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Szűcs G, Szekanecz Z, Szamosi S. Can we define difficult-to-treat systemic sclerosis? Expert Rev Clin Immunol 2024; 20:1065-1081. [PMID: 38711393 DOI: 10.1080/1744666x.2024.2352450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by microvascular alterations, immunopathology, and widespread fibrosis involving various organs. It is considered difficult to treat due to several reasons: complex pathogenesis, heterogeneity, late diagnosis, limited treatment options for certain organ manifestations, lack of personalized medicine. AREAS COVERED This review presents the heterogeneity, survival and organ manifestations with their risk factors of systemic sclerosis and their current treatment options, while drawing attention to difficult-to-treat forms of the disease, based on literature indexed in PubMed. EXPERT OPINION Despite recent advances in the management of SSc over the last decades, the disease presents significant morbidity and mortality. Although available treatment protocols brought significant advancements in terms of survival in SSc-associated interstitial lung disease and pulmonary arterial hypertension, less success has been achieved in the treatment of Raynaud's phenomenon and digital ulcers and the results are modest in case of heart, gastrointestinal, and renal manifestations. There are patients who do not respond to treatment and deteriorate even with adequate therapy. They can be considered difficult-to treat (D2T) cases. We have created a possible score system based on the individual organ manifestations and highlighted treatment options for the D2T SSc category.
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Affiliation(s)
- Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Fairley JL, Ross L, Nikpour M. Heart involvement in systemic sclerosis: emerging concepts. Curr Opin Rheumatol 2024:00002281-990000000-00130. [PMID: 39120541 DOI: 10.1097/bor.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW Systemic sclerosis (SSc)-associated heart involvement (SHI) is a significant cause of both morbidity and mortality in individuals with SSc. SHI can take many different forms, and likely is a spectrum of fibroinflammatory cardiac disease. Presenting features include arrhythmia, ventricular systolic or diastolic dysfunction, pericardial disease, and exercise intolerance. Risk of sudden cardiac death in SSc is likely 10-30-fold greater than general population estimates. In this review, we explore what is known about the pathogenesis of SHI, its prevention and management, and discuss available strategies for screening for SHI in light of new recommendations for the routine screening of SHI in all SSc patients. RECENT FINDINGS We describe the spectrum, clinical features, and pathogenesis of SHI. Furthermore, we review the new recommendations for screening for SHI in individuals with SSc. SUMMARY There is a large, under-recognized burden of SHI in people living with SSc, which likely contributes to the significant increase in sudden cardiac death observed in SSc. However, a broad-based screening approach, including asymptomatic, low-risk patients should be viewed with caution given the lack of evidence-based treatments and interventions for SHI particularly in this group.
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Affiliation(s)
- Jessica L Fairley
- The University of Melbourne
- St. Vincent's Hospital Melbourne, Melbourne, Victoria
| | - Laura Ross
- The University of Melbourne
- St. Vincent's Hospital Melbourne, Melbourne, Victoria
| | - Mandana Nikpour
- The University of Melbourne
- St. Vincent's Hospital Melbourne, Melbourne, Victoria
- The University of Sydney School of Public Health, Sydney
- Royal Prince Alfred Hospital Sydney
- SydneyMSK Research Flagship Centre, University of Sydney, Sydney, New South Wales, Australia
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Batani V, Dagna L, De Luca G. Therapeutic strategies for primary heart involvement in systemic sclerosis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:72-82. [PMID: 39015843 PMCID: PMC11248560 DOI: 10.1515/rir-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), even though often underdiagnosed. SSc-pHI has been recently defined as cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications. SSc-pHI represents a major determinant of mortality in SSc, accounting alone for about 12% of disease-related deaths; its early recognition and promptly therapeutic interventions are therefore crucial. Both perfusion defects and myocardial inflammation contribute to the occurrence of myocardial fibrosis that precipitates myocardial remodeling, potentially leading to heart failure and arrhythmic complications. To date, clear evidence and guidelines for effectively managing SSc pHI are not established yet, resulting in a lack of a defined therapeutic algorithm. In this review we summarize the most recent scientific literature on the prevailing therapeutic strategies and interventions to manage SSc-pHI, with particular focus on therapeutic strategies to counteract the 3 major pathogenic events of the disease, i.e. microvascular damage, myocardial inflammation and myocardial fibrosis.
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Affiliation(s)
- Veronica Batani
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
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Luo Y, Ross L, Zheng J, Bernstein EJ. Are there more acute cardiac hospitalizations in winter in patients with systemic sclerosis? An analysis from the National Inpatient Sample. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:59-66. [PMID: 38333525 PMCID: PMC10848930 DOI: 10.1177/23971983231197268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/09/2023] [Indexed: 02/10/2024]
Abstract
Objective Cold-induced transient myocardial ischemia has been described in patients with systemic sclerosis. The clinical impact of cold exposure in systemic sclerosis patients with acute cardiac conditions is unknown. We compared the seasonal variation of acute cardiac hospitalizations in patients with and without systemic sclerosis. Methods We performed a retrospective cross-sectional study using the National Inpatient Sample from 2016 to 2019. The primary outcome was acute cardiac hospitalization primarily due to heart failure, acute myocardial infarction, or cardiac arrhythmias. We compared the proportion of acute cardiac hospitalizations in each season in patients with and without systemic sclerosis. We also performed a subgroup analysis by US geographic region (Northeast, Midwest, South, West). Results There were a total of 10,118,002 acute cardiac hospitalizations over the 4-year study period. Compared to those without systemic sclerosis, patients with systemic sclerosis who were hospitalized for acute cardiac care were younger (mean age 67 ± 13 vs 70 ± 14 years, p < 0.01), a greater proportion were female (82% vs 45%, p < 0.01), and a smaller proportion were Caucasian (68% vs 71%, p < 0.01). There was a lesser proportion of traditional cardiovascular risk factors in systemic sclerosis compared to non-systemic sclerosis patients. There was no significant difference in the proportion of winter admissions between systemic sclerosis and non-systemic sclerosis patients for total acute cardiac hospitalizations (26.4% vs 25.9%, p = 0.51), heart failure (27.0% vs 26.5%, p = 0.64), acute myocardial infarction (26.9% vs 25.5%, p = 0.50), or arrhythmias (24.3% vs 25.0%, p = 0.68). The results were consistent across all four US geographic regions. Conclusion Our study did not support that patients with systemic sclerosis had a disproportionally higher risk of acute cardiac hospitalization in winter compared to the general population. We found that systemic sclerosis patients hospitalized for acute cardiac care had a lower burden of traditional cardiovascular risk factors than their non-systemic sclerosis counterparts.
