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Kida T, Matsuzaki K, Yokota I, Kawase N, Kadoya M, Inoue H, Kukida Y, Kaneshita S, Inoue T, Wada M, Kohno M, Fukuda W, Kawahito Y, Iwami T. Latent trajectory modelling of pulmonary artery pressure in systemic sclerosis: a retrospective cohort study. RMD Open 2022; 8:rmdopen-2022-002673. [PMID: 36581382 PMCID: PMC9806097 DOI: 10.1136/rmdopen-2022-002673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/15/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To visualise the trajectories of pulmonary arterial pressure (PAP) in systemic sclerosis (SSc) and identify the clinical phenotypes for each trajectory, by applying latent trajectory modelling for PAP repeatedly estimated by echocardiography. METHODS This was a multicentre, retrospective cohort study conducted at four referral hospitals in Kyoto, Japan. Patients with SSc who were treated at study sites between 2008 and 2021 and who had at least three echocardiographic measurements of systolic PAP (sPAP) were included. A group-based trajectory model was applied to the change in sPAP over time, and patients were classified into distinct subgroups that followed similar trajectories. Pulmonary hypertension (PH)-free survival was compared for each trajectory. Multinomial logistic regression analysis was performed for baseline clinical characteristics associated with trajectory assignment. RESULTS A total of 236 patients with 1097 sPAP measurements were included. We identified five trajectories: rapid progression (n=9, 3.8%), early elevation (n=30, 12.7%), middle elevation (n=54, 22.9%), late elevation (n=24, 10.2%) and low stable (n=119, 50.4%). The trajectories, in the listed order, showed progressively earlier elevation of sPAP and shorter PH-free survival. In the multinomial logistic regression analysis with the low stable as a reference, cardiac involvement was associated with rapid progression, diffuse cutaneous SSc was associated with early elevation and anti-centromere antibody was associated with middle elevation; older age of onset was associated with all three of these trajectories. CONCLUSION The pattern of changes in PAP over time in SSc can be classified into five trajectories with distinctly different clinical characteristics and outcomes.
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Affiliation(s)
- Takashi Kida
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan,Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Matsuzaki
- Agency for Health, Safety and Environment, Kyoto University, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Kawase
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hironori Inoue
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Shunya Kaneshita
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Takuya Inoue
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Makoto Wada
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Iwami
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Mukherjee M, Mercurio V, Balasubramanian A, Shah AA, Hsu S, Simpson CE, Damico R, Kolb TM, Hassoun PM, Mathai SC. Defining minimal detectable difference in echocardiographic measures of right ventricular function in systemic sclerosis. Arthritis Res Ther 2022; 24:146. [PMID: 35717399 PMCID: PMC9206258 DOI: 10.1186/s13075-022-02835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Echocardiography (2DE) is integral for screening and longitudinal evaluation of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). In the present study, we sought to establish the reliability, repeatability, and reproducibility of 2DE parameters in SSc patients with and without PAH and to define the minimal detectable difference (MDD), the smallest change detected beyond measurement error. METHODS SSc patients without known PAH and with invasively confirmed PAH on stable therapies underwent 2DE with strain at two time points. Analysis of variance (ANOVA) and coefficients of variation (CV) were calculated to assess for repeatability, reliability, and reproducibility. Intra- and inter-observer agreement were assessed using intraclass correlation. Bland-Altman analysis explored the level of agreement between evaluations. MDD was calculated using the standard error of measurement for each parameter by cohort. RESULTS ANOVA demonstrated few significant differences between evaluations across groups. Global right ventricular longitudinal systolic strain (GRVLSS, 9.7%) and fractional area change (FAC, 21.3%) had the largest CV, while tricuspid annular plane excursion (TAPSE), S' wave, and right ventricular outflow track velocity time integral (RVOT VTI) were 0.87%, 3.2%, and 6.0%, respectively. Intra- and inter-observer agreement was excellent. MDD for TAPSE, FAC, S' wave, RVOT VTI, GRVLSS, and RVSP were 0.11 cm, 0.03%, 1.27 cm/s, 0.81 cm, 1.14%, and 6.5 mmHg, respectively. CONCLUSIONS We demonstrate minimal measurement error in clinically important 2DE-based measures in SSc patients with and without PAH. Defining the MDD in this population has important implications for PAH screening, assessment of therapeutic response, and sample size calculations for future clinical trials.
