH crisis in a case with rheumatoid vasculitis eight months after undergoing adalimumab reduction. Since no repetition of arthralgia occurred after the adalimumab reduction, we decided to not increase the dose of adalimumab. However, hemodynamic collapse thereafter developed and even though steroid pulse therapy was administered, the patient nevertheless died. The autopsy showed clusters of acute and chronic inflammation around the remodeled pulmonary arteries along with micro-thrombi in the vessel lumen. We should consider the possibility of critical worsening of PH as a phenotype of vasculitis related to immunosuppressive therapy reduction.

Evaluation of computer-based computer tomography stratification against outcome models in connective tissue disease-related interstitial lung disease: a patient outcome study

BACKGROUND

To evaluate computer-based computer tomography (CT) analysis (CALIPER) against visual CT scoring and pulmonary function tests (PFTs) when predicting mortality in patients with connective tissue disease-related interstitial lung disease (CTD-ILD). To identify outcome differences between distinct CTD-ILD groups derived following automated stratification of CALIPER variables.

METHODS

A total of 203 consecutive patients with assorted CTD-ILDs had CT parenchymal patterns evaluated by CALIPER and visual CT scoring: honeycombing, reticular pattern, ground glass opacities, pulmonary vessel volume, emphysema, and traction bronchiectasis. CT scores were evaluated against pulmonary function tests: forced vital capacity, diffusing capacity for carbon monoxide, carbon monoxide transfer coefficient, and composite physiologic index for mortality analysis. Automated stratification of CALIPER-CT variables was evaluated in place of and alongside forced vital capacity and diffusing capacity for carbon monoxide in the ILD gender, age physiology (ILD-GAP) model using receiver operating characteristic curve analysis.

RESULTS

Cox regression analyses identified four independent predictors of mortality: patient age (P < 0.0001), smoking history (P = 0.0003), carbon monoxide transfer coefficient (P = 0.003), and pulmonary vessel volume (P < 0.0001). Automated stratification of CALIPER variables identified three morphologically distinct groups which were stronger predictors of mortality than all CT and functional indices. The Stratified-CT model substituted automated stratified groups for functional indices in the ILD-GAP model and maintained model strength (area under curve (AUC) = 0.74, P < 0.0001), ILD-GAP (AUC = 0.72, P < 0.0001). Combining automated stratified groups with the ILD-GAP model (stratified CT-GAP model) strengthened predictions of 1- and 2-year mortality: ILD-GAP (AUC = 0.87 and 0.86, respectively); stratified CT-GAP (AUC = 0.89 and 0.88, respectively).

CONCLUSIONS

CALIPER-derived pulmonary vessel volume is an independent predictor of mortality across all CTD-ILD patients. Furthermore, automated stratification of CALIPER CT variables represents a novel method of prognostication at least as robust as PFTs in CTD-ILD patients.