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Ha FJ, Brown Z, Stevens W, Prior D, Ross L, Ferdowsi N, Nikpour M, Burns AT. N-terminal pro-brain natriuretic peptide is associated with pulmonary hypertension or diastolic dysfunction in patients with systemic sclerosis: An Australian prospective cross-sectional study. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:178-184. [PMID: 39381051 PMCID: PMC11457770 DOI: 10.1177/23971983241249209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/08/2024] [Indexed: 10/10/2024]
Abstract
Introduction Pulmonary arterial hypertension and left ventricular diastolic dysfunction are associated with significant morbidity and mortality in systemic sclerosis. N-terminal pro-brain natriuretic peptide has been proposed as part of composite screening algorithms for pulmonary arterial hypertension. Our aim was to assess the prevalence of pulmonary hypertension and diastolic dysfunction, and evaluate their association with serum N-terminal pro-brain natriuretic peptide in systemic sclerosis patients. Methods Patients with systemic sclerosis were prospectively enrolled to undergo N-terminal pro-brain natriuretic peptide testing and transthoracic echocardiography at a tertiary Australian centre from January to October 2022. We collected demographic and transthoracic echocardiography variables including pulmonary hypertension estimated by tricuspid regurgitant velocity and diastolic dysfunction assessed by the ASE/EACVI 2016 guidelines. Pearson's correlation coefficient was used to evaluate association between N-terminal pro-brain natriuretic peptide and echocardiographic parameters. Results Sixty-one patients were enrolled (median age = 62 years (interquartile range = 55-69 years); 84% female). Two-thirds of patients had limited systemic sclerosis (40/61). Five patients (8%) had high likelihood of pulmonary hypertension by transthoracic echocardiography. Seven patients (11%) had diastolic dysfunction; however, seven patients (11%) had indeterminate diastology. Six patients underwent right heart catheterisation, with five patients diagnosed with pulmonary hypertension. N-terminal pro-brain natriuretic peptide in patients with pulmonary hypertension or diastolic dysfunction was significantly higher (median = 207 and 226 pg/mL, respectively) compared to patients without either condition (median = 69 pg/mL, p = 0.01). N-terminal pro-brain natriuretic peptide showed a statistically significant although limited correlation with estimated pulmonary pressures measured by tricuspid regurgitant velocity (r = 0.44, p = 0.002) and left ventricular filling pressures (r = 0.27, p = 0.04). Conclusion Pulmonary hypertension and diastolic dysfunction are both observed in systemic sclerosis. N-terminal pro-brain natriuretic peptide is associated with both conditions; however, it cannot distinguish between the two disease processes. Right heart catheterisation may be required to make this distinction.
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Affiliation(s)
- Francis J Ha
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
| | - Zoe Brown
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
| | - David Prior
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Laura Ross
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Nava Ferdowsi
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrew T Burns
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Zhou Y, Tabib T, Huang M, Yuan K, Kim Y, Morse C, Sembrat J, Valenzi E, Lafyatis R. Molecular Changes Implicate Angiogenesis and Arterial Remodeling in Systemic Sclerosis-Associated and Idiopathic Pulmonary Hypertension. Arterioscler Thromb Vasc Biol 2024; 44:e210-e225. [PMID: 38841857 PMCID: PMC11269037 DOI: 10.1161/atvbaha.123.320005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication of systemic sclerosis (SSc) and a leading cause of mortality among patients with this disease. PH can also occur as an idiopathic condition (idiopathic pulmonary arterial hypertension). Investigation of transcriptomic alterations in vascular populations is critical to elucidating cellular mechanisms underlying pathobiology of SSc-associated and idiopathic PH. METHODS We analyzed single-cell RNA sequencing profiles of endothelial and perivascular mesenchymal populations from explanted lung tissue of patients with SSc-associated PH (n=16), idiopathic pulmonary arterial hypertension (n=3), and healthy controls (n=15). Findings were validated by immunofluorescence staining of explanted human lung tissue. RESULTS Three disease-associated endothelial populations emerged. Two angiogenic endothelial cell (EC) subtypes markedly expanded in SSc-associated PH lungs: tip ECs expressing canonical tip markers PGF and APLN and phalanx ECs expressing genes associated with vascular development, endothelial barrier integrity, and Notch signaling. Gene regulatory network analysis suggested enrichment of Smad1 (SMAD family member 1) and PPAR-γ (peroxisome proliferator-activated receptor-γ) regulon activities in these 2 populations, respectively. Mapping of potential ligand-receptor interactions highlighted Notch, apelin-APJ (apelin receptor), and angiopoietin-Tie (tyrosine kinase with immunoglobulin-like and EGF-like domains 1) signaling pathways between angiogenic ECs and perivascular cells. Transitional cells, expressing both endothelial and pericyte/smooth muscle cell markers, provided evidence for the presence of endothelial-to-mesenchymal transition. Transcriptional programs associated with arterial endothelial dysfunction implicated VEGF-A (vascular endothelial growth factor-A), TGF-β1 (transforming growth factor beta-1), angiotensin, and TNFSF12 (tumor necrosis factor ligand superfamily member 12)/TWEAK (TNF-related weak inducer of apoptosis) in the injury/remodeling phenotype of PH arterial ECs. CONCLUSIONS These data provide high-resolution insights into the complexity and plasticity of the pulmonary endothelium in SSc-associated PH and idiopathic pulmonary arterial hypertension and provide direct molecular insights into soluble mediators and transcription factors driving PH vasculopathy.
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Affiliation(s)
- Yuechen Zhou
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh; Pittsburgh, PA 15261, USA
- School of Medicine, Tsinghua University; Beijing 100084, China
| | - Tracy Tabib
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh; Pittsburgh, PA 15261, USA
| | - Mengqi Huang
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh; Pittsburgh, PA 15261, USA
| | - Ke Yuan
- Division of Pulmonary Medicine, Boston Children’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Yunhye Kim
- Division of Pulmonary Medicine, Boston Children’s Hospital & Harvard Medical School, Boston, MA 02115, USA
| | - Christina Morse
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh; Pittsburgh, PA 15261, USA
| | - John Sembrat
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA 15261, USA
| | - Eleanor Valenzi
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA 15261, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh; Pittsburgh, PA 15261, USA
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Lui JK, Cozzolino M, Winburn M, Trojanowski MA, Wiener RS, LaValley MP, Bujor AM, Gopal DM, Klings ES. Role of Left Ventricular Dysfunction in Systemic Sclerosis-Related Pulmonary Hypertension. Chest 2024; 165:1505-1517. [PMID: 38128607 PMCID: PMC11177103 DOI: 10.1016/j.chest.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND In systemic sclerosis (SSc), pulmonary hypertension remains a significant cause of morbidity and mortality. Although conventionally classified as group 1 pulmonary arterial hypertension, systemic sclerosis-related pulmonary hypertension (SSc-PH) is a heterogeneous disease. The contribution of left-sided cardiac disease in SSc-PH remains poorly understood. RESEARCH QUESTION How often does left ventricular (LV) dysfunction occur in SSc among patients undergoing right heart catheterization and how does coexistent LV dysfunction with SSc-PH affect all-cause mortality in this patient population? STUDY DESIGN AND METHODS We conducted a retrospective, observational study of 165 patients with SSc who underwent both echocardiography and right heart catheterization. LV dysfunction was identified using LV global longitudinal strain (GLS) on speckle-tracking echocardiography based on a defined threshold of > -18%. SSc-PH was defined by a mean pulmonary artery pressure > 20 mmHg. RESULTS Among patients with SSc who have undergone right heart catheterization, LV dysfunction occurred in 74.2% with SSc-PH and 51.2% without SSc-PH. The median survival of patients with SSc-PH and LV dysfunction was 67.9 (95% CI, 38.3-102.0) months, with a hazard ratio of 12.64 (95% CI, 1.73-92.60) for all-cause mortality when adjusted for age, sex, SSc disease duration, and FVC compared with patients with SSc without pulmonary hypertension with normal LV function. INTERPRETATION LV dysfunction is common in SSc-PH. Patients with SSc-PH and LV dysfunction by LV GLS have increased all-cause mortality. This suggests that LV GLS may be helpful in identifying underlying LV dysfunction and in risk assessment of patients with SSc-PH.
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Affiliation(s)
- Justin K Lui
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
| | - Matthew Cozzolino
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Morgan Winburn
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Marcin A Trojanowski
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Michael P LaValley
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Andreea M Bujor
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Deepa M Gopal
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Elizabeth S Klings
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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Sarı A, Satış H, Ayan G, Küçükşahin O, Kalyoncu U, Fidancı AA, Ayvalı MO, Ata N, Ülgü MM, Birinci Ş, Akdoğan A. Survival in systemic sclerosis associated pulmonary arterial hypertension in the current treatment era-results from a nationwide study. Clin Rheumatol 2024; 43:1919-1925. [PMID: 38676757 DOI: 10.1007/s10067-024-06961-0] [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: 01/03/2024] [Revised: 03/13/2024] [Accepted: 03/26/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a leading cause of mortality in systemic sclerosis (SSc). This nationwide study aims to describe real world treatment characteristics and assess survival rates of patients with SSc-PAH. METHODS In this retrospective cohort study, patients with SSc-PAH were identified from Turkish Ministry of Health National Electronic Database (from January 2016 to September 2022), using ICD-10 codes. Data on demographics, treatment characteristics, and death was collected. Kaplan-Meier curves were used to calculate cumulative probabilities of survival at 1, 3, and 5 years. RESULTS Five hundred forty-seven patients (90.7% female) with SSc-PAH were identified. Median age at PAH diagnosis was 59.9 (50.0-67.4) years. During a median follow-up duration of 3.2 (1.5-4.8) years, 199 (36.4%) deaths occurred. Estimated survival rates at 1, 3, and 5 years were 90.2%, 73.2%, and 56.6%, respectively. Survival was similar among patients with and without interstitial lung disease (p = 0.20). Patients who used immunosuppressives had better survival than those who did not (p < 0.001). No difference was observed in survival rates according to initial PAH-specific treatment regimen (monotherapy or combination) (p = 0.49). CONCLUSION Compared to most of historical cohorts, higher survival rates for SSc-PAH were observed in this study. Early diagnosis of PAH may have contributed to these findings. The impact of immunosuppressive therapy on prognosis of SSc-PAH needs to be further investigated in prospective studies. Key Points • Early diagnosis is pivotal for better outcomes in SSc-PAH. • Implementation of PAH treatment guidelines in routine clinical practice is still poor and should be improved. • Effect of immunosuppressive therapies on disease course has to be defined in SSc-PAH.
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Affiliation(s)
- Alper Sarı
- Department of Rheumatology, Etlik City Hospital, Varlık Neighborhood, Halil Sezai Erkut Street, 06170, Yenimahalle, Ankara, Turkey.
| | - Hasan Satış
- Department of Rheumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Gizem Ayan
- Department of Rheumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Orhan Küçükşahin
- Department of Rheumatology, Yıldırım Beyazıt University, Ankara, Turkey
| | - Umut Kalyoncu
- Department of Rheumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ali Aykut Fidancı
- General Directorate of Information Systems, Ministry of Health, Ankara, Turkey
| | - Mustafa Okan Ayvalı
- General Directorate of Information Systems, Ministry of Health, Ankara, Turkey
| | - Naim Ata
- General Directorate of Information Systems, Ministry of Health, Ankara, Turkey
| | - Mustafa Mahir Ülgü
- General Directorate of Information Systems, Ministry of Health, Ankara, Turkey
| | - Şuayip Birinci
- Deputy Minister of Health, Ministry of Health, Ankara, Turkey
| | - Ali Akdoğan
- Department of Rheumatology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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Distler O, Bonderman D, Coghlan JG, Denton CP, Grünig E, Khanna D, McLaughlin VV, Müller-Ladner U, Pope JE, Vonk MC, Di Scala L, Lemarie JC, Perchenet L, Hachulla É. Performance of DETECT Pulmonary Arterial Hypertension Algorithm According to the Hemodynamic Definition of Pulmonary Arterial Hypertension in the 2022 European Society of Cardiology and the European Respiratory Society Guidelines. Arthritis Rheumatol 2024; 76:777-782. [PMID: 38146100 DOI: 10.1002/art.42791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/14/2023] [Accepted: 12/22/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE The evidence-based DETECT pulmonary arterial hypertension (PAH) algorithm is frequently used in patients with systemic sclerosis (SSc) to help clinicians screen for PAH by using noninvasive data to recommend patient referral to echocardiography and, if applicable, for a diagnostic right-sided heart catheterization. However, the hemodynamic definition of PAH was recently updated in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines. The performance of DETECT PAH in identifying patients with a high risk of PAH according to this new definition was assessed. METHODS In this post hoc analysis of DETECT, which comprised 466 patients with SSc, the performance of the DETECT PAH algorithm in identifying patients with a high risk of PAH as defined in the 2022 ESC/ERS guidelines (mean pulmonary arterial pressure [mPAP] >20 mm Hg, pulmonary capillary wedge pressure [PCWP] ≤15 mm Hg, and pulmonary vascular resistance >2 Wood units) was assessed using summary statistics and was descriptively compared to the known performance of DETECT PAH as defined in 2014, when it was developed (mPAP ≥25 mm Hg and PCWP ≤15 mm Hg). RESULTS The sensitivity of DETECT PAH in identifying patients with a high risk of PAH according to the 2022 ESC/ERS definition was lower (88.2%) compared to the 2014 definition (95.8%). Specificity improved from 47.8% to 50.8%. CONCLUSION The performance of the DETECT algorithm to screen for PAH in patients with SSc is maintained when PAH is defined according to the 2022 ESC/ERS hemodynamic definition, indicating that DETECT remains applicable to screen for PAH in patients with SSc.