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Affiliation(s)
- Yiming Luo
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Laura Ross
- Department of Medicine, St Vincent’s Hospital, The University of Melbourne, Melbourne, VIC, Australia
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Jiayi Zheng
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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De Luca G, Matucci-Cerinic M, Mavrogeni SI. Diagnosis and management of primary heart involvement in systemic sclerosis. Curr Opin Rheumatol 2024; 36:76-93. [PMID: 37962165 DOI: 10.1097/bor.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW In systemic sclerosis (SSc) primary heart involvement (pHI) is frequent, even though often unrecognized due to its occult nature and to the lack of a specific diagnostic algorithm. The purpose of this review is to report the state of the art of the evidence in the current literature, as well as the overall diagnostic modalities and therapeutic strategies for primary heart involvement in SSc. RECENT FINDINGS SSc-pHI is defined by the presence of cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications; it may be sub-clinical and must be confirmed through diagnostic investigations. Novel electrocardiographic analysis and cardiac magnetic resonance (CMR) with mapping techniques have been recently proposed, showing a great utility in the early identification of SSc-pHI and in the noninvasive characterization of myocardial tissue. Immunosuppressive therapy emerged as fundamental to curb myocardial inflammation, and recent preclinical and clinical data support the role of antifibrotic drugs to treat SSc-pHI. SUMMARY our review will help clinicians to properly integrate the available diagnostic modalities for the assessment of SSc-pHI. The ultimate goal is to propose a feasible diagnostic algorithm for the early identification of patients with SSc-pHI, and a schematic therapeutic approach to manage SSc-pHI.
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Affiliation(s)
- Giacomo De Luca
- Vita-Salute San Raffaele University
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sophie I Mavrogeni
- Onassis Cardiac Surgery Center
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Healthcare, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Fairley JL, Ross L, Quinlivan A, Hansen D, Paratz E, Stevens W, Kistler PM, McLellan A, La Gerche A, Nikpour M. Sudden cardiac death, arrhythmias and abnormal electrocardiography in systemic sclerosis: A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 62:152229. [PMID: 37354723 DOI: 10.1016/j.semarthrit.2023.152229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To calculate the frequency of sudden cardiac death(SCD), arrhythmia and conduction defects in SSc. METHODS MEDLINE/EMBASE were searched to January 2023. English-language studies reporting the incidence/frequency of SCD, arrhythmia and electrocardiography(ECG) abnormalities in SSc were included. Odds ratios(OR), estimations of annual incidence or pooled frequencies were calculated. RESULTS Seventy-nine studies(n = 13,609 participants with SSc) were included in the meta-analysis. Methodology and outcomes were heterogeneous. Ten studies included cohorts with known/suspected SSc-associated heart involvement(SHI), generally defined as clinically-manifest cardiac disease/abnormal cardiac investigations. The incidence of SCD in SHI was estimated to be 3.3% annually(n = 4 studies, 301PY follow-up). On ambulatory ECG, 18% of SHI cohorts had non-sustained ventricular tachycardia(NSVT; n = 4, 95%CI3.2-39.3%), 70% frequent premature ventricular complexes (PVCs; n = 1, 95%CI34.8-93.3%), and 8% atrial fibrillation (AF; n = 1, 95%CI4.2-13.6%). Nineteen studies included participants without SHI, defined as normal cardiac investigations/absence of cardiac disease. The estimated incidence of SCD was approximately 2.9% annually (n = 1, 67.5PY). Compared to healthy controls, individuals without SHI demonstrated NSVT 13.3-times more frequently (n = 2, 95%CI2-102), and paroxysmal supraventricular tachycardia 7-times more frequently (n = 4, 95%CI3-15). Other ambulatory ECG abnormalities included NSVT in 9% (n = 7, 95%CI6-14%), >1000 PVCs/24 h in 6% (n = 2, 95%CI1-13%), and AF in 7% (n = 5, 0-21%). Fifty studies included general SSc cohorts unselected for cardiac disease. The incidence of SCD was estimated to be 2.0% annually(n = 4 studies, 1646PY). Unselected SSc cohorts were 10.5-times more likely to demonstrate frequent PVCs (n = 2, 95%CI 2-59) and 2.5-times more likely to have an abnormal electrocardiography (n = 2, 95%CI1-4). CONCLUSIONS The incidence of SCD in SSc is estimated to be 1.0-3.3% annually, at least 10-fold higher than general population estimates. Arrhythmias including NSVT and frequent PVCs appear common, including amongst those without known/suspected SHI.
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Affiliation(s)
- Jessica L Fairley
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Laura Ross
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alannah Quinlivan
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dylan Hansen
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Paratz
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Wendy Stevens
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The University of Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Australia
| | - Alex McLellan
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andre La Gerche
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
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Ninagawa K, Kato M, Tsuneta S, Ishizaka S, Ujiie H, Hisada R, Kono M, Fujieda Y, Ito YM, Atsumi T. Beneficial effects of nintedanib on cardiomyopathy in patients with systemic sclerosis: a pilot study. Rheumatology (Oxford) 2023; 62:2550-2555. [PMID: 36458921 DOI: 10.1093/rheumatology/keac674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/29/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Nintedanib is an inhibitor of tyrosine kinases that has been shown to slow the progression of interstitial lung disease (ILD), including ILD associated with SSc. The aim of this study was to explore the effect of nintedanib on cardiomyopathy associated with systemic sclerosis (SSc). METHODS Twenty consecutively hospitalized patients with SSc-ILD were enrolled and prospectively followed. The rate of change at 6 months in cardiac magnetic resonance (CMR) parametric mapping, including myocardial extracellular volume, was primarily evaluated. Other endpoints included changes in CMR functional parameters, echocardiographic parameters, modified Rodnan skin score, serum biomarkers and pulmonary function test. RESULTS Nintedanib was administered in 10 patients, whereas the other 10 were treated without nintedanib or watched, according to ILD severity and progression. Baseline values of CMR parametric mapping were not different between the two groups. The rate of change at 6 months in myocardial extracellular volume was highly different, almost divergent, between the nintedanib group and the control group (-1.62% vs +2.00%, P = 0.0001). Among other endpoints, the change in right ventricular ejection fraction was significantly different between the two groups (P = 0.02), with a preferential change in the nintedanib group. CONCLUSION Our data indicate beneficial signals of nintedanib on cardiomyopathy associated with SSc. The anti-fibrotic effect of nintedanib might not be limited to the lung.