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Affiliation(s)
- Monica Mukherjee
- Divisions of Cardiology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Ami A Shah
- Divison of Rheumatology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Steven Hsu
- Divisions of Cardiology, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Rachel Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 540, Baltimore, MD, 21205, USA.
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Alenezi F, Covington TA, Mukherjee M, Mathai SC, Yu PB, Rajagopal S. Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart. Circ Res 2022; 130:1445-1465. [PMID: 35482838 PMCID: PMC9060389 DOI: 10.1161/circresaha.121.319990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is an increased appreciation for the importance of the right heart and pulmonary circulation in several disease states across the spectrum of pulmonary hypertension and left heart failure. However, assessment of the structure and function of the right heart and pulmonary circulation can be challenging, due to the complex geometry of the right ventricle, comorbid pulmonary airways and parenchymal disease, and the overlap of hemodynamic abnormalities with left heart failure. Several new and evolving imaging modalities interrogate the right heart and pulmonary circulation with greater diagnostic precision. Echocardiographic approaches such as speckle-tracking and 3-dimensional imaging provide detailed assessments of regional systolic and diastolic function and volumetric assessments. Magnetic resonance approaches can provide high-resolution views of cardiac structure/function, tissue characterization, and perfusion through the pulmonary vasculature. Molecular imaging with positron emission tomography allows an assessment of specific pathobiologically relevant targets in the right heart and pulmonary circulation. Machine learning analysis of high-resolution computed tomographic lung scans permits quantitative morphometry of the lung circulation without intravenous contrast. Inhaled magnetic resonance imaging probes, such as hyperpolarized 129Xe magnetic resonance imaging, report on pulmonary gas exchange and pulmonary capillary hemodynamics. These approaches provide important information on right ventricular structure and function along with perfusion through the pulmonary circulation. At this time, the majority of these developing technologies have yet to be clinically validated, with few studies demonstrating the utility of these imaging biomarkers for diagnosis or monitoring disease. These technologies hold promise for earlier diagnosis and noninvasive monitoring of right heart failure and pulmonary hypertension that will aid in preclinical studies, enhance patient selection and provide surrogate end points in clinical trials, and ultimately improve bedside care.
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Affiliation(s)
- Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | | | | | - Steve C. Mathai
- Johns Hopkins Division of Pulmonary and Critical Care Medicine, Baltimore, MD
| | - Paul B. Yu
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
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4
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Mukherjee M, Mercurio V, Hsu S, Mayer SA, Mathai SC, Hummers LK, Kass DA, Hassoun PM, Wigley FM, Tedford RJ, Shah AA. Assessment of right ventricular reserve utilizing exercise provocation in systemic sclerosis. Int J Cardiovasc Imaging 2021; 37:2137-2147. [PMID: 33860914 DOI: 10.1007/s10554-021-02237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/03/2021] [Indexed: 01/28/2023]
Abstract
Right ventricular (RV) capacity to adapt to increased afterload is the main determinant of outcome in pulmonary hypertension, a common morbidity seen in systemic sclerosis (SSc). We hypothesized that supine bicycle echocardiography (SBE), coupled with RV longitudinal systolic strain (RVLSS), improves detection of limitations in RV reserve in SSc. 56 SSc patients were prospectively studied during SBE with RV functional parameters compared at rest and peak stress. We further dichotomized patients based on resting RV systolic pressure (RVSP) to determine the effects of load on contractile response. Our pooled cohort analysis revealed reduced global RVLSS at rest (-16.2 ± 3.9%) with normal basal contractility (-25.6 ± 7.7%) and relative hypokinesis of the midventricular (-14.1 ± 6.0%) and apical (-8.9 ± 5.1%) segments. With exercise, global RVLSS increased significantly (p = 0.0005), however despite normal basal contractility at rest, there was no further augmentation with exercise. Mid and apical RVLSS increased with exercise suggestive of RV contractile reserve. In patients with resting RVSP < 35 mmHg, global and segmental RVLSS increased with exercise. In patients with resting RVSP ≥ 35 mmHg, global and segmental RVLSS did not increase with exercise and there was evidence of exertional RV dilation. Exercise provocation in conjunction with RVLSS identified differential regional contractile response to exercise in SSc patients. We further demonstrate the effect of increased loading conditions on RV contractile response exercise. These findings suggest subclinical impairments in RV reserve in SSc that may be missed by resting noninvasive 2DE-based assessments alone.