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Affiliation(s)
- Oliver Distler
- University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | | | - Ekkehard Grünig
- Heidelberg University Hospital and Deutsches Zentrum für Lungenforschung, Heidelberg, Germany
| | | | | | - Ulf Müller-Ladner
- Justus-Liebig-University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Janet E Pope
- Western University of Canada, London, Ontario, Canada
| | - Madelon C Vonk
- Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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Lammi MR, Mukherjee M, Saketkoo LA, Carey K, Hummers L, Hsu S, Krishnan A, Sandi M, Shah AA, Zimmerman SL, Hassoun PM, Mathai SC. Sildenafil Versus Placebo for Early Pulmonary Vascular Disease in Scleroderma (SEPVADIS): protocol for a randomized controlled trial. BMC Pulm Med 2024; 24:211. [PMID: 38689245 PMCID: PMC11061972 DOI: 10.1186/s12890-024-02892-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 02/01/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a leading cause of death in patients with systemic sclerosis (SSc). An important component of SSc patient management is early detection and treatment of PH. Recently the threshold for the diagnosis of PH has been lowered to a mean pulmonary artery pressure (mPAP) threshold of > 20 mmHg on right heart catheterization (RHC). However, it is unknown if PH-specific therapy is beneficial in SSc patients with mildly elevated pressure (SSc-MEP, mPAP 21-24 mmHg). METHODS The SEPVADIS trial is a randomized, double-blind, placebo-controlled phase 2 trial of sildenafil in SSc-MEP patients with a target enrollment of 30 patients from two academic sites in the United States. The primary outcome is change in six-minute walk distance after 16 weeks of treatment. Secondary endpoints include change in pulmonary arterial compliance by RHC and right ventricular function by cardiac magnetic resonance imaging at 16 weeks. Echocardiography, serum N-terminal probrain natriuretic peptide, and health-related quality of life is being measured at 16 and 52 weeks. DISCUSSION The SEPVADIS trial will be the first randomized study of sildenafil in SSc-MEP patients. The results of this trial will be used to inform a phase 3 study to investigate the efficacy of treating patients with mild elevations in mPAP. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04797286.
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Affiliation(s)
- Matthew R Lammi
- Louisiana State University Health Sciences, 1901 Perdido St, 70112, New Orleans, LA,, USA.
- Comprehensive Pulmonary Hypertension Center, University Medical Center, New Orleans, USA.
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA.
- Johns Hopkins University, Division of Pulmonary and Critical Care Medicine, Baltimore, USA.
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, Baltimore, USA
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA
- Tulane University School of Medicine, New Orleans, USA
| | - Kyle Carey
- Institute for Clinical and Translational Medicine, Johns Hopkins University, Baltimore, USA
| | - Laura Hummers
- Johns Hopkins University, Division of Rheumatology, Baltimore, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University, Baltimore, USA
| | - Amita Krishnan
- Louisiana State University Health Sciences, 1901 Perdido St, 70112, New Orleans, LA,, USA
- Comprehensive Pulmonary Hypertension Center, University Medical Center, New Orleans, USA
| | - Marie Sandi
- Louisiana State University Health Sciences, 1901 Perdido St, 70112, New Orleans, LA,, USA
| | - Ami A Shah
- Johns Hopkins University, Division of Rheumatology, Baltimore, USA
| | - Stefan L Zimmerman
- Johns Hopkins University, Department of Radiology and Radiological Science, Baltimore, USA
| | - Paul M Hassoun
- Johns Hopkins University, Division of Pulmonary and Critical Care Medicine, Baltimore, USA
| | - Steven C Mathai
- Johns Hopkins University, Division of Pulmonary and Critical Care Medicine, Baltimore, USA
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Distler O, Ofner C, Huscher D, Jordan S, Ulrich S, Stähler G, Grünig E, Held M, Ghofrani HA, Claussen M, Lange TJ, Klose H, Rosenkranz S, Vonk-Noordegraaf A, Vizza CD, Delcroix M, Opitz C, Pausch C, Scelsi L, Neurohr C, Olsson KM, Coghlan JG, Halank M, Skowasch D, Behr J, Milger K, Remppis BA, Skride A, Jureviciene E, Gumbiene L, Miliauskas S, Löffler-Ragg J, Wilkens H, Pittrow D, Hoeper MM, Ewert R. Treatment strategies and survival of patients with connective tissue disease and pulmonary arterial hypertension: a COMPERA analysis. Rheumatology (Oxford) 2024; 63:1139-1146. [PMID: 37462520 PMCID: PMC10986797 DOI: 10.1093/rheumatology/kead360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/27/2023] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) occurs in various connective tissue diseases (CTDs). We sought to assess contemporary treatment patterns and survival of patients with various forms of CTD-PAH. METHODS We analysed data from COMPERA, a European pulmonary hypertension registry, to describe treatment strategies and survival in patients with newly diagnosed PAH associated with SSc, SLE, MCTD, UCTD and other types of CTD. All-cause mortality was analysed according to the underlying CTD. For patients with SSc-PAH, we also assessed survival according to initial therapy with endothelin receptor antagonists (ERAs), phosphodiesterase type 5 inhibitors (PDE5is) or a combination of these two drug classes. RESULTS This analysis included 607 patients with CTD-PAH. Survival estimates at 1, 3 and 5 years for SSc-PAH (n = 390) were 85%, 59% and 42%; for SLE-PAH (n = 34) they were 97%, 77% and 61%; for MCTD-PAH (n = 33) they were 97%, 70% and 59%; for UCTD-PAH (n = 60) they were 88%, 67% and 52%; and for other CTD-PAH (n = 90) they were 92%, 69% and 55%, respectively. After multivariable adjustment, the survival of patients with SSc-PAH was significantly worse compared with the other conditions (P = 0.001). In these patients, the survival estimates were significantly better with initial ERA-PDE5i combination therapy than with initial ERA or PDE5i monotherapy (P = 0.016 and P = 0.012, respectively). CONCLUSIONS Mortality remains high in patients with CTD-PAH, especially for patients with SSc-PAH. However, for patients with SSc-PAH, our results suggest that long-term survival may be improved with initial ERA-PDE5i combination therapy compared with initial monotherapy.
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Affiliation(s)
- Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christian Ofner
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology, and Berlin Institute of Health, Charité-Universitätsmedizin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Suzana Jordan
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerd Stähler
- Klinik für Pneumologie, Klinik Fachklinik Löwenstein, Löwenstein, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research, Heidelberg, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - H Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center, Giessen, Germany
| | - Martin Claussen
- Fachabteilung Pneumologie, LungenClinic Großhansdorf, Großhansdorf, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans Klose
- Department of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine and the Cologne Cardiovascular Research Center, University of Cologne, Cologne, Germany
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - C Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven–University of Leuven, Leuven, Belgium
| | - Christian Opitz
- Department of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - Christine Pausch
- GWT-TUD GmbH, Innovation Center Real World Evidence, Dresden, Germany
| | - Laura Scelsi
- Fondazione IRCSS S. Matteo Pavia, Division of Cardiology Stolfo Davide, Azienda Sanitaria Universitaria Giuliano Isontina, Pavia, Italy
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Robert-Bosch-Krankenhaus Stuttgart, Stuttgart, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center of Lung Research, Gießen, Germany
| | | | - Michael Halank
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus of Technical University Dresden, Dresden, Germany
| | - Dirk Skowasch
- Innere Medizin–Kardiologie/Pneumologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Jürgen Behr
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research, Munich, Germany
| | - Katrin Milger
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research, Munich, Germany
| | | | - Andris Skride
- VSIA Pauls Stradins Clinical University Hospital, Riga, Lativa
| | - Elena Jureviciene
- Faculty of Medicine of Vilnius University, Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Lina Gumbiene
- Faculty of Medicine of Vilnius University, Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Skaidrius Miliauskas
- Department of Pulmonology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Judith Löffler-Ragg
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Heinrike Wilkens
- Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - David Pittrow
- GWT-TUD GmbH, Innovation Center Real World Evidence, Dresden, Germany
- Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center of Lung Research, Gießen, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Department of Respiratory Medicine, Universitätsmedizin Greifswald, Germany
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Seki N, Tsujimoto H, Tanemura S, Ishigaki S, Takei H, Sugahara K, Yoshimoto K, Akiyama M, Kaneko Y, Chiba K, Takeuchi T. Th17/IL-17A axis is critical for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc): SSc patients with high levels of serum IL-17A exhibit reduced lung functions and increased prevalence of PAH. Cytokine 2024; 176:156534. [PMID: 38354516 DOI: 10.1016/j.cyto.2024.156534] [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: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND It is thought that systemic sclerosis (SSc) might be a T helper 17 (Th17) cell-driven autoimmune disease. Noticeably, pulmonary arterial hypertension (PAH) is a leading cause of death in patients with SSc. Here, we investigated the association between serum Th17-related cytokines and prevalence of PAH in SSc patients. METHODS This study included 72 SSc patients and 51 healthy controls (HC). We determined clinical manifestations, immunophenotypes including Th subsets in peripheral blood lymphocytes, and the serum levels of interleukin (IL)-17A, IL-17A/F, IL-17B. IL-17C, IL-17D. IL-1β, IL-6, IL-21, IL-22, and IL-23. RESULTS The frequency of Th17 cells was significantly increased in SSc patients compared to HC and was positively correlated with the modified Rodnan skin scores. Furthermore, the serum levels of IL-17A, IL-17D, IL-1β, and IL-6 were significantly increased in SSc patients compared to HC. SSc patients with detected IL-17A showed high levels of IL-17A/F, IL-1β, IL-6, and IL-22, and high frequency of Th17 cells. Interestingly, these patients exhibited the reduced lung functions and increased prevalence of PAH significantly compared to patients with undetected IL-17A. Similarly, SSc patients with detected IL-17A and high IL-6 (≥1.2 pg/mL) exhibited the decreased lung functions and increased prevalence of PAH compared to patients with undetected IL-17A and low IL-6. CONCLUSION We found that SSc patients with high levels of serum IL-17A or both IL-17A and IL-6 show reduced lung functions and high prevalence of PAH. Consequently, it is highly probable that Th17/IL-17A axis is critical for the prevalence of PAH in SSc patients.
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Affiliation(s)
- Noriyasu Seki
- Research Unit Immunology & Inflammation, Innovative Research division, Mitsubishi Tanabe Pharma Corporation, Yokohama, Kanagawa 227-0033, Japan; Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hideto Tsujimoto
- Research Unit Immunology & Inflammation, Innovative Research division, Mitsubishi Tanabe Pharma Corporation, Yokohama, Kanagawa 227-0033, Japan; Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Shuhei Tanemura
- Research Unit Immunology & Inflammation, Innovative Research division, Mitsubishi Tanabe Pharma Corporation, Yokohama, Kanagawa 227-0033, Japan; Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Sho Ishigaki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hiroshi Takei
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kunio Sugahara
- Research Unit Immunology & Inflammation, Innovative Research division, Mitsubishi Tanabe Pharma Corporation, Yokohama, Kanagawa 227-0033, Japan; Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Keiko Yoshimoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kenji Chiba
- Research Unit Immunology & Inflammation, Innovative Research division, Mitsubishi Tanabe Pharma Corporation, Yokohama, Kanagawa 227-0033, Japan; Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan.