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Affiliation(s)
- Keita Ninagawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satonori Tsuneta
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Michihito Kono
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoichi M Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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He H, Lai J, Zhou J, Hou Y, Xu D, Li M, Zeng X. The clinical characteristics and outcomes of patients with systemic sclerosis with myocardial involvement. Orphanet J Rare Dis 2023; 18:83. [PMID: 37060032 PMCID: PMC10103520 DOI: 10.1186/s13023-023-02699-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/06/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Myocardial involvement (MI) is the primary cause of death in patients with systemic sclerosis (SSc). We analyzed patients with SSc and MI to identify their characteristics and outcome. METHOD We retrospectively collected data from SSc patients with MI admitted to Peking Union Medical College Hospital between January 2012 and May 2021. SSc patients without MI were randomly selected as controls after matching age and gender at a ratio of 1:3. RESULTS In total, 21 SSc patients (17 females) with MI were enrolled. The mean age at SSc onset was 42.3 ± 15.1 years old. Compared with controls, myositis (42.9% vs. 14.3%, P = 0.014) and elevation of CK (33.3% vs. 4.8%, P = 0.002) were more common in patients with MI. Of the 7 patients without cardiovascular symptoms, 3 /5 showed elevations in cardiac troponin-I (cTnI), 6 showed elevations of N-terminal brain natriuretic peptide (NT-proBNP). Eleven patients were followed up for a median period of 15.5 months and four patients developed newly occurring left ventricular ejection fraction (LVEF) < 50%. CONCLUSION One third of SSc patients with MI were asymptomatic. Regular monitoring of CTnI, NT-proBNP and echocardiography is helpful for the diagnosis of MI during the early stages. Its prognosis is poor.
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Affiliation(s)
- Huilin He
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Jinzhi Lai
- Department of Cardiology, Peking Union Medical College Hospital, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Yong Hou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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Dumitru RB, Bissell L, Erhayiem B, Fent G, Kidambi A, Abignano G, Greenwood JP, Biglands J, Del Galdo F, Plein S, Buch MH. Subclinical Systemic Sclerosis Primary Heart Involvement by Cardiovascular Magnetic Resonance Shows No Significant Interval Change. ACR Open Rheumatol 2023; 5:71-80. [PMID: 36604819 PMCID: PMC9926075 DOI: 10.1002/acr2.11515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/24/2022] [Accepted: 11/04/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Subclinical systemic sclerosis (SSc) primary heart involvement is commonly described. Whether these findings progress over time is not clear. The study aimed to investigate cardiovascular magnetic resonance (CMR) interval change of subclinical SSc primary heart involvement. METHODS Patients with SSc with no cardiovascular disease underwent two CMR scans that included T1 mapping and quantitative stress perfusion. The CMR change (mean difference) and association between CMR measures and clinical phenotype were assessed. The study had a prospective design. RESULTS Thirty-one patients with SSc participated, with a median (interquartile range) follow-up of 33 (17-37) months (10 [32%] in the diffuse subset, 16 [52%] with interstitial lung disease [ILD], and 11 [29%] who were Scl-70+). Four of thirty-one patients had focal late gadolinium enhancement (LGE) at visit 1; one of four had an increase in LGE scar mass between visits. Two patients showed new focal LGE at visit 2. No change in other CMR indices was noted. The three patients with SSc with increased or new LGE at visit 2 had diffuse cutaneous SSc with ILD, and two were Scl-70+. A reduction in forced vital capacity and total lung capacity was associated with a reduction in left ventricular ejection fraction (ρ = 0.413, P = 0.021; ρ = 0.335, P = 0.07) and myocardial perfusion reserve (MPR) (ρ = 0.543, P = 0.007; ρ = 0.627, P = 0.002). An increase in the N-terminal pro-brain natriuretic peptide level was associated with a reduction in MPR (ρ = -0.448, P = 0.042). Patients on disease-modifying antirheumatic drugs (DMARDs) had an increase in native T1 (mean [SD] 1208 [65] vs. 1265 [56] milliseconds, P = 0.008). No other clinically meaningful CMR change in patients receiving DMARDs or vasodilators was noted. CONCLUSION Serial CMR detects interval subclinical SSc primary heart involvement progression; however, this study suggests abnormalities remain largely stable with follow-up.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Maya H. Buch
- University of Leeds, Leeds, UK, and University of ManchesterManchesterUK
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Arrhythmias and Conduction Disturbances in Patients with Systemic Sclerosis—A Systematic Literature Review. Int J Mol Sci 2022; 23:ijms232112963. [PMID: 36361752 PMCID: PMC9658897 DOI: 10.3390/ijms232112963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/29/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by skin and internal organ fibrosis and microvascular impairment, which can affect major organs, including the heart. Arrhythmias are responsible for approximately 6% of deaths in patients with SSc, and mainly occur due to myocardial fibrosis, which causes electrical inhomogeneity. The aim of this study was to determine the frequency of arrhythmias and conduction disturbances in SSc cohorts, and to identify the characteristics and risk factors associated with the occurrence of dysrhythmias in patients with SSc. A systematic literature review using PubMed, Embase, Web of Science and Scopus databases was performed. Full-text articles in English with arrhythmias as the main topic published until 21 April 2022 were included. Most prevalent arrhythmias were premature supraventricular and ventricular contractions, while the most frequent conduction disturbance was represented by right bundle branch block (RBBB). Elevated concentrations of N-terminal prohormones of brain natriuretic peptides (NT-pro BNP) were associated with numerous types of atrial and ventricular arrhythmias, and with the occurrence of RBBB. A lower value of the turbulence slope (TS) emerged as an independent predictor for ventricular arrhythmias. In conclusion, dysrhythmias are frequent in SSc cohorts. Paraclinical and laboratory parameters are useful instruments that could lead to early diagnosis in the course of the disease.
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Ferlito A, Campochiaro C, Tomelleri A, Dagna L, De Luca G. Primary heart involvement in systemic sclerosis, from conventional to innovative targeted therapeutic strategies. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:179-188. [PMID: 36211207 PMCID: PMC9537702 DOI: 10.1177/23971983221083772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/08/2022] [Indexed: 10/03/2023]
Abstract
Primary heart involvement is frequent in systemic sclerosis, even though often sub-clinical, and includes cardiac abnormalities that are predominantly attributable to systemic sclerosis rather than other causes and/or complications. A timely diagnosis is crucial to promptly start the appropriate therapy and to prevent the potential life-threatening early and late complications. There is little evidence on how to best manage systemic sclerosis-primary heart involvement as no specific treatment recommendations for heart disease are available, and a shared treatment approach is still lacking. The objective of this review is to summarize the state of the art of current literature and the overall management strategies and therapeutic approaches for systemic sclerosis-primary heart involvement. Novel insights into pathogenic mechanisms of systemic sclerosis-primary heart involvement are presented to facilitate the comprehension of therapeutic targets and novel treatment strategies.