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Affiliation(s)
- Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA
| | - Susan A Mayer
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.,Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - David A Kass
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ryan J Tedford
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.,Division of Cardiology, Medical University South Carolina, Charleston, SC, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
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5
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Mecoli CA, Shah AA, Boin F, Wigley FM, Hummers LK. The Utility of Plasma Vascular Biomarkers in Systemic Sclerosis: A Prospective Longitudinal Analysis. Arthritis Rheumatol 2020; 72:1341-1349. [PMID: 32200572 DOI: 10.1002/art.41265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE In cross-sectional studies, pulmonary hypertension (PH) and ischemic digital lesions are 2 scleroderma vascular outcomes associated with abnormalities in biomarkers of angiogenesis. The clinical usefulness of these biomarkers is unknown, in part due to lack of data on longitudinal measurement. This prospective longitudinal study was undertaken to evaluate vascular biomarker measurements in patients with systemic sclerosis (SSc) over time. METHODS We conducted a prospective cohort study of 300 patients with SSc who were followed up for at least a 5-year period and lacked evidence of PH and/or active ischemic digital lesions at enrollment. Levels of hepatocyte growth factor (HGF), soluble Flt-1 (sFlt-1), soluble endoglin, endostatin, and placental growth factor (PLGF) were obtained at multiple time points and assessed for their ability to predict the development of PH/ischemic digital lesions. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated. RESULTS Forty-six patients (15%) developed PH and 69 patients (23%) developed an ischemic digital lesion. In time-to-event analyses, the following 3 biomarkers measured at cohort entry were found to be significantly associated with the development of PH: HGF (HR 1.99 [95% CI 1.24-3.17], P = 0.004), sFlt-1 (HR 3.04 [95% CI 1.29-7.14], P = 0.011), and PLGF (HR 2.74 [95% CI 1.32-5.69], P = 0.007). As time approaching PH diagnosis decreased, there was no corresponding increase in any biomarker level. Upon converting each continuous vascular biomarker into a binary variable, a dose-response relationship was observed for the number of elevated biomarkers at cohort entry and the risk of developing PH. With each additional elevated biomarker at cohort entry, there was a 78% increase in the risk of developing PH (HR 1.78 [95% CI 1.2-2.6], P = 0.004). CONCLUSION These data suggest that molecules involved in angiogenesis reflect vascular perturbation, and that elevations in these biomarkers at first encounter can indicate patients who are at risk of PH development.
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Affiliation(s)
| | - Ami A Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Laura K Hummers
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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6
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Semalulu T, Rudski L, Huynh T, Langleben D, Wang M, Fritzler MJ, Pope J, Baron M, Hudson M. An evidence-based strategy to screen for pulmonary arterial hypertension in systemic sclerosis. Semin Arthritis Rheum 2020; 50:1421-1427. [PMID: 32245697 DOI: 10.1016/j.semarthrit.2020.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical practice guidelines recommend screening all systemic sclerosis (SSc) patients for pulmonary arterial hypertension (PAH) with yearly echocardiograms. There is a paucity of evidence to support these guidelines. RESEARCH QUESTION Can a prediction model identify SSc patients with a very low probability of PAH and therefore not requiring annual screening echocardiogram? STUDY DESIGN AND METHODS We performed a case-control study of 925 unselected SSc subjects nested in a multi-centered, longitudinal cohort. The probability of PAH for each subject was calculated using the results of multivariate logistic regression models. A cut-off was identified for the estimated probability of PAH below which no subject developed PAH (100% sensitivity). RESULTS Study subjects were predominantly female (87.5%), with mean (SD) age 58.6 (11.7) years and disease duration of 18.2 (12.2) years. Thirty-seven subjects developed PAH during 5407.97 person-years of observation (incidence rate 0.68 per 100 person-years). Shortness of breath (SOB), diffusing capacity for carbon monoxide (DLCO) and NT-proBNP were independent predictors of PAH. All SSc-PAH cases had a probability of PAH of >1.1%. Subjects below this cut-off, none of whom had PAH, accounted for 46.2% of the study population. INTERPRETATION A simple prediction model identified subjects at very low probability of PAH who could potentially forego annual screening echocardiogram. This represents almost half of SSc subjects in a general SSc population. This study, which is the first evidence-based study for the rational use of follow-up echocardiograms in an unselected SSc cohort, requires validation. The scoring system is freely available online at http://pahtool.ladydavis.ca.