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan; Saitama Medical University, Iruma-gun, Saitama 350-0495, Japan
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Gegenava M, Gegenava T. Association of pulmonary hypertension with outcomes in patients with Systemic sclerosis and other connective tissue disorders: review and meta-analysis. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2024; 41:e2024023. [PMID: 38567564 PMCID: PMC11008328 DOI: 10.36141/svdld.v41i1.14570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIM Pulmonary hypertension (PH) is a frequent complication of connective tissue disorders (CTDs), with a major impact on the prognosis of the disease. The aim of our study was to perform a systemic review and meta-analysis of published literature evaluating survival function in patients with systemic sclerosis (SSc) with and without PH and to compare survival function between patients with SSc, systemic lupus erythematosus (SLE), other CTDs, and conditions associated with PH. METHODS The established protocol of the Cochrane Collaboration Steps and meta-analysis of observational studies in epidemiology recommendations (MOOSE) were used. RESULTS 7 studies, including 1470 SSc-PH patients and 1368 SSc patients without PH, and 4 studies, including 108 SLE-PH patients and 1288 SLE patients without PH, assessed survival function were selected. Six studies (including 777 SSc, 249 SLE, 90 idiopathic pulmonary arterial hypertension (IPAH) and 29 primary Sjogren's syndrome patients) comparing survival function in different subgroups of patients with confirmed PH were included. SSc patients with PH showed the worst survival as compared to SSc patients without PH [OR (95% CI) 3.70 (2.42-5.67); p<0.00001]. The same pattern was observed in patients with SLE. SSc patients with PH were characterized by lower survival function compared to other reasons for PH, including SLE [OR (95% CI) 2.76 (1.95-3.91); p<0.00001]. CONCLUSIONS Patients with SSc-PH are characterized by significantly lower survival function as compared to SSc patients without PH. Among the different entities of PH, SSc shows the worst survival, underlining prognostic significance of detection and evaluation of PH according to the currently established approach.
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Affiliation(s)
- Maka Gegenava
- Department of Internal Medicine N°2, Tbilisi State Medical University, Tbilisi, Georgia
| | - Tea Gegenava
- Department of Internal Medicine N°1, Tbilisi State Medical University, Tbilisi, Georgia
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Shi H, Gao P, Liu H, Su J, He X. Diagnostic value of combined FVC%/DLCO% and echocardiography in connective tissue disorder‑associated pulmonary hypertension. MEDICINE INTERNATIONAL 2024; 4:8. [PMID: 38283134 PMCID: PMC10811443 DOI: 10.3892/mi.2024.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024]
Abstract
The main objective of the present study was to investigate whether forced vital capacity (FVC)%/diffusing capacity of the lungs for carbon monoxide (DLCO)% can be used to predict the presence of pulmonary hypertension (PH) in connective tissue disorders (CTDs). For this purpose, a total of 53 individuals who were diagnosed with CTDs and had undergone right heart catheterization between July, 2019 and July, 2022 were included in the present study. Based on the mean pulmonary artery pressure (mPAP) measured during right heart catheterization, the participants were divided into the PH and non-PH groups. The differences in demographic characteristics, including sex, age, body mass index, smoking index, FVC%/DLCO% and pulmonary artery systolic pressure (PASP) were determined by echocardiography; moreover, the 6-min walk distance, plasma brain natriuretic peptide (BNP) levels, white blood cell count, red blood cell distribution width, erythrocyte sedimentation rate and C-reactive protein levels were compared between the two groups to identify independent predictors of PH. The independent predictors were subsequently evaluated for their correlation with mPAP to assess their predictive value for PH. FVC%/DLCO%, echocardiographic PASP, and plasma BNP levels were identified as independent predictors of PH. FVC%/DLCO% and echocardiographic PASP exhibited a significant correlation with mPAP, while the correlation between plasma BNP and mPAP levels was not statistically significant. The area under the curve (AUC) value for FVC%/DLCO% alone in predicting PH was 0.791, with an optimal diagnostic threshold of 1.35, a sensitivity of 0.794 and a specificity of 0.789. The AUC for echocardiographic PASP alone in predicting PH was 0.783, with an optimal diagnostic threshold of 39.5 mmHg, a sensitivity of 0.794 and a specificity of 0.684. When combined, the AUC of the two factors in predicting PH was 0.872, with a sensitivity of 0.941 and a specificity of 0.684. Collectively, the data of the present study indicate that FVC%/DLCO% may be used as a predictive factor for CTD-PH, and its combined application with echocardiographic PASP measurement may provide additional evidence for the clinical diagnosis of CTD-PH.
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Affiliation(s)
- Huimin Shi
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Pengfei Gao
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Huijin Liu
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Jie Su
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
| | - Xuegai He
- The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan 471003, P.R. China
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Chen X, Quan R, Qian Y, Yang Z, Yu Z, Zhang C, Yang Y, Zhang G, Shen J, Wang Q, Gu Q, Xiong C, Jing X, Han H, He J. 10-year survival of pulmonary arterial hypertension associated with connective tissue disease: insights from a multicentre PAH registry. Rheumatology (Oxford) 2023; 62:3555-3564. [PMID: 36912696 PMCID: PMC10629783 DOI: 10.1093/rheumatology/kead103] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES To report the 10-year survival rate and prognostic factors of pulmonary arterial hypertension associated with CTD (CTD-PAH) patients, to compare treatment and survival between patients enrolled before and after 2015, and to validate the discrimination of the recommended four-strata model in predicting 10-year survival at follow-up in Chinese CTD-PAH patients. METHODS This study was derived from a Chinese national multicentre prospective registry study from 2009 to 2019. Medical records were collected at baseline and follow-up, including PAH-targeted therapy and binary therapy (both CTD and PAH-targeted therapy). RESULTS A total of 266 CTD-PAH patients were enrolled and the 10-year survival rate was 59.9% (median follow-up time: 4.85 years). Underlying CTD (SSc), baseline 6-min walking distance and SaO2 were independent risk factors for 10-year survival. The proportion of patients receiving PAH-targeted combination therapy increased from 10.1% (2009-2014) to 26.5% (2015-2019) and that of binary therapy increased from 14.8% to 35%. The 1-year survival rate increased from 89.8% (2009-2014) to 93.9%, and the 3-year survival rate increased from 80.1% (2009-2014) to 86.5% (both P > 0.05). The four-strata strategy performed well in predicting 10-year survival at follow-up (C-index = 0.742). CONCLUSION The 10-year survival rate of CTD-PAH patients was reported for the first time. The 10-year prognosis was poor, but there was a tendency for more standardized treatment and better survival in patients enrolled after 2015. The recommended four-strata model at follow-up can effectively predict 10-year survival in CTD-PAH patients.
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Affiliation(s)
- Xiaoxi Chen
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Ruilin Quan
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Yuling Qian
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China
| | - Caojin Zhang
- Department of Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhua Yang
- Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Gangcheng Zhang
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, China
| | - Jieyan Shen
- Department of Cardiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Gu
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Changming Xiong
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Xiaoli Jing
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
| | - Huijun Han
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo He
- Department of Pulmonary Vascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease, Beijing, China
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Simpson CE, Ambade AS, Harlan R, Roux A, Aja S, Graham D, Shah AA, Hummers LK, Hemnes AR, Leopold JA, Horn EM, Berman-Rosenzweig ES, Grunig G, Aldred MA, Barnard J, Comhair SAA, Tang WHW, Griffiths M, Rischard F, Frantz RP, Erzurum SC, Beck GJ, Hill NS, Mathai SC, Hassoun PM, Damico RL. Kynurenine pathway metabolism evolves with development of preclinical and scleroderma-associated pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2023; 325:L617-L627. [PMID: 37786941 PMCID: PMC11068393 DOI: 10.1152/ajplung.00177.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023] Open
Abstract
Understanding metabolic evolution underlying pulmonary arterial hypertension (PAH) development may clarify pathobiology and reveal disease-specific biomarkers. Patients with systemic sclerosis (SSc) are regularly surveilled for PAH, presenting an opportunity to examine metabolic change as disease develops in an at-risk cohort. We performed mass spectrometry-based metabolomics on longitudinal serum samples collected before and near SSc-PAH diagnosis, compared with time-matched SSc subjects without PAH, in a SSc surveillance cohort. We validated metabolic differences in a second cohort and determined metabolite-phenotype relationships. In parallel, we performed serial metabolomic and hemodynamic assessments as the disease developed in a preclinical model. For differentially expressed metabolites, we investigated corresponding gene expression in human and rodent PAH lungs. Kynurenine and its ratio to tryptophan (kyn/trp) increased over the surveillance period in patients with SSc who developed PAH. Higher kyn/trp measured two years before diagnostic right heart catheterization increased the odds of SSc-PAH diagnosis (OR 1.57, 95% CI 1.05-2.36, P = 0.028). The slope of kyn/trp rise during SSc surveillance predicted PAH development and mortality. In both clinical and experimental PAH, higher kynurenine pathway metabolites correlated with adverse pulmonary vascular and RV measurements. In human and rodent PAH lungs, expression of TDO2, which encodes tryptophan 2,3 dioxygenase (TDO), a protein that catalyzes tryptophan conversion to kynurenine, was significantly upregulated and tightly correlated with pulmonary hypertensive features. Upregulated kynurenine pathway metabolism occurs early in PAH, localizes to the lung, and may be modulated by TDO2. Kynurenine pathway metabolites may be candidate PAH biomarkers and TDO warrants exploration as a potential novel therapeutic target.NEW & NOTEWORTHY Our study shows an early increase in kynurenine pathway metabolism in at-risk subjects with systemic sclerosis who develop pulmonary arterial hypertension (PAH). We show that kynurenine pathway upregulation precedes clinical diagnosis and that this metabolic shift is associated with increased disease severity and shorter survival times. We also show that gene expression of TDO2, an enzyme that generates kynurenine from tryptophan, rises with PAH development.
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Affiliation(s)
- Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Anjira S Ambade
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Robert Harlan
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Aurelie Roux
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Susan Aja
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - David Graham
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, United States
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Cornell University Medical Center, New York, New York, United States
| | - Erika S Berman-Rosenzweig
- Division of Pediatric Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Gabriele Grunig
- Divisions of Environmental and Pulmonary Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States
| | - Micheala A Aldred
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - John Barnard
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Suzy A A Comhair
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - W H Wilson Tang
- Division of Heart Failure and Transplant Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, United States
| | - Megan Griffiths
- Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Franz Rischard
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, Arizona, United States
| | - Robert P Frantz
- Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Serpil C Erzurum
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Gerald J Beck
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts University, Boston, Massachusetts, United States
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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Khangoora V, Bernstein EJ, King CS, Shlobin OA. Connective tissue disease-associated pulmonary hypertension: A comprehensive review. Pulm Circ 2023; 13:e12276. [PMID: 38088955 PMCID: PMC10711418 DOI: 10.1002/pul2.12276] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/13/2023] [Accepted: 07/30/2023] [Indexed: 10/16/2024] Open
Abstract
Connective tissue diseases (CTDs) can be associated with various forms of pulmonary hypertension, including pulmonary arterial hypertension (PAH), pulmonary veno-occlusive disease, pulmonary venous hypertension, interstitial lung disease-associated pulmonary hypertension, chronic thromboembolic pulmonary hypertension, and sometimes a combination of several processes. The prevalence of PAH varies among the different CTDs, with systemic sclerosis (SSc) having the highest at 8%-12%. The most recent European Society of Cardiology/European Respiratory Society guidelines recommend routine annual screening for PAH in SSc and CTDs with SSc features. As CTDs can be associated with a myriad of presentations of pulmonary hypertension, a thorough evaluation to include a right heart catheterization to clearly delineate the hemodynamic profile is essential in developing an appropriate treatment plan. Treatment strategies will depend on the predominant phenotype of pulmonary vasculopathy. In general, management approach to CTD-PAH mirrors that of idiopathic PAH. Despite this, outcomes of CTD-PAH are inferior to those of idiopathic PAH, with those of SSc-PAH being particularly poor. Reasons for this may include extrapulmonary manifestations of CTDs, including renal disease and gastrointestinal involvement, concurrent interstitial lung disease, and differences in the innate response of the right ventricle to increased pulmonary vascular resistance. Early referral for lung transplant evaluation of patients with CTD-PAH, particularly SSc-PAH, is recommended. It is hoped that in the near future, additional therapies may be added to the armamentarium of effective treatments for CTD-PAH. Ultimately, a better understanding of the pathogenesis of CTD-PAH will be required to develop targeted therapies for this morbid condition.