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Affiliation(s)
| | - Corrado Campochiaro
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Tomelleri
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
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13
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Assessment of disease outcome measures in systemic sclerosis. Nat Rev Rheumatol 2022; 18:527-541. [PMID: 35859133 DOI: 10.1038/s41584-022-00803-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
The assessment of disease activity in systemic sclerosis (SSc) is challenging owing to its heterogeneous manifestations across multiple organ systems, the variable rate of disease progression and regression, and the relative paucity of patients in early-phase therapeutic trials. Despite some recent successes, most clinical trials have failed to show efficacy, underscoring the need for improved outcome measures linked directly to disease pathogenesis, particularly applicable for biomarker studies focused on skin disease. Current outcome measures in SSc-associated interstitial lung disease and SSc skin disease are largely adequate, although advancing imaging technology and the incorporation of skin mRNA biomarkers might provide opportunities for earlier detection of the therapeutic effect. Biomarkers can further inform pathogenesis, enabling early phase trials to act as reverse translational studies through the incorporation of routine high-throughput sequencing.
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García AG, Fabregate M, Manzano L, Guillén del Castillo A, Rivas MR, Argibay A, Ballvé AM, Pintó IR, Salas XP, Marí-Alfonso B, Moraga EC, Argüelles DC, Comet LS, González-Echávarri C, Ortego-Centeno N, Hitos JAV, Parra JAT, Martínez LT, Marín MTH, Freire M, Chamorro AJ, Fraile IP, Vuelta ABM, Trigo SS, Vilella CT, Pla VF, Aznar CPS. Left Ventricular Diastolic Dysfunction in Systemic Sclerosis: Clinical, immunological and survival differences in the Spanish RESCLE Registry. Semin Arthritis Rheum 2022; 55:152033. [DOI: 10.1016/j.semarthrit.2022.152033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/07/2022] [Accepted: 05/24/2022] [Indexed: 11/15/2022]
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Sclerodermic Cardiomyopathy—A State-of-the-Art Review. Diagnostics (Basel) 2022; 12:diagnostics12030669. [PMID: 35328222 PMCID: PMC8947572 DOI: 10.3390/diagnostics12030669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/27/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic autoimmune disorder with unknown triggering factors, and complex pathophysiologic links which lead to fibrosis of skin and internal organs, including the heart, lungs, and gut. However, more than 100 years after the first description of cardiac disease in SSc, sclerodermic cardiomyopathy (SScCmp) is an underrecognized, occult disease with important adverse long-term prognosis. Laboratory tests, electrocardiography (ECG) and cardiovascular multimodality imaging techniques (transthoracic 2D and 3D echocardiography, cardiac magnetic resonance (CMR), and novel imaging techniques, including myocardial deformation analysis) provide new insights into the cardiac abnormalities in patients with SSc. This state-of-the-art review aims to stratify all the cardiac investigations needed to diagnose and follow-up the SScCmp, and discusses the epidemiology, risk factors and pathophysiology of this important cause of morbidity of the SSc patient.
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Drosos GC, Vedder D, Houben E, Boekel L, Atzeni F, Badreh S, Boumpas DT, Brodin N, Bruce IN, González-Gay MÁ, Jacobsen S, Kerekes G, Marchiori F, Mukhtyar C, Ramos-Casals M, Sattar N, Schreiber K, Sciascia S, Svenungsson E, Szekanecz Z, Tausche AK, Tyndall A, van Halm V, Voskuyl A, Macfarlane GJ, Ward MM, Nurmohamed MT, Tektonidou MG. EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases, including systemic lupus erythematosus and antiphospholipid syndrome. Ann Rheum Dis 2022; 81:768-779. [PMID: 35110331 DOI: 10.1136/annrheumdis-2021-221733] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To develop recommendations for cardiovascular risk (CVR) management in gout, vasculitis, systemic sclerosis (SSc), myositis, mixed connective tissue disease (MCTD), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). METHODS Following European League against Rheumatism (EULAR) standardised procedures, a multidisciplinary task force formulated recommendations for CVR prediction and management based on systematic literature reviews and expert opinion. RESULTS Four overarching principles emphasising the need of regular screening and management of modifiable CVR factors and patient education were endorsed. Nineteen recommendations (eleven for gout, vasculitis, SSc, MCTD, myositis, SS; eight for SLE, APS) were developed covering three topics: (1) CVR prediction tools; (2) interventions on traditional CVR factors and (3) interventions on disease-related CVR factors. Several statements relied on expert opinion because high-quality evidence was lacking. Use of generic CVR prediction tools is recommended due to lack of validated rheumatic diseases-specific tools. Diuretics should be avoided in gout and beta-blockers in SSc, and a blood pressure target <130/80 mm Hg should be considered in SLE. Lipid management should follow general population guidelines, and antiplatelet use in SLE, APS and large-vessel vasculitis should follow prior EULAR recommendations. A serum uric acid level <0.36 mmol/L (<6 mg/dL) in gout, and disease activity control and glucocorticoid dose minimisation in SLE and vasculitis, are recommended. Hydroxychloroquine is recommended in SLE because it may also reduce CVR, while no particular immunosuppressive treatment in SLE or urate-lowering therapy in gout has been associated with CVR lowering. CONCLUSION These recommendations can guide clinical practice and future research for improving CVR management in rheumatic and musculoskeletal diseases.