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Affiliation(s)
- T Semalulu
- Department of Medicine, McMaster University, Canada
| | - L Rudski
- Department of Medicine, McGill University, Montreal, Canada; Division of Cardiology, Jewish General Hospital, Montreal, Canada
| | - T Huynh
- Department of Medicine, McGill University, Montreal, Canada; Division of Cardiology, McGill University Health Centre, Montreal, Canada
| | - D Langleben
- Department of Medicine, McGill University, Montreal, Canada; Division of Cardiology, Jewish General Hospital, Montreal, Canada; Lady Davis Institute for Medical Research, Montreal, Canada
| | - M Wang
- Lady Davis Institute for Medical Research, Montreal, Canada
| | | | - M J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - J Pope
- St. Joseph's Healthcare, London, Canada
| | - M Baron
- Department of Medicine, McGill University, Montreal, Canada; Division of Rheumatology, Jewish General Hospital, Room A-725, 3755 Côte Sainte-Catherine Road, Montreal, Quebec H3T 1E2, Canada
| | - M Hudson
- Department of Medicine, McGill University, Montreal, Canada; Lady Davis Institute for Medical Research, Montreal, Canada; Division of Rheumatology, Jewish General Hospital, Room A-725, 3755 Côte Sainte-Catherine Road, Montreal, Quebec H3T 1E2, Canada.
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7
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Argula RG, Ward C, Feghali-Bostwick C. Therapeutic Challenges And Advances In The Management Of Systemic Sclerosis-Related Pulmonary Arterial Hypertension (SSc-PAH). Ther Clin Risk Manag 2019; 15:1427-1442. [PMID: 31853179 PMCID: PMC6916691 DOI: 10.2147/tcrm.s219024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disorder with multi-organ involvement. SSc-associated pulmonary arterial hypertension (SSc-PAH) is one of the leading causes of morbidity and mortality in the SSc population. With advances in our understanding of pulmonary arterial hypertension (PAH) diagnosis and treatment, outcomes for all PAH patients have significantly improved. While SSc-PAH patients have also benefited from these advances, significant challenges remain. Diagnosis of PAH is a challenging endeavor in SSc patients who often have many co-existing pulmonary and cardiac comorbidities. Given the significantly elevated prevalence and lifetime risk of PAH in the SSc population, screening for SSc-PAH is a critically useful strategy. Treatment with pulmonary arterial (PA) vasodilators has resulted in a dramatic improvement in the survival and quality of life of PAH patients. While therapy with PA vasodilators is beneficial in SSc-PAH patients, therapy effects appear to be attenuated when compared to responses in patients with idiopathic PAH (IPAH). This review attempts to chronicle and summarize the advances in our understanding of the optimal screening strategies to identify PAH in patients with SSc. The article also reviews the advances in the therapeutic and risk stratification strategies for SSc-PAH patients.
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Affiliation(s)
- Rahul G Argula
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Celine Ward
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Carol Feghali-Bostwick
- Department of Medicine, Division of Rheumatology, Medical University of South Carolina, Charleston, SC 29425, USA
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Hung G, Mercurio V, Hsu S, Mathai SC, Shah AA, Mukherjee M. Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis. Curr Rheumatol Rep 2019; 21:68. [PMID: 31813082 PMCID: PMC11151284 DOI: 10.1007/s11926-019-0867-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- George Hung
- Division of Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4100, Baltimore, MD, 21224, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA.
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9
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Mecoli CA, Shah AA, Boin F, Wigley FM, Hummers LK. Vascular complications in systemic sclerosis: a prospective cohort study. Clin Rheumatol 2018; 37:2429-2437. [PMID: 29804150 DOI: 10.1007/s10067-018-4148-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 01/25/2023]
Abstract
Two major complications in scleroderma patients that cause substantial morbidity and mortality are ischemic digital lesions (DL) and pulmonary hypertension (PH). The clinician's ability to predict which patients will develop these complications is imperfect. We conducted a prospective observational cohort study of 300 patients with scleroderma who were followed for at least a 5-year period. At baseline, patients lacked evidence of PH and were without a current DL. At each 6-month visit, the patient was examined for signs/symptoms of PH and/or a DL. The primary outcomes were (1) PH defined as a mean pulmonary artery pressure ≥ 25 mmHg by right heart catheterization and (2) ≥ 1 DL defined as new onset of severe vascular compromise. Thirty patients (10%) developed PH (11 group 1/PAH, 4 group II, 15 group III) and 69 developed DL. The average time from enrollment until diagnosis of PH was 3.2 ± 2 years. In multivariable analyses, patients who developed PH were more likely to have diffuse disease (HR 3.2, p = 0.004), a forced vital capacity (FVC)/diffusing capacity of the lungs for carbon monoxide (DLCO) ratio > 1.6 (HR 1.7, p = 0.008), and elevated RVSP (HR = 1.07, p = 0.007). Patients who developed PAH were more likely to have a FVC/DLCO ratio > 1.6 (HR = 5.8, p = 0.014), and patients who developed group III PH were less likely to have an elevated FVC (HR = 0.92, p = 0.001). Patients were more likely to develop a DL if they had a history of prior DL (HR = 7.0, p < 0.001), or were men (HR = 2.3, p = 0.007). In a prevalent cohort of scleroderma patients, individuals who develop PH or DL have simple to measure clinical features that can predict these complications years before they occur.