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Affiliation(s)
- Vikramjit Khangoora
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Elana J. Bernstein
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Christopher S. King
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
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14
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Kularatne M, Boucly A, Savale L, Solinas S, Cheron C, Roche A, Jevnikar M, Jaïs X, Montani D, Humbert M, Sitbon O. Pharmacological management of connective tissue disease-associated pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:2101-2115. [PMID: 37869785 DOI: 10.1080/14656566.2023.2273395] [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: 07/05/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, progressive pulmonary vasculopathy (Group 1 Pulmonary Hypertension (PH)) that complicates the course of many connective tissue diseases (CTD). Detailed testing is required to differentiate PAH from other types of PH caused by CTD such as left heart disease (Group 2 PH), pulmonary parenchymal disease (Group 3 PH), and chronic thromboembolic pulmonary hypertension (Group 4 PH). PAH is most frequently seen in systemic sclerosis but can also be seen with systemic lupus erythematosus, mixed CTD, and primary Sjogren's syndrome. AREAS COVERED This review discusses the epidemiology of CTD-associated PAH, outlines the complex diagnosis approach, and finishes with an in-depth discussion on the current treatment paradigm. Focus is placed on challenges faced in the treatment of CTD-associated PAH, (decreased efficacy and poorer tolerance of pharmacological therapies) and includes a discussion on the future investigational treatments. EXPERT OPINION Despite significant advances over the past decades with more aggressive treatment algorithms, CTD-associated PAH patients continue to have poorer survival compared to those with idiopathic PAH. This review highlights factors leading to disparate outcomes compared to other forms of PAH, and discusses on further improvements that may increase quality of life and survival for CTD-associated PAH patients.
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Affiliation(s)
- Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Céline Cheron
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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15
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Fairley JL, Hansen D, Ross L, Proudman S, Sahhar J, Ngian GS, Walker J, Host LV, Morrisroe K, Apostolopoulous D, Ferdowsi N, Wilson M, Tabesh M, Stevens W, Nikpour M. Clinical characteristics and survival of pulmonary arterial hypertension with or without interstitial lung disease in systemic sclerosis. Arthritis Res Ther 2023; 25:77. [PMID: 37173780 PMCID: PMC10176744 DOI: 10.1186/s13075-023-03059-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES To describe the clinical phenotype and prognosis of people in the Australian Scleroderma (SSc) Cohort Study with pulmonary arterial hypertension (PAH) with or without interstitial lung disease (ILD). METHODS Participants meeting ACR/EULAR criteria for SSc were divided into four mutually exclusive groups: those meeting criteria for PAH (PAH-only), ILD (ILD-only), concurrent PAH and ILD (PAH-ILD) or neither PAH nor ILD (SSc-only). Logistic or linear regression analyses were used for associations between clinical features, health-related quality of life (HRQoL) and physical function. Survival analysis was performed using Kaplan-Meier estimates and Cox-regression modelling. RESULTS Of 1561 participants, 7% fulfilled criteria for PAH-only, 24% ILD-only, 7% PAH-ILD and 62% SSc-only. People with PAH-ILD were more frequently male, with diffuse skin involvement, higher inflammatory markers, older age of SSc onset and higher frequency of extensive ILD than the cohort overall (p < 0.001). People of Asian race more frequently developed PAH-ILD (p < 0.001). People with PAH-ILD or PAH-only had worse WHO functional class and 6-min-walk-distance than ILD-only (p < 0.001). HRQoL scores were worst in those with PAH-ILD (p < 0.001). Survival was reduced in the PAH-only and PAH-ILD groups (p < 0.01). Multivariable hazard modelling demonstrated the worst prognosis in extensive ILD and PAH (HR = 5.65 95% CI 3.50-9.12 p < 0.01), followed by PAH-only (HR = 4.21 95% CI 2.89-6.13 p < 0.01) and PAH with limited ILD (HR = 2.46 95% CI 1.52-3.99 p < 0.01). CONCLUSIONS The prevalence of concurrent PAH-ILD in the ASCS is 7%, with poorer survival in those patients with PAH-ILD compared to ILD or SSc alone. The presence of PAH confers a poorer overall prognosis than even extensive ILD; however, further data are required to better understand the clinical outcomes of this high-risk patient group.
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Affiliation(s)
- Jessica L Fairley
- The University of Melbourne at St. Vincent's Hospital, 41 Victoria Parade Fitzroy, Melbourne, VIC, 3065, Australia
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Dylan Hansen
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Laura Ross
- The University of Melbourne at St. Vincent's Hospital, 41 Victoria Parade Fitzroy, Melbourne, VIC, 3065, Australia
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Susanna Proudman
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joanne Sahhar
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Gene-Siew Ngian
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Jennifer Walker
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Kathleen Morrisroe
- The University of Melbourne at St. Vincent's Hospital, 41 Victoria Parade Fitzroy, Melbourne, VIC, 3065, Australia
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Diane Apostolopoulous
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Nava Ferdowsi
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Michelle Wilson
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Maryam Tabesh
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Wendy Stevens
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital, 41 Victoria Parade Fitzroy, Melbourne, VIC, 3065, Australia.
- St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
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16
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Sánchez-Aguilera Sánchez-Paulete P, Lázaro Salvador M, Berenguel Senén A, Méndez Perles C, Rodríguez Padial L. Role of cardiopulmonary exercise test in early diagnosis of pulmonary hypertension in scleroderma patients. Med Clin (Barc) 2023; 160:283-288. [PMID: 36049974 DOI: 10.1016/j.medcli.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, high mortality and progressive disease. Early diagnosis and treatment improves the prognosis. Patients with scleroderma disease presents high risk of developing PAH. Established screening strategies - echocardiogram and DETECT algorithm - recognize the disease when it is already advanced. Cardiopulmonary exercise testing (CPET) detects pulmonary vascular injury in earlier stages. METHODS Prospective study of 52 consecutive patients diagnosed of scleroderma in our health area, during 2 years (2018 and 2019). All of them undergo CPET, in addition to the annual systematic screening. Sensitivity of current PAH screening is compared to CPET. To confirm the presence of PAH, right heart catheterization (RHC) is performed. In case of suspected PAH in CPET, but non-confirmatory right heart catheterization at rest, patients carried out exercise RHC. RESULTS Fifty-two CPET were performed, of which 16 suggested PAH. Resting RHC confirmed PAH in 5 patients and exercise RHC in 7 (diagnostic sensitivity of CPET together with rest and exercise catheterization of 100%). Of these 16 patients, DETECT had identified 10, of whom resting RHC confirmed PAH in 3 and exercise RHC in 2 (guideline-based diagnostic algorithm sensitivity 70%). CONCLUSIONS CPET and exercise RHC could detect PAH earlier than established screening in patients with scleroderma disease, allowing early diagnosis.
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17
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Ouchene L, Muntyanu A, Assayag D, Veilleux È, Abril A, Ferrara G, Yacyshyn E, Pineau CA, O'Brien E, Baron M, Osman M, Gniadecki R, Netchiporouk E. Skin disorders and interstitial lung disease: Part II-The spectrum of cutaneous diseases with lung disease association. J Am Acad Dermatol 2023; 88:767-782. [PMID: 36228940 DOI: 10.1016/j.jaad.2022.09.051] [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: 06/30/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
Part 2 of this 2-part CME introduces dermatologists to noninfectious inflammatory skin diseases associated with pulmonary involvement. In many cases, dermatologists may be the first physicians recognizing respiratory complications associated with these diagnoses. Because pulmonary involvement is often the leading cause of morbidity and mortality, dermatologists should be comfortable screening and monitoring for lung disease in high-risk patients, recognizing cutaneous stigmata of lung disease in these patients and referring to pulmonary specialists, when appropriate, for prompt treatment initiation. Some treatments used for skin disease may not be appropriate in the context of lung disease and hence, choosing a holistic approach is important. Interstitial lung disease and pulmonary hypertension are the most common pulmonary complications and a significant cause of mortality in autoimmune connective tissue diseases, especially systemic sclerosis, dermatomyositis, and mixed connective tissue disease. Pulmonary complications, notably interstitial lung disease, are also common and life-threatening in sarcoidosis and vasculitis, while they are variable in neutrophilic and autoimmune blistering diseases.
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Affiliation(s)
- Lydia Ouchene
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Anastasiya Muntyanu
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Deborah Assayag
- Division of Pulmonary Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Èvicka Veilleux
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Yacyshyn
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Christian A Pineau
- Division of Rheumatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Elizabeth O'Brien
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Murray Baron
- Division of Rheumatology, McGill University Health Centre, Montréal, Québec, Canada
| | - Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
| | - Elena Netchiporouk
- Division of Dermatology, McGill University Health Centre, Montréal, Québec, Canada.
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18
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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19
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Moccaldi B, De Michieli L, Binda M, Famoso G, Depascale R, Perazzolo Marra M, Doria A, Zanatta E. Serum Biomarkers in Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24044178. [PMID: 36835590 PMCID: PMC9967966 DOI: 10.3390/ijms24044178] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening complication of connective tissue diseases (CTDs) characterised by increased pulmonary arterial pressure and pulmonary vascular resistance. CTD-PAH is the result of a complex interplay among endothelial dysfunction and vascular remodelling, autoimmunity and inflammatory changes, ultimately leading to right heart dysfunction and failure. Due to the non-specific nature of the early symptoms and the lack of consensus on screening strategies-except for systemic sclerosis, with a yearly transthoracic echocardiography as recommended-CTD-PAH is often diagnosed at an advanced stage, when the pulmonary vessels are irreversibly damaged. According to the current guidelines, right heart catheterisation is the gold standard for the diagnosis of PAH; however, this technique is invasive, and may not be available in non-referral centres. Hence, there is a need for non-invasive tools to improve the early diagnosis and disease monitoring of CTD-PAH. Novel serum biomarkers may be an effective solution to this issue, as their detection is non-invasive, has a low cost and is reproducible. Our review aims to describe some of the most promising circulating biomarkers of CTD-PAH, classified according to their role in the pathophysiology of the disease.
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Affiliation(s)
- Beatrice Moccaldi
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Marco Binda
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-0498212190
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
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20
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Lewis C, Sanderson R, Vasilottos N, Zheutlin A, Visovatti S. Pulmonary Arterial Hypertension in Connective Tissue Diseases Beyond Systemic Sclerosis. Heart Fail Clin 2023; 19:45-54. [DOI: 10.1016/j.hfc.2022.08.016] [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: 11/24/2022]
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21
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Zhao J, Wang Q, Deng X, Qian J, Tian Z, Liu Y, Li M, Zeng X. The treatment strategy of connective tissue disease associated pulmonary arterial hypertension: Evolving into the future. Pharmacol Ther 2022; 239:108192. [DOI: 10.1016/j.pharmthera.2022.108192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
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22
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Sangani RA, Lui JK, Gillmeyer KR, Trojanowski MA, Bujor AM, LaValley MP, Klings ES. Clinical characteristics and outcomes in pulmonary manifestations of systemic sclerosis: Contribution from pulmonary hypertension and interstitial lung disease severity. Pulm Circ 2022; 12:e12117. [PMID: 36238967 PMCID: PMC9535436 DOI: 10.1002/pul2.12117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 06/11/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Patients with systemic sclerosis complicated by both pulmonary hypertension (SSc-PH) and interstitial lung disease (SSc-PH-ILD) have poor prognosis compared to those with SSc-PH or SSc-ILD alone. Little is known of how ILD severity affects outcomes in those with SSc-PH, or how PH severity affects outcomes in those with SSc-ILD. Herein, we aimed to delineate clinical features of patients with SSc-PH and SSc-ILD and determine to what degree PH and ILD severity contribute to mortality in patients with SSc. We conducted parallel retrospective studies in cohorts of patients with SSc-PH and SSc-ILD. We categorized ILD severity by pulmonary function testing and PH severity by cardiopulmonary hemodynamics. Our primary outcome was all-cause mortality from time of PH or ILD diagnosis for the SSc-PH and SSc-ILD cohorts, respectively. We calculated adjusted risks of time to all-cause mortality using Cox proportional hazards models. In patients with SSc-PH, severe ILD (HR: 3.54; 95% CI: 1.05, 11.99) was associated with increased hazards for all-cause mortality. By contrast, mild and moderate ILD were not associated with increased mortality risk. In patients with SSc-ILD, both moderate (HR: 2.65; 95% CI: 1.12, 6.31) and severe PH (HR: 6.60; 95% CI: 2.98, 14.61) were associated with increased hazards for all-cause mortality, while mild PH was not. Through our parallel study design, the risk of all-cause mortality increases as severity of concomitant ILD or PH worsens. Therapies that target slowing disease progression earlier in the disease course may be beneficial.