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Affiliation(s)
- George C Drosos
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Daisy Vedder
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Eline Houben
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Laura Boekel
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Internal Medicine, University of Messina, Messina, Italy
| | - Sara Badreh
- EULAR Patient Research Partner, Brussels, Belgium
| | - Dimitrios T Boumpas
- 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital Corp, Stockholm, Sweden
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Miguel Ángel González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla and University of Cantabria, Santander, Spain
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - György Kerekes
- Intensive Care Unit, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | | | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Colney Lane, UK
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, University of Barcelona, Hospital Clínic, Barcelona, Spain
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Karen Schreiber
- EMEUNET member, Danish Hospital for Rheumatic Diseases, Sonderburg, Denmark
| | - Savino Sciascia
- EMEUNET member, CMID-Nephrology, San Giovanni Bosco Hospital, University of Torino, Torino, Italy
| | - Elisabet Svenungsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen Faculty of Medicine, Debrecen, Hungary
| | - Anne-Kathrin Tausche
- Department of Rheumatology, University Clinic Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Alan Tyndall
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Vokko van Halm
- Department of Cardiology, Amsterdam University Medical Center, location VU University medical center, Amsterdam, The Netherlands
| | - Alexandre Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Nurmohamed
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Amsterdam University Medical Center, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece .,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Bruni C, Buch MH, Furst DE, De Luca G, Djokovic A, Dumitru RB, Giollo A, Polovina M, Steelandt A, Bratis K, Suliman YA, Milinkovic I, Baritussio A, Hasan G, Xintarakou A, Isomura Y, Markousis-Mavrogenis G, Tofani L, Mavrogeni S, Gargani L, Caforio ALP, Tschöpe C, Ristic A, Klingel K, Plein S, Behr ER, Allanore Y, Kuwana M, Denton CP, Khanna D, Krieg T, Marcolongo R, Galetti I, Zanatta E, Tona F, Seferovic P, Matucci-Cerinic M. Primary systemic sclerosis heart involvement: A systematic literature review and preliminary data-driven, consensus-based WSF/HFA definition. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:24-32. [PMID: 35386946 PMCID: PMC8922675 DOI: 10.1177/23971983211053246] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 09/23/2021] [Indexed: 02/03/2023]
Abstract
Introduction Primary heart involvement in systemic sclerosis may cause morpho-functional and electrical cardiac abnormalities and is a common cause of death. The absence of a clear definition of primary heart involvement in systemic sclerosis limits our understanding and ability to focus on clinical research. We aimed to create an expert consensus definition for primary heart involvement in systemic sclerosis. Methods A systematic literature review of cardiac involvement and manifestations in systemic sclerosis was conducted to inform an international and multi-disciplinary task force. In addition, the nominal group technique was used to derive a definition that was then subject to voting. A total of 16 clinical cases were evaluated to test face validity, feasibility, reliability and criterion validity of the newly created definition. Results In total, 171 publications met eligibility criteria. Using the nominal group technique, experts added their opinion, provided statements to consider and ranked them to create the consensus definition, which received 100% agreement on face validity. A median 60(5-300) seconds was taken for the feasibility on a single case. Inter-rater agreement was moderate (mKappa (95% CI) = 0.56 (0.46-1.00) for the first round and 0.55 (0.44-1.00) for the second round) and intra-rater agreement was good (mKappa (95% CI) = 0.77 (0.47-1.00)). Criterion validity showed a 78 (73-84)% correctness versus gold standard. Conclusion A preliminary primary heart involvement in systemic sclerosis consensus-based definition was created and partially validated, for use in future clinical research.
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Affiliation(s)
- Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Maya H Buch
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Daniel E Furst
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
- Department Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology Allergy and Rare diseases, IRCSS San Raffaele Hospital, Vita Salute San Raffaele University, Milano, Italy
| | - Aleksandra Djokovic
- Department of Cardiology, University Hospital Centre Bezanijska Kosa, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Raluca B Dumitru
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Alessandro Giollo
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Marija Polovina
- Department of Cardiology, University Hospital Centre Bezanijska Kosa, Belgrade, Serbia
| | - Alexia Steelandt
- Rheumatology Department, Paris University, Cochin Hospital, Paris, France
| | - Kostantinos Bratis
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Yossra Atef Suliman
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assuit University Hospital, Assuit, Arab Republic of Egypt
| | - Ivan Milinkovic
- Department of Cardiology, University Hospital Centre Bezanijska Kosa, Belgrade, Serbia
| | - Anna Baritussio
- Cardiology and Cardio-Immunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Ghadeer Hasan
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Yohei Isomura
- Department of Allergy and Rheumatology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Lorenzo Tofani
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Centre and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Alida LP Caforio
- Cardiology and Cardio-Immunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Brussels, Belgium
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité Campus Virchow-Klinikum, Charité – University Medicine Berlin, Berlin, Germany
| | - Arsen Ristic
- Department of Cardiology, University Hospital Centre Bezanijska Kosa, Belgrade, Serbia
| | - Karin Klingel
- Institute for Pathology and Neuropathology, Cardiopathology, University of Tuebingen, Tuebingen, Germany
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Elijah R Behr
- Cardiology Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George’s University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Yannick Allanore
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Dinesh Khanna
- University of Michigan Scleroderma Program, Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Thomas Krieg
- Translational Matrix Biology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Renzo Marcolongo
- Cardiology and Cardio-Immunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University Hospital of Padua, Padua, Italy
| | - Ilaria Galetti
- Federation of European Scleroderma Associations (FESCA), Brussels, Belgium
| | - Elisabetta Zanatta
- Department of Medicine, Division of Rheumatology, University of Padua, Padova, Italy
| | - Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Petar Seferovic
- Department of Cardiology, University Hospital Centre Bezanijska Kosa, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
- Unit of Immunology, Rheumatology Allergy and Rare diseases, IRCSS San Raffaele Hospital, Vita Salute San Raffaele University, Milano, Italy
- Department of Geriatric Medicine, Division of Rheumatology, Careggi University Hospital, Florence, Italy
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De Luca G, Bombace S, Monti L. Heart Involvement in Systemic Sclerosis: the Role of Magnetic Resonance Imaging. Clin Rev Allergy Immunol 2022; 64:343-357. [PMID: 35072931 DOI: 10.1007/s12016-022-08923-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis (SSc) is a severe connective tissue disease characterized by diffuse vascular damage and aberrant activation of immune system, resulting in inflammation and fibrosis of skin and internal organs, including the heart. Cardiac involvement is frequent in SSc, even though often unrecognized due to the occult nature at early stages and to the lack of a defined diagnostic algorithm. Once clinically evident, heart involvement is associated with a poor prognosis, representing the leading cause of death in about one third of SSc patients. Thus, its early recognition and monitoring are of crucial importance to allow a prompt therapeutic intervention and to improve patients' outcomes. Cardiac Magnetic Resonance (CMR) is a non-invasive, non-radiating imaging technique of great importance for the assessment of cardiovascular system, and represents the modality of choice for the morpho-functional and structural characterization of the heart. In SSc, CMR allows a precise definition of biventricular and biatrial size and function, and a detailed tissue characterization. CMR has been therefore extensively proposed in SSc as a non-invasive diagnostic tool to characterize heart involvement, particularly myocardial involvement. In this review, we summarize the most recent evidences to support the use of CMR in SSc as an important tool to recognize and characterize scleroderma heart disease. Furthermore, the unmet needs and the future perspectives of a CMR-based approach for the early detection of SSc heart involvement are discussed.