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Affiliation(s)
- Christopher A Mecoli
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Bldg, Center Tower, Suite 4100, Baltimore, MD, 21224, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Bldg, Center Tower, Suite 4100, Baltimore, MD, 21224, USA
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Bldg, Center Tower, Suite 4100, Baltimore, MD, 21224, USA
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Bldg, Center Tower, Suite 4100, Baltimore, MD, 21224, USA.
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10
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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Affiliation(s)
- Fredrick M Wigley
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
| | - Nicholas A Flavahan
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
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Adrovic A, Oztunc F, Barut K, Koka A, Gojak R, Sahin S, Demir T, Kasapcopur O. The frequency of pulmonary hypertension in patients with juvenile scleroderma. Bosn J Basic Med Sci 2015; 15:30-5. [PMID: 26614849 DOI: 10.17305/bjbms.2015.596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/25/2015] [Accepted: 07/26/2015] [Indexed: 01/15/2023] Open
Abstract
Juvenile scleroderma (JS) represents a rarely seen group of connective tissue diseases with multiple organ involvement. Cardiac involvement in JSS is well known and, although rare in children, it may be an important cause of mortality and morbidity. Therefore, an early determination of cardio-vascular and pulmonary involvement is of the most relevance to reduce the mortality in patients with juvenile scleroderma. The aim of the study was to explore the non-invasive methods (Doppler echocardiography, pulmonary function tests), Forced vital capacity (FVC) and Carbon monoxide diffusion capacity (DLCO) in the assessment of the cardiopulmonary involvement in patients with JS. The assessment of pulmonary arterial pressure (PAP) and risk factors for pulmonary arterial hypertension (PAH) were made by the measurement of maximum tricuspid insufficiency (TI), end-diastolic pulmonary insufficiency (PI), ratio of acceleration time (AT) to ejection time (ET) (AT/ET), right atrial pressure (RAP) and contraction of vena cava inferior during inspiration. Thirty-five patients with confirmed JS were included in the study. The mean age of onset of the disease was 9.57 years (median 10 years, range 2-18 years). The mean disease duration and follow-up time was 2 years (median 1 year, range 0.5-8 years) and 3.57 years (median 2 years, range 0.5-14.5 years), respectively.The values of all the analyzed parameters including TI, PI, AT/ET, PAP, FVC and DLCO were found to be within normal ranges in all the patients tested, confirming an uncommonness of cardiopulmonary involvement in patients with juvenile scleroderma.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey.
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Abstract
PURPOSE OF REVIEW This review summarizes recent advances in pulmonary hypertension, a leading cause of morbidity and mortality in scleroderma (SSc). RECENT FINDINGS Although WHO Group I pulmonary arterial hypertension (PAH) is the most common cause of pulmonary hypertension, all WHO Groups can occur. PAH is now a criterion for the diagnosis of SSc. Results of recent research have resulted in greater insight into the epidemiology of SSc-pulmonary hypertension with regard to prevalence, incidence and clinical risk factors. There is also greater understanding of the role of inflammation in the pathogenesis of SSc-PAH. Advances have also been made in the evaluation and screening of patients with SSc-PAH, and early detection has been shown to improve survival in a disease that typically has worse outcomes than other forms of PAH. Finally, recommendations have been made with regard to goal-directed therapy. SUMMARY Although there have been many recent advances in SSc-pulmonary hypertension, further research is needed in order to prevent/cure this deadly complication.