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Affiliation(s)
- Ruchika A. Sangani
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Justin K. Lui
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
- Department of BiostatisticsBoston University School of Public HealthBostonMassachusettsUSA
| | - Kari R. Gillmeyer
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Marcin A. Trojanowski
- Arthritis and Autoimmune Diseases CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Andreea M. Bujor
- Arthritis and Autoimmune Diseases CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Michael P. LaValley
- Department of BiostatisticsBoston University School of Public HealthBostonMassachusettsUSA
- Arthritis and Autoimmune Diseases CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Elizabeth S. Klings
- The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
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23
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Aurangabadkar GM, Aurangabadkar MY, Choudhary SS, Ali SN, Khan SM, Jadhav US. Pulmonary Manifestations in Rheumatological Diseases. Cureus 2022; 14:e29628. [PMID: 36321051 PMCID: PMC9612897 DOI: 10.7759/cureus.29628] [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: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Pulmonary involvement complicates the various aspects of care in patients suffering from autoimmune disorders. The epidemiological data generated over the last 10 to 15 years have improved the overall understanding of the risk factors and pathophysiological mechanisms involved in pulmonary involvement in rheumatological conditions. Recent advances in genetics have provided superior insight into the pathogenesis of autoimmune diseases and the underlying pulmonary involvement. This review article provides a concise overview of the four most common rheumatological conditions associated with pulmonary involvement: systemic lupus erythematosus (SLE), dermatomyositis/polymyositis, rheumatoid arthritis (RA), and systemic sclerosis (SSc). The clinical, epidemiological, and genetic aspects of these diseases are summarized in this article with particular emphasis on the characteristic patterns of pulmonary involvement in radiological imaging and various treatment options for each of these autoimmune diseases and their lung manifestations.
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24
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Bonomi F, Peretti S, Lepri G, Venerito V, Russo E, Bruni C, Iannone F, Tangaro S, Amedei A, Guiducci S, Matucci Cerinic M, Bellando Randone S. The Use and Utility of Machine Learning in Achieving Precision Medicine in Systemic Sclerosis: A Narrative Review. J Pers Med 2022; 12:1198. [PMID: 35893293 PMCID: PMC9331823 DOI: 10.3390/jpm12081198] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is a rare connective tissue disease that can affect different organs and has extremely heterogenous presentations. This complexity makes it difficult to perform an early diagnosis and a subsequent subclassification of the disease. This hinders a personalized approach in clinical practice. In this context, machine learning (ML), a branch of artificial intelligence (AI), is able to recognize relationships in data and predict outcomes. METHODS Here, we performed a narrative review concerning the application of ML in SSc to define the state of art and evaluate its role in a precision medicine context. RESULTS Currently, ML has been used to stratify SSc patients and identify those at high risk of severe complications. Additionally, ML may be useful in the early detection of organ involvement. Furthermore, ML might have a role in target therapy approach and in predicting drug response. CONCLUSION Available evidence about the utility of ML in SSc is sparse but promising. Future improvements in this field could result in a big step toward precision medicine. Further research is needed to define ML application in clinical practice.
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Affiliation(s)
- Francesco Bonomi
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Silvia Peretti
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Gemma Lepri
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Vincenzo Venerito
- Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari Aldo Moro, 70121 Bari, Italy; (V.V.); (F.I.)
| | - Edda Russo
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Cosimo Bruni
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
- Department of Rheumatology, University Hospital of Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari Aldo Moro, 70121 Bari, Italy; (V.V.); (F.I.)
| | - Sabina Tangaro
- Department of Soil, Plant and Food Sciences, University of Bari Aldo Moro, Istituto Nazionale di Fisica Nucleare, Sezione di Bari, 70121 Bari, Italy;
| | - Amedeo Amedei
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Serena Guiducci
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
| | - Marco Matucci Cerinic
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Silvia Bellando Randone
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (S.P.); (G.L.); (E.R.); (C.B.); (A.A.); (S.G.); (M.M.C.)
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25
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Xanthouli P, Miazgowski J, Benjamin N, Gordjani O, Egenlauf B, Harutyunova S, Seeger R, Marra AM, Blank N, Lorenz HM, Grünig E, Eichstaedt CA. Prognostic meaning of right ventricular function and output reserve in patients with systemic sclerosis. Arthritis Res Ther 2022; 24:173. [PMID: 35864554 PMCID: PMC9306074 DOI: 10.1186/s13075-022-02863-1] [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: 03/22/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study was to investigate the prognostic impact of right ventricular (RV) function at rest and during exercise in patients with systemic sclerosis (SSc) presenting for a screening for pulmonary hypertension (PH). Methods In this study, data from SSc patients who underwent routinely performed examinations for PH screening including echocardiography and right heart catheterization at rest and during exercise were analysed. Uni- and multivariable analyses were performed to identify prognostic parameters. Results Out of 280 SSc patients screened for PH, 225 were included in the analysis (81.3% female, mean age 58.1±13.0 years, 68% limited cutaneous SSc, WHO-FC II–III 74%, 24 manifest PH). During the observation period of 3.2±2.7 (median 2.6) years 35 patients died. Tricuspid annular plane systolic excursion (TAPSE) at rest <18 mm (p=0.001), RV output reserve as increase of cardiac index (CI) during exercise <2 l/min (p<0.0001), RV pulmonary vascular reserve (Δ mean pulmonary artery pressure/Δ cardiac output) ≥3 mmHg/l/min (p<0.0001), peak CI <5.5 l/min/m2 (p=0.001), pulmonary arterial compliance <2 ml/mmHg (p=0.002), TAPSE/systolic pulmonary arterial pressure (sPAP) ratio ≤0.6 ml/mmHg (p<0.0001) and echocardiographic qualitative RV function at rest (p<0.0001) significantly predicted worse survival. In the multivariable analysis TAPSE/sPAP ratio and diffusion capacity for carbon monoxide ≤65% were identified as independent prognostic predictors and had 75% sensitivity and 69% specificity to predict future development of pulmonary vascular disease (PVD) during follow-up. Conclusions This study demonstrates that assessment of RV function at rest and during exercise may provide crucial information to identify SSc patients who are at a high risk of poor outcome and for the development of PH and/or PVD.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Miazgowski
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Ojan Gordjani
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Rebekka Seeger
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University and School of Medicine, Naples, Italy
| | - Norbert Blank
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany. .,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany. .,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
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26
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Rodriguez-Arias JJ, García-Álvarez A. Sex Differences in Pulmonary Hypertension. FRONTIERS IN AGING 2022; 2:727558. [PMID: 35822006 PMCID: PMC9261364 DOI: 10.3389/fragi.2021.727558] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) includes multiple diseases that share as common characteristic an elevated pulmonary artery pressure and right ventricular involvement. Sex differences are observed in practically all causes of PH. The most studied type is pulmonary arterial hypertension (PAH) which presents a gender bias regarding its prevalence, prognosis, and response to treatment. Although this disease is more frequent in women, once affected they present a better prognosis compared to men. Even if estrogens seem to be the key to understand these differences, animal models have shown contradictory results leading to the birth of the estrogen paradox. In this review we will summarize the evidence regarding sex differences in experimental animal models and, very specially, in patients suffering from PAH or PH from other etiologies.
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Affiliation(s)
| | - Ana García-Álvarez
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, IDIBAPS, Madrid, Spain.,Universidad de Barcelona, Barcelona, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Madrid, Spain
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27
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Wang RR, Yuan TY, Wang JM, Chen YC, Zhao JL, Li MT, Fang LH, Du GH. Immunity and inflammation in pulmonary arterial hypertension: From pathophysiology mechanisms to treatment perspective. Pharmacol Res 2022; 180:106238. [DOI: 10.1016/j.phrs.2022.106238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 02/08/2023]
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28
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Ng SA, Low AHL. Systemic sclerosis in Asians: Are there racial differences? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:98-109. [PMID: 35585950 PMCID: PMC9109507 DOI: 10.1177/23971983221074749] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/28/2021] [Indexed: 10/08/2023]
Abstract
Systemic sclerosis is a multisystemic autoimmune disease characterized by vasculopathy and fibrosis. Racial factors exert a significant influence on the epidemiology, clinical manifestations, antibody profile, mortality and genetic factors in systemic sclerosis. In this review, we examined Asian systemic sclerosis cohorts reported in Asia and multi-racial cohort studies to evaluate the disease characteristics and outcomes of systemic sclerosis in Asians. Asian patients have distinct genetic susceptibility to systemic sclerosis, younger age of systemic sclerosis onset, higher frequency of diffuse skin involvement, different autoantibody profiles such as higher frequency of anti-Scl70 and anti-U1-RNP antibodies, and more severe clinical phenotype. There was a suggestion of poorer survival among Asians that may be contributed by more severe disease, socioeconomic factors and differences in healthcare systems. Recognizing the influence of racial differences in systemic sclerosis disease course is important as it has implications for appropriate treatment, monitoring and prognostication.
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Affiliation(s)
- Sue-Ann Ng
- Department of Rheumatology and
Immunology, Singapore General Hospital, Singapore
- Duke-National University of Singapore,
Singapore
| | - Andrea Hsiu Ling Low
- Department of Rheumatology and
Immunology, Singapore General Hospital, Singapore
- Duke-National University of Singapore,
Singapore
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29
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Abstract
IMPORTANCE Pulmonary arterial hypertension (PAH) is a subtype of pulmonary hypertension (PH), characterized by pulmonary arterial remodeling. The prevalence of PAH is approximately 10.6 cases per 1 million adults in the US. Untreated, PAH progresses to right heart failure and death. OBSERVATIONS Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 20 mm Hg and is classified into 5 clinical groups based on etiology, pathophysiology, and treatment. Pulmonary arterial hypertension is 1 of the 5 groups of PH and is hemodynamically defined by right heart catheterization demonstrating a mean pulmonary artery pressure greater than 20 mm Hg, a pulmonary artery wedge pressure of 15 mm Hg or lower, and a pulmonary vascular resistance of 3 Wood units or greater. Pulmonary arterial hypertension is further divided into subgroups based on underlying etiology, consisting of idiopathic PAH, heritable PAH, drug- and toxin-associated PAH, pulmonary veno-occlusive disease, PAH in long-term responders to calcium channel blockers, and persistent PH of the newborn, as well as PAH associated with other medical conditions including connective tissue disease, HIV, and congenital heart disease. Early presenting symptoms are nonspecific and typically consist of dyspnea on exertion and fatigue. Currently approved therapy for PAH consists of drugs that enhance the nitric oxide-cyclic guanosine monophosphate biological pathway (sildenafil, tadalafil, or riociguat), prostacyclin pathway agonists (epoprostenol or treprostinil), and endothelin pathway antagonists (bosentan and ambrisentan). With these PAH-specific therapies, 5-year survival has improved from 34% in 1991 to more than 60% in 2015. Current treatment consists of combination drug therapy that targets more than 1 biological pathway, such as the nitric oxide-cyclic guanosine monophosphate and endothelin pathways (eg, ambrisentan and tadalafil), and has shown demonstrable improvement in morbidity and mortality compared with the previous conventional single-pathway targeted monotherapy. CONCLUSIONS AND RELEVANCE Pulmonary arterial hypertension affects an estimated 10.6 per 1 million adults in the US and, without treatment, typically progresses to right heart failure and death. First-line therapy with drug combinations that target multiple biological pathways are associated with improved survival.
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Affiliation(s)
- Nicole F Ruopp
- Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Barbara A Cockrill
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Xiong A, Liu Q, Zhong J, Cao Y, Xiang Q, Hu Z, Zhou S, Song Z, Chen H, Zhang Y, Cui H, Shuai S. Increased risk of mortality in systemic sclerosis-associated pulmonary hypertension: a systemic review and meta-analysis. Adv Rheumatol 2022; 62:10. [PMID: 35354494 DOI: 10.1186/s42358-022-00239-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a frequent complication of systemic sclerosis (SSc) and is currently one of the primary causes of death in patients with this disease. We conducted a systematic review and meta-analysis to assess the association between PH and mortality in patients with SSc to verify trends in mortality in patients with SSc-associated PH. METHODS We searched the PubMed and Embase databases for published studies on SSc-associated PH from inception to May 2021. All cohort studies in which mortality and/or survival for SSc-associated PH were reported were included in the analysis. The outcome parameters were pooled and analyzed using a random-effects model via generic inverse-variance weighting in conventional and cumulative meta-analysis. RESULTS The literature search identified 1161 citations, and the full texts of 54 studies were examined. Sixteen articles, with a total of 7857 patients with SSc and 1140 patients with SSc-associated PH, were included in the meta-analysis. Patients with SSc-associated PH had a higher pooled risk of mortality than patients with SSc without PH (risk ratio = 3.12; 95% confidence interval: [2.44, 3.98]). CONCLUSIONS This meta-analysis revealed a higher mortality in patients with SSc-associated PH. PH was a significant predictor of death in patients with SSc. Thus, early diagnosis and treatment of PH are important in patients with SSc.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China. .,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China.
| | - Qingting Liu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Jiaxun Zhong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Yuzi Cao
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Qilang Xiang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Ziyi Hu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Shifeng Zhou
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Huini Chen
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Yan Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Hongxu Cui
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, 97 Renmin South Road, Shunqing District, Nanchong, Sichuan, China.,Inflammation and Immunology Key Laboratory of Nanchong, Nanchong, Sichuan, China
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31
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Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension. Sci Rep 2022; 12:5289. [PMID: 35347225 PMCID: PMC8960788 DOI: 10.1038/s41598-022-09353-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/11/2022] [Indexed: 11/08/2022] Open
Abstract
To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 ± 20.6% vs 93.6 ± 20.6%, P < 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 ± 5.2 mm vs 19.9 ± 6.7 mm, P < 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P < 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P < 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment.