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Zagouras AA, Chatterjee S, Tang WHW. Heart Failure with Preserved Ejection Fraction and Cardiomyopathy: an Under-recognized Complication of Systemic Sclerosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ross L, Paratz E, Baron M, La Gerche A, Nikpour M. Sudden Cardiac Death in Systemic Sclerosis: Diagnostics to Assess Risk and Inform Management. Diagnostics (Basel) 2021; 11:1781. [PMID: 34679479 PMCID: PMC8534599 DOI: 10.3390/diagnostics11101781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Cardiac disease is a leading cause of death in systemic sclerosis (SSc) and sudden cardiac death (SCD) is thought to occur more commonly in SSc than in the general population. Diffuse myocardial fibrosis, myocarditis and ischaemic heart disease are all prevalent in SSc and can be reasonably hypothesised to contribute to an increased risk of SCD. Despite this, SCD remains a relatively understudied area of SSc with little understood about SSc-specific risk factors and opportunities for primary prevention. In this review, we present an overview of the possible mechanisms of SCD in SSc and our current understanding of how each of these mechanisms may contribute to cardiac death. This review highlights the need for a future research agenda that addresses the underlying epidemiology of SCD in SSc and identifies opportunities for intervention to modify the disease course of heart disease in SSc.
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Affiliation(s)
- Laura Ross
- Department of Rheumatology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia;
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
| | - Elizabeth Paratz
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
- Department of Cardiology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Murray Baron
- Department of Rheumatology, Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T 1E2, Canada;
| | - André La Gerche
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
- Department of Cardiology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia;
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
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Dumitru RB, Bissell LA, Erhayiem B, Fent G, Kidambi A, Swoboda P, Abignano G, Donica H, Burska A, Greenwood JP, Biglands J, Del Galdo F, Plein S, Buch MH. Predictors of subclinical systemic sclerosis primary heart involvement characterised by microvasculopathy and myocardial fibrosis. Rheumatology (Oxford) 2021; 60:2934-2945. [PMID: 34080001 DOI: 10.1093/rheumatology/keaa742] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/26/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES SSc primary heart involvement (SSc-pHI) is a significant cause of mortality. We aimed to characterize and identify predictors of subclinical SSc-pHI using cardiovascular MRI. METHODS A total of 83 SSc patients with no history of cardiovascular disease or pulmonary arterial hypertension and 44 healthy controls (HCs) underwent 3 Tesla contrast-enhanced cardiovascular MRI, including T1 mapping and quantitative stress perfusion. High-sensitivity troponin I and N-terminal pro-brain natriuretic peptide were also measured. RESULTS Cardiovascular MRI revealed a lower myocardial perfusion reserve in the SSc patients compared with HCs {median (interquartile range (IQR)] 1.9 (1.6-2.4) vs 3 (2-3.6), P < 0.001}. Late gadolinium enhancement, indicating focal fibrosis, was observed in 17/83 patients but in none of the HCs, with significantly higher extracellular volume (ECV), suggestive of diffuse fibrosis, in SSc vs HC [mean (s.d.) 31 (4) vs 25 (2), P < 0.001]. Presence of late gadolinium enhancement and higher ECV was associated with skin score [odds ratio (OR) = 1.115, P = 0.048; R2 = 0.353, P = 0.004], and ECV and myocardial perfusion reserve was associated with the presence of digital ulcers at multivariate analysis (R2 = 0.353, P < 0.001; R2 = 0.238, P = 0.011). High-sensitivity troponin I was significantly higher in patients with late gadolinium enhancement, and N-terminal pro-brain natriuretic peptide was associated with ECV (P < 0.05). CONCLUSION Subclinical SSc-pHI is characterized by myocardial microvasculopathy, diffuse and focal myocardial fibrosis but preserved myocardial contractile function. This subclinical phenotype of SSc-pHI was associated with high-sensitivity troponin I, N-terminal pro-brain natriuretic peptide, SSc disease severity and complicated peripheral vasculopathy. These data provide information regarding the underlying pathophysiological processes and provide a basis for identifying individuals at risk of SSc-pHI.
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Affiliation(s)
- Raluca B Dumitru
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - Lesley-Anne Bissell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - Bara Erhayiem
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Graham Fent
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Ananth Kidambi
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Peter Swoboda
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Giuseppina Abignano
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - Helena Donica
- Department of Biochemical Diagnostics, Medical University of Lublin, Lublin, Poland
| | - Agata Burska
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - John P Greenwood
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Biglands
- Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Biomedical Research Centre, National Institute for Health Research, Leeds, UK
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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22
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Tona F, Zanatta E, Montisci R, Muraru D, Beccegato E, De Zorzi E, Benvenuti F, Civieri G, Cozzi F, Iliceto S, Doria A. Higher Ventricular-Arterial Coupling Derived from Three-Dimensional Echocardiography Is Associated with a Worse Clinical Outcome in Systemic Sclerosis. Pharmaceuticals (Basel) 2021; 14:646. [PMID: 34358072 PMCID: PMC8308671 DOI: 10.3390/ph14070646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022] Open
Abstract
Primary myocardial involvement is common in systemic sclerosis (SSc). Ventricular-arterial coupling (VAC) reflecting the interplay between ventricular performance and arterial load, is a key determinant of cardiovascular (CV) performance. We aimed to investigate VAC, VAC-derived indices, and the potential association between altered VAC and survival free from death/hospitalization for major adverse CV events (MACE) in scleroderma. Only SSc patients without any anamnestic and echocardiographic evidence of primary myocardial involvement who underwent three-dimensional echocardiography (3DE) were included in this cross-sectional study and compared with healthy matched controls. 3DE was used for noninvasive measurements of end-systolic elastance (Ees), arterial elastance (Ea), VAC (Ea/Ees) and end-diastolic elastance (Eed); the occurrence of death/hospitalization for MACE was recorded during follow-up. Sixty-five SSc patients (54 female; aged 56 ± 14 years) were included. Ees (p = 0.04), Ea (p = 0.04) and Eed (p = 0.01) were higher in patients vs. controls. Thus, VAC was similar in both groups. Ees was lower and VAC was higher in patients with diffuse cutaneous form (dcSSc) vs. patients with limited form (lcSSc) (p = 0.001 and p = 0.02, respectively). Over a median follow-up of 4 years, four patients died for heart failure and 34 were hospitalized for CV events. In patients with VAC > 0.63 the risk of MACE was higher (HR 2.5; 95% CI 1.13-5.7; p = 0.01) and survival free from death/hospitalization was lower (p = 0.005) than in those with VAC < 0.63. Our study suggests that VAC may be impaired in SSc patients without signs and symptoms of primary myocardial involvement. Moreover, VAC appears to have a prognostic role in SSc.