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Valenzuela A, Nandagopal S, Steen VD, Chung L. Monitoring and Diagnostic Approaches for Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Rheum Dis Clin North Am 2015. [PMID: 26210131 DOI: 10.1016/j.rdc.2015.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary arterial hypertension (PAH) is one of the leading causes of death in patients with systemic sclerosis (SSc). Given the high prevalence and poor survival of SSc-PAH, and that aggressive management of mild disease may be associated with better outcomes, screening is critical. Right heart catheterization (RHC) is the gold standard for the definitive diagnosis of PAH, and should be performed in those patients in whom this diagnosis is suspected. Once a diagnosis of PAH is confirmed by RHC, treatment with PAH-specific therapies should be initiated as soon as possible.
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Affiliation(s)
- Antonia Valenzuela
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA
| | - Saranya Nandagopal
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 2nd Floor, Redwood City, CA 94063, USA
| | - Virginia D Steen
- Division of Rheumatology, Allergy, and Immunology, Georgetown University School of Medicine, Pasquerilla Health Center, 6th Floor 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA.
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Sung YK, Chung L. Connective tissue disease-associated pulmonary arterial hypertension. Rheum Dis Clin North Am 2015; 41:295-313. [PMID: 25836644 DOI: 10.1016/j.rdc.2015.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by vascular remodeling of pulmonary arterioles that leads to increased pulmonary vascular resistance, right heart failure, and death. It is associated with connective tissue diseases, including systemic sclerosis, systemic lupus erythematosus, and mixed connective tissue disease. PAH is characterized by dyspnea on exertion and fatigue. Syncopal events suggest severe disease. Patients may present with signs of right heart failure. One- and 3-year survival rates are approximately 81% and 52%, respectively. Given the high prevalence and mortality, algorithms for screening are currently under investigation and will hopefully lead to earlier diagnosis and improved survival.
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Affiliation(s)
- Yon K Sung
- Division of Pulmonary and Critical Care Medicine, Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Lorinda Chung
- Division of Rheumatology and Immunology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Division of Rheumatology, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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Development of pulmonary hypertension in a high-risk population with systemic sclerosis in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) cohort study. Semin Arthritis Rheum 2014; 44:55-62. [DOI: 10.1016/j.semarthrit.2014.03.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/21/2014] [Accepted: 03/03/2014] [Indexed: 01/08/2023]
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Abstract
Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by vasculopathy and excessive collagen production leading to fibrosis of the skin and internal organs. SSc patients are at risk of developing pulmonary hypertension (PH), a debilitating, progressive condition of the pulmonary vasculature that leads to right heart failure and death. This review is an updated summary of the epidemiology and risk factors for PH in SSc. We describe the current literature examining the incidence, prevalence, and demographic and clinical risk factors associated with PH in SSc. We also discuss classical and novel autoantibodies and potential biomarkers that may be helpful in the assessment of risk and prognosis of PH in SSc patients. The ultimate objective in understanding the risk of developing PH in SSc is early diagnosis and early initiation of appropriate therapy with the hope for improved outcomes for patients with SSc-PH.
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Shah AA, Wigley FM. My approach to the treatment of scleroderma. Mayo Clin Proc 2013; 88:377-93. [PMID: 23541012 PMCID: PMC3666163 DOI: 10.1016/j.mayocp.2013.01.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
Systemic sclerosis (scleroderma) is unique among the rheumatic diseases because it presents the challenge of managing a chronic multisystem autoimmune disease with a widespread obliterative vasculopathy of small arteries that is associated with varying degrees of tissue fibrosis. The hallmark of scleroderma is clinical heterogeneity with subsets that vary in the degree of disease expression, organ involvement, and ultimate prognosis. Thus, the term scleroderma is used to describe patients who have common manifestations that link them together, whereas a highly variable clinical course exists that spans from mild and subtle findings to aggressive, life-threatening multisystem disease. The physician needs to carefully characterize each patient to understand the specific manifestations and level of disease activity to decide appropriate treatment. This is particularly important in treating a patient with scleroderma because there is no treatment that has been proven to modify the overall disease course, although therapy that targets specific organ involvement early before irreversible damage occurs improves both quality of life and survival. This review describes our approach as defined by evidence, expert opinion, and our experience treating patients. Scleroderma is a multisystem disease with variable expression; thus, any treatment plan must be holistic, yet at the same time focus on the dominant organ disease. The goal of therapy is to improve quality of life by minimizing specific organ involvement and subsequent life-threatening disease. At the same time the many factors that alter daily function need to be addressed, including nutrition, pain, deconditioning, musculoskeletal disuse, comorbid conditions, and the emotional aspects of the disease, such as fear, depression, and the social withdrawal caused by disfigurement.
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Affiliation(s)
- Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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