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sPAP/PAAT Ratio as a New Index of Pulmonary Vascular Load: A Study in Normal Subjects and Ssc Patients with and without PH. PATHOPHYSIOLOGY 2022; 29:134-142. [PMID: 35366295 PMCID: PMC8949923 DOI: 10.3390/pathophysiology29010012] [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: 01/28/2022] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
In pulmonary hypertension (PH), the development of right ventricular (RV) dilatation and RV failure are signs of accelerated progression of the disease, resulting in an increased risk of cardiac death. Even the noninvasive assessment of systolic blood pressure in the pulmonary artery undertaken by echocardiography does not provide a measure of ventricle–pulmonary interaction. Some studies have shown the potential for echocardiography to indirectly evaluate pulmonary vascular resistance (PVR) and the acceleration time of pulmonary outflow (PAAT). We used systolic pulmonary artery pressure (sPAP) and pulmonary vascular resistance to develop an sPAP/PAAT ratio (strength/surface unit)/(time) for this study. From January 2017 to December 2018, 60 healthy subjects and 63 patients with systemic scleroderma (Ssc) (60 females, 3 males), 27 with PH and 36 without PH at two-dimensional echocardiographic/Doppler, were screened. In normal subjects, the mean sPAP/PAAT ratio was 0.26 ± 0.063, which indicated optimal pulmonary arterial ventricle coupling and biventricular function. The data derived from the analysis of the Ssc patients showed that those presenting pre-capillary PH at cardiac catheterization had an sPAP/PAAT ratio of 0.40 ± 0.05. There was a significant correlation between sPAP/PAAT with Walk Distance (WD) and PVR, but not with TAPSE. Interobserver variability was less than 5%. The sPAP/PAAT ratio is a new parameter that may indicate pulmonary vascular afterload and interaction, both in normal subjects and in patients with Ssc and PH.
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33
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Mohri T, Goda A, Takeuchi K, Kikuchi H, Inami T, Kohno T, Sakata K, Soejima K, Satoh T. High prevalence of occult left ventricular diastolic dysfunction detected by exercise stress test in systemic sclerosis. Sci Rep 2022; 12:2423. [PMID: 35165319 PMCID: PMC8844378 DOI: 10.1038/s41598-022-06400-7] [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: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the poor prognosis of systemic sclerosis (SSc) due to the co-occurrence of left ventricular diastolic dysfunction (LVDD), presence of occult LVDD has not been sufficiently investigated. This retrospective study aimed to reveal the prevalence and determinants of occult LVDD in patients with SSc by exercise stress test. Forty-five SSc patients (age, 63 ± 13 years; men/women, 6/39) with normal pulmonary artery pressure and pulmonary artery wedge pressure (PAWP) at rest underwent a symptom-limited exercise test with right heart catheterization using a supine cycle ergometer; haemodynamic parameters at rest, leg raise and during exercise were evaluated. Occult LVDD defined PAWP ≥ 25 mmHg during exercise was seen in 13 patients (29%). Higher PAWP, lower pulmonary vascular resistance and diastolic pulmonary pressure gradient, larger left atrium at rest, and higher PAWP during leg raise (15 ± 4 vs 10 ± 4 mmHg in non-LVDD group, p < 0.001) were observed in the occult LVDD group. The area under the ROC curve for PAWP after leg raise was largest at 0.83 (95% CI: 0.70–0.95, p = 0.001). About one-third (29%) of SSc patients with normal haemodynamics at rest showed occult LVDD. A higher PAWP after leg raise could be useful for detecting occult LVDD.
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Clinical phenotypes, hemodynamic characteristics and prognosis of Chinese patients with systemic sclerosis-associated precapillary pulmonary hypertension: a retrospective study. Clin Rheumatol 2022; 41:1675-1686. [PMID: 35099674 DOI: 10.1007/s10067-021-06016-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/17/2021] [Accepted: 12/04/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is associated with interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). This study aimed to explore the prevalence, clinical features, hemodynamic characteristics and prognosis of different severity of ILD in a cohort of patients with SSc-associated precapillary pulmonary hypertension (SSc-PH) and investigate the differences between SSc-PAH and idiopathic pulmonary arterial hypertension (IPAH) patients. METHOD SSc-PH patients and IPAH patients, admitted to Shanghai Pulmonary Hospital (August 1, 2008-January 31, 2020) and diagnosed by right-sided heart catheterization (RHC) or echocardiography, were retrospectively included. SSc-PH patients had a baseline chest high-resolution computed tomography (HRCT), and PH classification was based on the extent of ILD. Clinical, pulmonary function, hemodynamic characteristics and survival data were extracted. RESULTS The study included 45 SSc-PH patients (60% had coexisting ILD and 77.8% were SSc-Group 1 PH/SSc-PAH [without ILD or with mild ILD], 22.2% were SSc-Group 3 PH/SSc-PH with severe ILD) and 52 IPAH patients. SSc-PH with ILD had lower arterial oxygen partial pressure (PaO2) than those without ILD. Hemodynamic characteristics and survival rates were comparable between SSc-PAH with mild ILD and those without ILD. SSc-Group 3 PH had lower pulmonary vascular resistance (PVR) and more severe restrictive ventilatory dysfunction than SSc-Group 1 PH, but the survival rate was equally poor. SSc-PAH had a poorer prognosis than IPAH patients despite the better hemodynamic characteristics. CONCLUSIONS ILD was common in SSc-PH patients. Careful phenotyping of PH in SSc-PH patients is very important as it is imperative to recognize its impact on clinical course, treatment and survival. KEY POINTS • ILD was common in Chinese SSc-PH patients. • SSc-PH patients with ILD had lower PaO2 than those without ILD. • Hemodynamic characteristics and survival rates were similar in SSc-PAH patients with mild ILD and those without ILD. • Patients in SSc-Group 3 PH had lower pulmonary vascular resistance (PVR) and more severe restrictive ventilatory dysfunction than those in SSc-Group 1 PH, but the survival rate was equally poor. SSc-PAH patients had a poorer prognosis than IPAH patients despite their better hemodynamic characteristics.
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35
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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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36
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Benfaremo D, Svegliati S, Paolini C, Agarbati S, Moroncini G. Systemic Sclerosis: From Pathophysiology to Novel Therapeutic Approaches. Biomedicines 2022; 10:biomedicines10010163. [PMID: 35052842 PMCID: PMC8773282 DOI: 10.3390/biomedicines10010163] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 12/30/2022] Open
Abstract
Systemic sclerosis (SSc) is a systemic, immune-mediated chronic disorder characterized by small vessel alterations and progressive fibrosis of the skin and internal organs. The combination of a predisposing genetic background and triggering factors that causes a persistent activation of immune system at microvascular and tissue level is thought to be the pathogenetic driver of SSc. Endothelial alterations with subsequent myofibroblast activation, excessive extracellular matrix (ECM) deposition, and unrestrained tissue fibrosis are the pathogenetic steps responsible for the clinical manifestations of this disease, which can be highly heterogeneous according to the different entity of each pathogenic step in individual subjects. Although substantial progress has been made in the management of SSc in recent years, disease-modifying therapies are still lacking. Several molecular pathways involved in SSc pathogenesis are currently under evaluation as possible therapeutic targets in clinical trials. These include drugs targeting fibrotic and metabolic pathways (e.g., TGF-β, autotaxin/LPA, melanocortin, and mTOR), as well as molecules and cells involved in the persistent activation of the immune system (e.g., IL4/IL13, IL23, JAK/STAT, B cells, and plasma cells). In this review, we provide an overview of the most promising therapeutic targets that could improve the future clinical management of SSc.
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Affiliation(s)
- Devis Benfaremo
- Clinica Medica, Department of Internal Medicine, Ospedali Riuniti “Umberto I-G.M. Lancisi-G. Salesi”, 60126 Ancona, Italy;
| | - Silvia Svegliati
- Department of Clinical and Molecular Sciences, Marche Polytechnic University, 60126 Ancona, Italy; (S.S.); (C.P.); (S.A.)
| | - Chiara Paolini
- Department of Clinical and Molecular Sciences, Marche Polytechnic University, 60126 Ancona, Italy; (S.S.); (C.P.); (S.A.)
| | - Silvia Agarbati
- Department of Clinical and Molecular Sciences, Marche Polytechnic University, 60126 Ancona, Italy; (S.S.); (C.P.); (S.A.)
| | - Gianluca Moroncini
- Clinica Medica, Department of Internal Medicine, Ospedali Riuniti “Umberto I-G.M. Lancisi-G. Salesi”, 60126 Ancona, Italy;
- Department of Clinical and Molecular Sciences, Marche Polytechnic University, 60126 Ancona, Italy; (S.S.); (C.P.); (S.A.)
- Correspondence:
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37
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Kolstad KD, Khatri A, Donato M, Chang SE, Li S, Steen VD, Utz PJ, Khatri P, Chung L. Cytokine signatures differentiate systemic sclerosis patients at high versus low risk for pulmonary arterial hypertension. Arthritis Res Ther 2022; 24:39. [PMID: 35139913 PMCID: PMC8827262 DOI: 10.1186/s13075-022-02734-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/01/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) affects approximately 10% of patients with systemic sclerosis (SSc) and is a leading cause of death. We sought to identify serum cytokine signatures that risk stratify SSc patients for this potentially fatal complication. METHODS Subjects at high risk for PAH and with incident PAH based on right heart catheterization (RHC) were enrolled in the multi-center prospective registry, Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS). Low-risk SSc patients were enrolled at Stanford and had normal pulmonary function test and echocardiogram parameters. Serum was available from 71 high-risk patients, 81 incident PAH patients, 10 low-risk patients, and 20 healthy controls (HC). Custom 14- and 65-plex arrays were used for cytokine analysis. Cytokine expression was compared between patient groups by principal component analysis and Tukey's test result. A multiple hypotheses corrected p value <0.05 was considered significant. RESULTS Exploratory analysis using principal components showed unique clustering for each patient group. There was a significant difference in cytokine expression in at least one group comparison for every cytokine. Overall, there was very little difference in cytokine expression comparing high-risk and PAH patient groups; however, these groups had substantially different cytokine profiles compared to low-risk patients and HC. CONCLUSION These data suggest that cytokine profiles can distinguish SSc patients who are at high-risk for or have PAH from SSc patients who may be at lower risk for PAH and HC. However, high-risk and PAH patients had very similar cytokine profiles, suggesting that these patients are on a disease continuum.
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Affiliation(s)
- Kathleen D. Kolstad
- grid.168010.e0000000419368956Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA USA ,grid.19006.3e0000 0000 9632 6718Department of Medicine, Division of Rheumatology, University of California Los Angeles, Los Angeles, CA USA
| | - Avani Khatri
- grid.168010.e0000000419368956Institute for Immunity, Transplantation, and Infection, Stanford University, Palo Alto, CA USA
| | - Michele Donato
- grid.168010.e0000000419368956Institute for Immunity, Transplantation, and Infection, Stanford University, Palo Alto, CA USA
| | - Sarah E. Chang
- grid.168010.e0000000419368956Institute for Immunity, Transplantation, and Infection, Stanford University, Palo Alto, CA USA
| | - Shufeng Li
- grid.168010.e0000000419368956Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA USA
| | - Virginia D. Steen
- grid.411667.30000 0001 2186 0438Division of Rheumatology, Georgetown University Medical Center, Washington, DC USA
| | - Paul J. Utz
- grid.168010.e0000000419368956Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA USA
| | - Purvesh Khatri
- grid.168010.e0000000419368956Institute for Immunity, Transplantation, and Infection, Stanford University, Palo Alto, CA USA ,grid.168010.e0000000419368956Department of Medicine, Center for Biomedical Informatics Research, Stanford University, Palo Alto, CA USA
| | - Lorinda Chung
- grid.168010.e0000000419368956Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA USA ,grid.280747.e0000 0004 0419 2556Department of Medicine, Division of Rheumatology, Palo Alto VA Health Care System, Palo Alto, CA USA
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Tyagi R, Kant S, Pradhan A, Wakhlu A, Bajaj DK, Bajpai J. Estimates of Prevalence of Pulmonary Hypertension according to Different International Definitions. Can Respir J 2021; 2021:1385322. [PMID: 34876943 PMCID: PMC8645389 DOI: 10.1155/2021/1385322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background Pulmonary hypertension is a dreaded disease associated with considerable morbidity and mortality. The pulmonary hypertension developing due to chronic respiratory disease is a unique subset with symptoms often getting masqueraded by the underlying respiratory condition. The importance of early detection of this complication has been realized worldwide, and recently, the definition of pulmonary hypertension was revised to set the cutoff of mean pulmonary artery pressure (mPAP) at 20 mmHg instead of 25 mmHg at rest. In our study, we have tried to estimate the difference this new definition brings to the prevalence of pulmonary hypertension among interstitial lung disease patients at our centre. Methods This was a cross-sectional study in which all the patients of ILDs (n = 239) attending the outdoor and indoor Department of Respiratory Medicine, King George's Medical University, India, for the duration of one year were subjected to transthoracic echocardiography along with measurement of serum pro-B-type natriuretic peptide (BNP) and troponin T values. The data were analyzed using the different definitions, and the prevalence was compared. Result Incidence of pulmonary hypertension among ILD patients at mPAP cutoff ≥ 25 was 28.9%, while that at value ≥20 mmHg, incidence of pulmonary hypertension increased to 46.0%. An increment of 15-20% in incidence of pulmonary hypertension was observed among different types of ILD when cutoff of mPAP was changed. Conclusion The new definition helps in a significant increase in the detection of pulmonary hypertension, which certainly helps in earlier detection and better management of patients.