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Affiliation(s)
- Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, 35128 Padova, Italy; (D.M.); (E.B.); (G.C.); (S.I.)
| | - Elisabetta Zanatta
- Department of Medicine, Padova University Hospital, 35128 Padova, Italy; (E.Z.); (E.D.Z.); (F.B.); (F.C.); (A.D.)
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, 09042 Cagliari, Italy;
| | - Denisa Muraru
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, 35128 Padova, Italy; (D.M.); (E.B.); (G.C.); (S.I.)
| | - Elena Beccegato
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, 35128 Padova, Italy; (D.M.); (E.B.); (G.C.); (S.I.)
| | - Elena De Zorzi
- Department of Medicine, Padova University Hospital, 35128 Padova, Italy; (E.Z.); (E.D.Z.); (F.B.); (F.C.); (A.D.)
| | - Francesco Benvenuti
- Department of Medicine, Padova University Hospital, 35128 Padova, Italy; (E.Z.); (E.D.Z.); (F.B.); (F.C.); (A.D.)
| | - Giovanni Civieri
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, 35128 Padova, Italy; (D.M.); (E.B.); (G.C.); (S.I.)
| | - Franco Cozzi
- Department of Medicine, Padova University Hospital, 35128 Padova, Italy; (E.Z.); (E.D.Z.); (F.B.); (F.C.); (A.D.)
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, 35128 Padova, Italy; (D.M.); (E.B.); (G.C.); (S.I.)
| | - Andrea Doria
- Department of Medicine, Padova University Hospital, 35128 Padova, Italy; (E.Z.); (E.D.Z.); (F.B.); (F.C.); (A.D.)
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23
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Abstract
Primary systemic sclerosis heart involvement (pSHI) is an important disease manifestation that accounts for a significant proportion of systemic sclerosis (SSc)-associated mortality. A broad clinical spectrum of pSHI exists, which ranges from asymptomatic perfusion abnormalities to diastolic dysfunction or acute myocarditis and congestive heart failure. With improving sensitivity of cardiac investigations, it is increasingly recognized that there is a large burden of subclinical cardiac disease in patients with SSc. Early signs of pSHI can be subtle and determining the etiology of cardiac abnormalities from other causes of cardiomyopathy such as hypertension, ischemic heart disease (IHD), and pulmonary vascular disease remain challenging. Early identification of pSHI potentially provides clinicians with a window of opportunity for intervention to avert progression to heart failure. However, optimal screening and treatment guidelines are lacking, and it is an area of much needed further clinical research.
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24
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Fasano S, Iacono D, Riccardi A, Ciccia F, Valentini G. The role of aspirin in the primary prevention of accelerated atherosclerosis in systemic autoimmune rheumatic diseases. Rheumatology (Oxford) 2020; 59:3593-3602. [DOI: 10.1093/rheumatology/keaa335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/17/2020] [Indexed: 01/04/2023] Open
Abstract
Abstract
Aspirin is the most commonly used medication worldwide. Beside its well-known anti-inflammatory effects, a role has emerged in the prevention of cardiovascular events. However, a significant benefit has been demonstrated in secondary cardiovascular prevention only, while there is limited evidence supporting a role in primary prevention. This discrepancy might depend on the that so far, the high-risk populations that will achieve the greatest benefits yet experiencing minimal harmful side effects have not been identified. Patients with autoimmune systemic rheumatic diseases have an increased risk of cardiovascular complications compared with the general population, which makes aspirin of potential value in these subjects. Moving from general aspects of aspirin pharmacology and specific issues in general population, the aim of this study is to review the evidence about the role of low-dose aspirin in primary cardiovascular prevention in autoimmune systemic rheumatic diseases.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Daniela Iacono
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Antonella Riccardi
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Francesco Ciccia
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Gabriele Valentini
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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25
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Benvenuti F, Zanatta E, Avouac J, Müller-Ladner U, Cozzi F, Hoffmann-Vold AM, Gabrielli A, Distler O, Matucci-Cerinic M, Allanore Y, Doria A. The power of the EUSTAR cohort: key findings to date and implications for management of systemic sclerosis patients. Expert Rev Clin Immunol 2020; 16:1065-1074. [DOI: 10.1080/1744666x.2021.1836962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Francesco Benvenuti
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Jérôme Avouac
- Rhumatologie, Hôpital Cochin, APHP, Université de Paris, Paris, France
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus‐Liebig University Giessen, Bad Nauheim, Germany
| | - Franco Cozzi
- Internal Medicine Unit, Ospedale Classificato Villa Salus, Venice, Italy
| | | | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Yannick Allanore
- Rhumatologie, Hôpital Cochin, APHP, Université de Paris, Paris, France
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
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26
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Terrier B, Dechartres A, Gouya H, Ben Arfi M, Bérézne A, Régent A, Dunogué B, London J, Cohen P, Guillevin L, Le Jeunne C, Legmann P, Vignaux O, Mouthon L. Cardiac Intravoxel Incoherent Motion Diffusion-Weighted Magnetic Resonance Imaging With T1 Mapping to Assess Myocardial Perfusion and Fibrosis in Systemic Sclerosis: Association With Cardiac Events From a Prospective Cohort Study. Arthritis Rheumatol 2020; 72:1571-1580. [PMID: 32379399 DOI: 10.1002/art.41308] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 04/30/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Myocardial involvement may occur during systemic sclerosis (SSc) and can lead to impaired myocardial contraction and/or arrhythmia. Cardiac magnetic resonance imaging (MRI) is used for noninvasive characterization of the myocardium. The aim of this study was to evaluate the utility of cardiac MRI with intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) and longitudinal relaxation time (T1) sequence mapping for assessment of myocardial microvascular and interstitium impairment in SSc. METHODS In this single-center prospective cohort study, 40 consecutive patients with SSc and 20 healthy controls were assessed by cardiac MRI with IVIM DWI and T1 mapping sequences on a 3T scanning system. Images were analyzed independently by 2 assessors, and Bland-Altman plots were used to assess interreader concordance and reproducibility. Characteristics of the patients were compared according to quartiles of T1 and perfusion fraction (f-coefficient) values, using exact Cochran-Ermitage trend tests for qualitative variables and analysis of variance for quantitative variables. Kaplan-Meier cardiac events-free survival curves were plotted and compared with a log-rank test for trend. RESULTS T1 values were higher in SSc patients than in healthy controls, and were higher in the diffuse cutaneous SSc (dcSSc) subset (P = 0.02). Higher T1 values were associated with the immunologic pattern seen in patients with the dcSSc form (P = 0.0001), a higher modified Rodnan skin thickness score (MRSS) (P = 0.003), and a higher frequency of interstitial lung disease (P = 0.03). Moreover, higher T1 values were correlated with higher MRSS scores (r = +0.32, P = 0.04) and reduced forced vital capacity (r = -0.34, P = 0.048), and tended to be correlated with reduced total lung capacity (r = -0.30, P = 0.07). Lower f-coefficient values, as a measure of decreased tissue perfusion, were associated with less frequent use of vasodilators (P = 0.02 for angiotensin-converting enzyme inhibitors and P = 0.06 for calcium-channel blockers) and more frequent use of glucocorticoids (P = 0.02). The f-coefficients were inversely correlated with the T1 values (r = -0.31, P = 0.02). Furthermore, higher T1 values were associated with higher incidence of cardiac events (log-rank test for trend P = 0.03). CONCLUSION Increased T1 values, potentially suggesting microscopic fibrosis, were observed more frequently in patients with dcSSc, and higher T1 values were associated with interstitial lung disease and more frequent cardiac events during follow-up. The results of this study show that cardiac MRI with T1 mapping sequences and IVIM DWI may be useful in assessing myocardial involvement in patients with SSc.