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Affiliation(s)
- Richa Tyagi
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Surya Kant
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, UP, India
| | - Anupam Wakhlu
- Department of Rheumatology, King George's Medical University, Lucknow, UP, India
| | - Darshan Kumar Bajaj
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Jyoti Bajpai
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
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Xu B, Xu G, Yu Y, Lin J. The role of TGF-β or BMPR2 signaling pathway-related miRNA in pulmonary arterial hypertension and systemic sclerosis. Arthritis Res Ther 2021; 23:288. [PMID: 34819148 PMCID: PMC8613994 DOI: 10.1186/s13075-021-02678-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/07/2021] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication of connective tissue disease (CTD), causing death in systemic sclerosis (SSc). The past decade has yielded many scientific insights into microRNA (miRNAs) in PAH and SSc. This growth of knowledge has well-illustrated the complexity of microRNA (miRNA)-based regulation of gene expression in PAH. However, few miRNA-related SSc-PAH were elucidated. This review firstly discusses the role of transforming growth factor-beta (TGF-β) signaling and bone morphogenetic protein receptor type II (BMPR2) in PAH and SSc. Secondly, the miRNAs relating to TGF-β and BMPR2 signaling pathways in PAH and SSc or merely PAH were subsequently summarized. Finally, future studies might develop early diagnostic biomarkers and target-oriented therapeutic strategies for SSc-PAH and PAH treatment.
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Affiliation(s)
- Bei Xu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, People's Republic of China, 310003
| | - Guanhua Xu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, People's Republic of China, 310003
| | - Ye Yu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, People's Republic of China, 310003
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province, People's Republic of China, 310003.
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40
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Hughes M, Zanatta E, Sandler RD, Avouac J, Allanore Y. Improvement with time of vascular outcomes in systemic sclerosis: a systematic review and meta-analysis study. Rheumatology (Oxford) 2021; 61:2755-2769. [PMID: 34791057 DOI: 10.1093/rheumatology/keab850] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/15/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Vascular disease in systemic sclerosis (SSc) is associated with significant morbidity and mortality. Preliminary data may lead to the suggestion of a modifiable unified-vascular endophenotype. Our aim was to determine whether the prevalence, mortality, and severity of SSc-vascular disease have changed over time. METHODS We performed a systematic review and meta-analysis of the literature in PubMed 1950-2019 related to SSc-digital ulcers (DUs), pulmonary artery hypertension (PAH) and scleroderma renal crisis (SRC). We included full-text articles and extracted study characteristics and assessed risk of bias/quality. We examined the prevalence, mortality, and surrogate measures of SSc-associated vascular disease severity. RESULTS We included 55 studies in our meta-analysis. The pooled prevalence of DUs (41.0%), PAH (9.5%) and SRC (4.9%) remained largely stable over time. There was significant improvement in PAH 1-year (p= 0.001) and SRC mortality (P = <0.001), but not PAH 3-year (p= 0.312) or 5-year (p= 0.686) mortality. The prevalence of DU healing did not significantly change (p= 0.265). There was a trend (all P=∼0.1) towards improvement in PAH surrogates: mean pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure. For SRC, there was evidence that the overall frequency of dialysis (66.7%, p= 0.297) and permanent dialysis (34.5%, p= 0.036) increased over time. CONCLUSION Despite the heterogeneity and scarcity of the disease, there have been major improvements obtained in the various vascular complications in SSc leading to benefit in survival. This is supported by a trend towards improvement in several surrogate markers and demonstrates that progresses in vascular management translate into major patient benefit.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Robert D Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Jérôme Avouac
- Rhumatologie, Hôpital Cochin, APHP, Université de Paris, Paris, France
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, AP-HP, Paris Descartes University, Paris, France
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41
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Song J, Chen Y, Cui Y, Kong X, Liu J, Cao Y, Zhou X, Wetzl J, Shi H. Evaluation and Comparison of Quantitative Right Ventricular Strain Assessment by Cardiac Magnetic Resonance in Pulmonary Hypertension Using Feature Tracking and Deformable Registration Algorithms. Acad Radiol 2021; 28:e306-e313. [PMID: 32624401 DOI: 10.1016/j.acra.2020.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE AND OBJECTIVE Deformable registration algorithms (DRA) has been used to detect left ventricular myocardial changes, however, its clinical utility in right ventricular (RV) function has not been evaluated. In this study, we aim to evaluate and compare quantitative RV strain assessment by cardiac magnetic resonance in pulmonary hypertension (PH) using feature tracking (FT) and DRA. MATERIALS AND METHODS Thirty patients were confirmed to have PH using right heart catheterization, and 16 healthy controls were evaluated with cardiac magnetic resonance. Global and segmental RV strain was measured by DRA and FT methods. Intraclass correlation coefficients (ICCs), coefficient of variation, and Bland-Altman analysis were used to assess and compare the interobserver and intraobserver variability of the DRA and FT methods. RESULTS DRA was more sensitive than FT in the detection of RV circumferential and septal dysfunction. The global longitudinal strain (GLS) obtained by the two methods was reduced in mild-moderate PH patients (mean pulmonary artery pressure≤45 mm Hg), and the GLS and global circumferential strain (GCS) were reduced in severe PH patients (mean pulmonary artery pressure >45 mm Hg). DRA and FT methods demonstrate similar observer agreement in global strain using ICC (ICC greater than 0.90), but RV strain derived from DRA had lower variability using COV ([8%-14%] for DRA versus [11%-39%] for FT).For segmental longitudinal strain, DRA showed higher ICC and lower COV compared with that of the FT method. Correlations between RVEF and RV global strain parameters were strong (p < 0.01):GLS-DRA, r = -0.696; GLS-FT, r = -0.832; GCS-DRA, r = -0.745; and GCS-FT, r = -0.817. GLS-DRA was weakly correlated with mPAP (r = 0.385, p < 0.05).In multiple linear regression analysis, RVEF and mPAP were independent predictors of GLS-DRA (R2 = 0.57, p < 0.01). CONCLUSIONS The DRA method is more sensitive and robust for RV myocardial strain measurements than FT method.
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Affiliation(s)
- Jing Song
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Yousan Chen
- Department of Radiology, Wuhan General Hospital of Chinese People's Liberation Army, Wuhan, China
| | - Yue Cui
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Xiangchuang Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Jia Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Yukun Cao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ltd, Shanghai, China
| | | | - Heshui Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China.
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42
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Deshwal H, Weinstein T, Sulica R. Advances in the management of pulmonary arterial hypertension. J Investig Med 2021; 69:1270-1280. [PMID: 34580123 PMCID: PMC8485135 DOI: 10.1136/jim-2021-002027] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
The management of pulmonary arterial hypertension (PAH) has significantly evolved over the last decades in the wake of more sensitive diagnostics and specialized clinical programs that can provide focused medical care. In the current era of PAH care, 1-year survival rates have increased to 86%–90% from 65% in the 1980s, and average long-term survival has increased to 6 years from 2.8 years. The heterogeneity in the etiology and disease course has opened doors to focusing research in phenotyping the disease and understanding the pathophysiology at a cellular and genetic level. This may eventually lead to precision medicine and the development of medications that may prevent or reverse pulmonary vascular remodeling. With more insight, clinical trial designs and primary end-points may change to identify the true survival benefit of pharmacotherapy. Identifying responders from non-responders to therapy may help provide individualized patient-centered care rather than an algorithm-based approach. The purpose of this review is to highlight the latest advances in screening, diagnosis, and management of PAH.
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Affiliation(s)
- Himanshu Deshwal
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Tatiana Weinstein
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Roxana Sulica
- Pulmonary, Sleep and Critical Care Medicine, New York University Grossman School of Medicine, New York, New York, USA
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West J, Rathinasabapathy A, Chen X, Shay S, Gladson S, Talati M. Overexpression of Msx1 in Mouse Lung Leads to Loss of Pulmonary Vessels Following Vascular Hypoxic Injury. Cells 2021; 10:cells10092306. [PMID: 34571956 PMCID: PMC8471093 DOI: 10.3390/cells10092306] [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: 07/02/2021] [Revised: 08/11/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive lung disease caused by thickening of the pulmonary arterial wall and luminal obliteration of the small peripheral arteries leading to increase in vascular resistance which elevates pulmonary artery pressure that eventually causes right heart failure and death. We have previously shown that transcription factor Msx1 (mainly expressed during embryogenesis) is strongly upregulated in transformed lymphocytes obtained from PAH patients, especially IPAH. Under pathological conditions, Msx1 overexpression can cause cell dedifferentiation or cell apoptosis. We hypothesized that Msx1 overexpression contributes to loss of small pulmonary vessels in PAH. In IPAH lung, MSX1 protein localization was strikingly increased in muscularized remodeled pulmonary vessels, whereas it was undetectable in control pulmonary arteries. We developed a transgenic mouse model overexpressing MSX1 (MSX1OE) by about 4-fold and exposed these mice to normoxic, sugen hypoxic (3 weeks) or hyperoxic (100% 02 for 3 weeks) conditions. Under normoxic conditions, compared to controls, MSX1OE mice demonstrated a 30-fold and 2-fold increase in lung Msx1 mRNA and protein expression, respectively. There was a significant retinal capillary dropout (p < 0.01) in MSX1OE mice, which was increased further (p < 0.03) with sugen hypoxia. At baseline, the number of pulmonary vessels in MSX1OE mice was similar to controls. In sugen-hypoxia-treated MSX1OE mice, the number of small (0-25 uM) and medium (25-50 uM) size muscularized vessels increased approximately 2-fold (p < 0.01) compared to baseline controls; however, they were strikingly lower (p < 0.001) in number than in sugen-hypoxia-treated control mice. In MSX1OE mouse lung, 104 genes were upregulated and 67 genes were downregulated compared to controls. Similarly, in PVECs, 156 genes were upregulated and 320 genes were downregulated from siRNA to MSX1OE, and in PVSMCs, 65 genes were upregulated and 321 genes were downregulated from siRNA to MSX1OE (with control in the middle). Many of the statistically significant GO groups associated with MSX1 expression in lung, PVECs, and PVSMCs were similar, and were involved in cell cycle, cytoskeletal and macromolecule organization, and programmed cell death. Overexpression of MSX1 suppresses many cell-cycle-related genes in PVSMCs but induces them in PVECs. In conclusion, overexpression of Msx1 leads to loss of pulmonary vessels, which is exacerbated by sugen hypoxia, and functional consequences of Msx1 overexpression are cell-dependent.