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Affiliation(s)
- Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, AP-HP, Paris, France
| | | | - Moncef Ben Arfi
- Hôpital Cochin, AP-HP, Paris, France, and American Hospital of Paris, Neuilly-sur-Seine, France
| | - Alice Bérézne
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, Paris, France
| | - Alexis Régent
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bertrand Dunogué
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jonathan London
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pascal Cohen
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Claire Le Jeunne
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | - Olivier Vignaux
- Hôpital Cochin, AP-HP, Paris, France, and American Hospital of Paris, Neuilly-sur-Seine, France
| | - Luc Mouthon
- National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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27
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Sebestyén V, Szűcs G, Páll D, Ujvárosy D, Ötvös T, Csige I, Pataki T, Lőrincz I, Szabó Z. Electrocardiographic markers for the prediction of ventricular arrhythmias in patients with systemic sclerosis. Rheumatology (Oxford) 2020; 59:478-486. [PMID: 31943100 PMCID: PMC7032033 DOI: 10.1093/rheumatology/kez644] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/02/2019] [Indexed: 12/27/2022] Open
Abstract
SSc is an autoimmune disease characterized by microvascular damage, endothelial dysfunction and fibrosis of the skin and the internal organs. Cardiac manifestation in patients with SSc is one of the major organ involvements. Approximately 20% of SSc patients suffer from primary cardiovascular disease and another 20% may have secondary cardiac involvement. Although cardiac arrhythmias are mostly linked to myocardial fibrosis, atrioventricular conduction abnormalities are secondary to the fibrosis of the pulse conduction system. Despite the severe consequences of ventricular rhythm disturbances in patients with SSc, the exact role of electrocardiographic markers in the prediction of these arrhythmias has not yet been clearly elucidated. Therefore, the question is whether certain ECG parameters reflecting ventricular repolarization may help to recognize scleroderma patients with increased risk for ventricular arrhythmias and sudden cardiac death.
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Affiliation(s)
- Veronika Sebestyén
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | | | - Dénes Páll
- Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dóra Ujvárosy
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Tamás Ötvös
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Imre Csige
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Tamás Pataki
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
| | - István Lőrincz
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
| | - Zoltán Szabó
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
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28
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Abstract
Epidemiological studies reporting demographic, clinical and serological factors predictive of various outcomes in systemic sclerosis (SSc) range from the prediction of mortality to the development and progression of disease manifestations. However, predicting the disease trajectory in the individual patient is a challenging but important step towards a stratified approach to disease management. Recent technological advances provide the opportunity for new subgroupings of disease based on risk stratification, through the systematic analysis of high-dimensional clinical data combined with genes, their transcription products and their corresponding translated proteins. In addition, these variables offer a rich vein of research to identify non-invasive biomarkers for predicting organ involvement and to assess disease activity and response to therapy. Selection of patients with a clinical phenotype or molecular signature relevant to the therapy under study combined with recent efforts to standardise outcome measures, show promise for improving clinical trial design and the identification of effective targeted therapies.
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29
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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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30
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Zanatta E, Colombo C, D’Amico G, d’Humières T, Dal Lin C, Tona F. Inflammation and Coronary Microvascular Dysfunction in Autoimmune Rheumatic Diseases. Int J Mol Sci 2019; 20:ijms20225563. [PMID: 31703406 PMCID: PMC6888405 DOI: 10.3390/ijms20225563] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 02/07/2023] Open
Abstract
Autoimmune rheumatic diseases (ARDs) form a heterogeneous group of disorders that include systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), idiopathic inflammatory myopathies (IIMs), and systemic vasculitis. Coronary microvascular dysfunction (CMD) is quite common in patients with ARDs and is linked to increased cardiovascular morbidity and mortality. Inflammation plays a crucial role in the pathogenesis of both accelerated atherosclerosis and CMD in ARDs, especially in patients affected by SLE and RA. In this regard, some studies have highlighted the efficacy of immunosuppressants and/or biologics in restoring CMD in these patients. By contrast, the role of inflammation in the pathogenesis of CMD-SSc appears to be much less relevant compared to endothelial dysfunction and microvascular ischemia, with calcium-channel blockers providing some benefits. Few studies have endeavored to assess the occurrence of CMD in IIMs and systemic vasculitis, thus warranting further investigations. The present review summarizes the current evidence on the occurrence of CMD in ARDs, focusing on the role of inflammation and possible therapeutic approaches.
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Affiliation(s)
| | - Claudia Colombo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Gianpiero D’Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Thomas d’Humières
- Department of Cardiovascular Physiology, AP-HP, Henri-Mondor Teaching Hospital, 94010 Créteil, France;
| | - Carlo Dal Lin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
| | - Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padua, Italy; (C.C.); (G.D.); (C.D.L.)
- Correspondence:
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31
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McHugh J. Protecting against myocardial disease in SSc. Nat Rev Rheumatol 2019; 15:574. [DOI: 10.1038/s41584-019-0299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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