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Affiliation(s)
| | | | | | | | | | - Megha Talati
- Correspondence: ; Tel.: +1-615-322-8095; Fax: +1-615-343-7448
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44
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Genin V, Horeau-Langlard D, Diot E, Gagnadoux F, Lavigne C, Fournet M, Durant C, Agard C. [Characteristics of patients with connective tissue disease-associated pulmonary arterial hypertension treated with prostanoids: A multicenter retrospective study]. Rev Med Interne 2021; 42:825-831. [PMID: 34462153 DOI: 10.1016/j.revmed.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/18/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe complication of connective tissue disease (CTD). Data on use of prostanoids in this particular subset of patients are lacking. We aimed to describe the characteristics of patients with PAH-CTD treated with prostanoids and the outcomes under treatment. METHODS In this multicenter retrospective study, all patients treated with prostanoids since 2006 were included. Data on PAH and CTD were collected at the time of prostanoid introduction and under treatment. RESULTS Twenty-one patients were included, of whom 20 (95%) had limited cutaneous systemic sclerosis. Nineteen patients were treated with oral monotherapy or combination before addition of prostanoid. Treprostinil was the most used molecule (57% of patients). At the time of prostanoid introduction, 90% of patients were considered at high risk for death. Among patients who had right heart catheterization during follow-up, there was no significant difference in haemodynamics. No extrarespiratory worsening of the CTD was reported. The 1-year survival under prostanoid was 62%. In univariate analysis, NYHA functional class was associated with survival under treatment. CONCLUSION This study provides original data on use of prostanoids in a cohort consisting mainly of systemic sclerosis. It underlines the difficulty to achieve a standardized assessment in this subset of patients. Safety profile was comparable with data reported in idiopathic PAH.
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Affiliation(s)
- V Genin
- Service de médecine interne, Hôtel-Dieu, CHU de Nantes, centre de compétence HTAP de l'adulte, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - D Horeau-Langlard
- Service de pneumologie, hôpital Laennec, CHU de Nantes, centre de compétence HTAP de l'adulte, boulevard Jacques-Monod, Saint-Herblain, France
| | - E Diot
- Service de médecine interne, hôpital Bretonneau, CHRU de Tours, centre de compétence HTAP de l'adulte, 2, boulevard Tonnellé, Tours, France
| | - F Gagnadoux
- Service de pneumologie, CHU d'Angers, centre de compétence HTAP de l'adulte, 4, rue Larrey, Angers, France
| | - C Lavigne
- Service de médecine interne-immunologie clinique, CHU d'Angers, centre de compétence HTAP de l'adulte, 4, rue Larrey, Angers, France
| | - M Fournet
- Service de cardiologie, hôpital Pontchaillou, CHU de Rennes, 2, rue Henri le Guilloux, 35000 Rennes, France
| | - C Durant
- Service de médecine interne, Hôtel-Dieu, CHU de Nantes, centre de compétence HTAP de l'adulte, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Agard
- Service de médecine interne, Hôtel-Dieu, CHU de Nantes, centre de compétence HTAP de l'adulte, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Bauer Y, de Bernard S, Hickey P, Ballard K, Cruz J, Cornelisse P, Chadha-Boreham H, Distler O, Rosenberg D, Doelberg M, Roux S, Nayler O, Lawrie A. Identifying early pulmonary arterial hypertension biomarkers in systemic sclerosis: machine learning on proteomics from the DETECT cohort. Eur Respir J 2021; 57:13993003.02591-2020. [PMID: 33334933 PMCID: PMC8276065 DOI: 10.1183/13993003.02591-2020] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/17/2020] [Indexed: 12/31/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating complication of systemic sclerosis (SSc). Screening for PAH in SSc has increased detection, allowed early treatment for PAH and improved patient outcomes. Blood-based biomarkers that reliably identify SSc patients at risk of PAH, or with early disease, would significantly improve screening, potentially leading to improved survival, and provide novel mechanistic insights into early disease. The main objective of this study was to identify a proteomic biomarker signature that could discriminate SSc patients with and without PAH using a machine learning approach and to validate the findings in an external cohort. Serum samples from patients with SSc and PAH (n=77) and SSc without pulmonary hypertension (non-PH) (n=80) were randomly selected from the clinical DETECT study and underwent proteomic screening using the Myriad RBM Discovery platform consisting of 313 proteins. Samples from an independent validation SSc cohort (PAH n=22 and non-PH n=22) were obtained from the University of Sheffield (Sheffield, UK). Random forest analysis identified a novel panel of eight proteins, comprising collagen IV, endostatin, insulin-like growth factor binding protein (IGFBP)-2, IGFBP-7, matrix metallopeptidase-2, neuropilin-1, N-terminal pro-brain natriuretic peptide and RAGE (receptor for advanced glycation end products), that discriminated PAH from non-PH in SSc patients in the DETECT Discovery Cohort (average area under the receiver operating characteristic curve 0.741, 65.1% sensitivity/69.0% specificity), which was reproduced in the Sheffield Confirmatory Cohort (81.1% accuracy, 77.3% sensitivity/86.5% specificity). This novel eight-protein biomarker panel has the potential to improve early detection of PAH in SSc patients and may provide novel insights into the pathogenesis of PAH in the context of SSc. Early screening for pulmonary arterial hypertension in patients with systemic sclerosis improves patient outcome. This study identified a novel eight-protein biomarker panel that has the potential to assist early detection of PAH in this patient group.https://bit.ly/373BNkL
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Affiliation(s)
- Yasmina Bauer
- Galapagos GmbH, Basel, Switzerland.,Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Peter Hickey
- Dept of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK.,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | | | | | - Oliver Distler
- Dept of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | - Allan Lawrie
- Dept of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
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46
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Naranjo M, Hassoun PM. Systemic Sclerosis-Associated Pulmonary Hypertension: Spectrum and Impact. Diagnostics (Basel) 2021; 11:911. [PMID: 34065226 PMCID: PMC8161029 DOI: 10.3390/diagnostics11050911] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a catastrophic complication of one of the most common and devastating autoimmune diseases. Once diagnosed, it becomes the leading cause of mortality among this patient population. Screening modalities and risk assessments have been designed and validated by various organizations and societies in order to identify patients early in their disease course and promptly refer them to expert centers for a hemodynamic assessment and formal diagnosis. Moreover, several large multicenter clinical trials have now included patients with SSc-PAH to assess their response to therapy. Despite an improved understanding of the condition and significant advances in supportive and targeted therapy, outcomes have remained far from optimal. Therefore, rigorous phenotyping and search for novel therapies are desperately needed for this devastating condition.
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Affiliation(s)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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47
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Wu CH, Lin CY, Hsu CH, Lin SH, Weng CT. Connective Tissue Disease-Associated Pulmonary Arterial Hypertension in Southern Taiwan: A Single-Center 10-Year Longitudinal Observation Cohort. Healthcare (Basel) 2021; 9:healthcare9050615. [PMID: 34065585 PMCID: PMC8160731 DOI: 10.3390/healthcare9050615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a life-threatening disease with different etiologies and outcomes. We aimed to explore differences in clinical features and outcomes of idiopathic PAH (iPAH) and connective tissue disease-related PAH (CTD-PAH) in Taiwanese patients and determine risk factors for mortality. Methods: We retrospectively reviewed the medical records of patients with right-sided heart catheterization-diagnosed PAH between January 2005 and December 2015. The iPAH (n = 31) and CTD-PAH (n = 14) patients were enrolled and followed until December 31, 2019. Between-group comparisons were conducted. Potential predictors of the mortality of PAH were determined using the Cox proportional hazard regression model. Results: CTD-PAH patients had higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and lower predicted diffusing capacity of carbon monoxide (DLCO) than iPAH patients. The mortality rates were similar between CTD-PAH and iPAH (21.4% vs. 22.6%, p = 0.99). A mean pulmonary arterial pressure (mPAP) > 46 mmHg was a predictor of PAH-induced mortality (adjusted hazard ratio 21.8, 95% confidence interval 2.32–204.8). Conclusions: A higher mPAP level, but not underlying CTDs, imposed a significantly increased risk of mortality to patients with PAH.
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Affiliation(s)
- Chun-Hsin Wu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
- Division of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
- Correspondence: ; Tel.: +886-6-235-3535 (ext. 5383)
| | - Chun-Yu Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Chia-Tse Weng
- Division of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
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Bellan M, Giubertoni A, Piccinino C, Buffa M, Cromi D, Sola D, Pedrazzoli R, Gagliardi I, Calzaducca E, Zecca E, Patrucco F, Patti G, Sainaghi PP, Pirisi M. Cardiopulmonary Exercise Testing Is an Accurate Tool for the Diagnosis of Pulmonary Arterial Hypertension in Scleroderma Related Diseases. Pharmaceuticals (Basel) 2021; 14:ph14040342. [PMID: 33917930 PMCID: PMC8068386 DOI: 10.3390/ph14040342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
The early diagnosis of pulmonary arterial hypertension (PAH) is a major determinant of prognosis in patients affected by connective tissue diseases (CTDs) complicated by PAH. In the present paper we investigated the diagnostic accuracy of cardiopulmonary exercise testing (CPET) in this specific setting. We recorded clinical and laboratory data of 131 patients who underwent a CPET at a pulmonary hypertension clinic. Out of them, 112 (85.5%) had a diagnosis of CTDs; 8 (6.1%) received a diagnosis of CTDs-PAH and 11 (8.4%) were affected PH of different etiology. Among CPET parameters the following parameters showed the best diagnostic performance for PAH: peak volume of oxygen uptake (VO2; AUC: 0.845, CI95% 0.767-0.904), ratio between ventilation and volume of exhaled carbon dioxide (VE/VCO2 slope; AUC: 0.888, CI95%: 0.817-0.938) and end-tidal partial pressures (PetCO2; AUC: 0.792, CI95%: 0.709-0.861). These parameters were comparable among CTDs-PAH and PH of different etiology. The diagnostic performance was even improved by creating a composite score which included all the three parameters identified. In conclusion, CPET is a very promising tool for the stratification of risk of PAH among CTDs patients; the use of composite measures may improve diagnostic performance.
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Affiliation(s)
- Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
- Correspondence:
| | - Ailia Giubertoni
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Cristina Piccinino
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Mariachiara Buffa
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Debora Cromi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Daniele Sola
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Roberta Pedrazzoli
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Ileana Gagliardi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Elisa Calzaducca
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Erika Zecca
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Filippo Patrucco
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Giuseppe Patti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
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Nailfold Capillaroscopy in Systemic Sclerosis Patients with and without Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10071528. [PMID: 33917407 PMCID: PMC8038744 DOI: 10.3390/jcm10071528] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc)-related pulmonary arterial hypertension (SSc-PAH) is a leading cause of mortality in SSc. The extent of peripheral microvasculopathy assessed through nailfold capillaroscopy might correlate with the presence of PAH in SSc patients. We searched the PubMed, Cochrane Library, Scopus, and Web of Science databases and performed a random effects meta-analysis of observational studies comparing nailfold capillaroscopic alterations in SSc-PAH versus SSc-noPAH patients. Weighted mean differences (WMD) with the corresponding confidence intervals (CIs) were estimated. The quality of the included studies was evaluated using a modified Newcastle-Ottawa scale. Seven studies with 101 SSc-PAH and 277 SSc-noPAH participants were included. Capillary density was marginally reduced in the SSc-PAH group (WMD: -1.0, 95% CI: -2.0 to 0.0, I2 = 86%). This effect was strengthened once PAH diagnosis was confirmed by right heart catheterization (WMD: -1.2, 95% CI: -2.3 to -0.1, I2 = 85%). An increase in capillary loop width was observed in SSc-PAH compared to SSc-noPAH patients (WMD: 10.9, 95% CI: 2.5 to 19.4, I2 = 78%). Furthermore, SSc-PAH patients had a 7.3 times higher likelihood of active or late scleroderma pattern (95% CI: 3.0 to 18.0, I2 = 4%). SSc-PAH patients presented with worse nailfold capillaroscopic findings compared to SSc-noPAH patients.
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50
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Vonk MC, Vandecasteele E, van Dijk AP. Pulmonary hypertension in connective tissue diseases, new evidence and challenges. Eur J Clin Invest 2021; 51:e13453. [PMID: 33216992 PMCID: PMC7988614 DOI: 10.1111/eci.13453] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/08/2020] [Accepted: 11/15/2020] [Indexed: 12/21/2022]
Abstract
Pulmonary arterial hypertension is a lethal complication of different connective tissue diseases such as systemic sclerosis, mixed connective tissue disease and systemic lupus erythematosus. Although the treatment possibilities for patients with pulmonary arterial hypertension have increased in the last two decades and survival of patients with idiopathic pulmonary arterial hypertension has improved, the latter is not the case for patients with pulmonary arterial hypertension associated with connective tissue disease. In this narrative review, we review recent literature and describe the improvement of early diagnostic possibilities, screening modalities and treatment options. We also point out the pitfalls in diagnosis in this patient category and describe the unmet needs and what the focus of future research should be.
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Affiliation(s)
- Madelon C. Vonk
- Department of the Rheumatic diseasesRadboud University Nijmegen Medical CentreNijmegenthe Netherlands
| | | | - Arie P. van Dijk
- Department of CardiologyRadboud University Nijmegen Medical CentreNijmegenthe Netherlands
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