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Batani V, Dagna L, De Luca G. Therapeutic strategies for primary heart involvement in systemic sclerosis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:72-82. [PMID: 39015843 PMCID: PMC11248560 DOI: 10.1515/rir-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), even though often underdiagnosed. SSc-pHI has been recently defined as cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications. SSc-pHI represents a major determinant of mortality in SSc, accounting alone for about 12% of disease-related deaths; its early recognition and promptly therapeutic interventions are therefore crucial. Both perfusion defects and myocardial inflammation contribute to the occurrence of myocardial fibrosis that precipitates myocardial remodeling, potentially leading to heart failure and arrhythmic complications. To date, clear evidence and guidelines for effectively managing SSc pHI are not established yet, resulting in a lack of a defined therapeutic algorithm. In this review we summarize the most recent scientific literature on the prevailing therapeutic strategies and interventions to manage SSc-pHI, with particular focus on therapeutic strategies to counteract the 3 major pathogenic events of the disease, i.e. microvascular damage, myocardial inflammation and myocardial fibrosis.
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Affiliation(s)
- Veronica Batani
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
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Fairley JL, Hansen D, Proudman S, Sahhar J, Ngian GS, Walker J, Host LV, La Gerche A, Prior D, Burns A, Morrisroe K, Stevens W, Nikpour M, Ross L. Prognostic and functional importance of both overt and subclinical left ventricular systolic dysfunction in systemic sclerosis. Semin Arthritis Rheum 2024; 66:152443. [PMID: 38631275 DOI: 10.1016/j.semarthrit.2024.152443] [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: 10/29/2023] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To quantify the frequency and clinical implications of systemic sclerosis (SSc)-associated left ventricular function (LV) impairment. METHODS Australian Scleroderma Cohort Study participants meeting ACR/EULAR criteria for SSc with ≥1 echocardiographic LVEF measurement were included. Overt LV dysfunction was indicated by reduced LV ejection fraction (LVEF) and subclinical LV dysfunction was measured using impaired LV global longitudinal strain (LV-GLS>-16 %). Those with secondary causes of LV dysfunction (myocardial ischaemia, valvulopathy and pulmonary arterial hypertension) were excluded. Chi-squared tests, two-sample t-tests or Wilcoxon rank-sum tests were used for between-group comparison as appropriate. Generalised estimating equations(GEE) were used to model longitudinal data. Kaplan-Meier and Cox proportional hazard models were used for survival analyses. RESULTS Of 1141 participants with no co-morbid cardiac disease, 2.4 % ever recorded a LVEF<50 %, while only 0.6 % ever recorded a LVEF≤40 %. LV-GLS data were available for 90 % of participants at one centre (n = 218). Impaired LV-GLS was detected in 21 % despite LVEF≥50 %. Those with a LVEF<50 % were more frequently male (p = 0.01) with dcSSc (p < 0.01), higher inflammatory markers (p < 0.02) and skeletal muscle disease (p < 0.05). In multivariable analyses, recording a LVEF<50 % was associated with increased mortality (HR2.3, 95 %CI1.0-4.8, p = 0.04). Impaired LV-GLS was also associated with poorer survival in univariable analyses (HR3.4, 95 %CI1.0-11.8, p = 0.05). Those with a LVEF<50 % more frequently recorded WHO Class III/IV dyspnoea (OR3.5, 95 %CI1.6-7.7, p < 0.01), with shorter six-minute walk distance (p = 0.01), higher Health Assessment Questionnaire-Disability Index scores (p < 0.01) and lower Short Form-36 Physical Component Summary scores (p = 0.02). Increased dyspnoea (WHO Class III/IV dyspnoea; OR3.6, 95 %CI1.4-9.2, p < 0.01) was also seen in those with impaired LV-GLS. CONCLUSIONS Both overt and subclinical SSc-associated LV dysfunction are associated with worse survival and impaired physical function. The frequency of abnormal LV-GLS in those with consistently normal LVEF suggests an under-appreciated burden of subtle LV systolic dysfunction in SSc that has a significant impact on patient symptomatology.
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Affiliation(s)
- Jessica L Fairley
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
| | - Dylan Hansen
- Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susanna Proudman
- Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gene-Siew Ngian
- Department of Rheumatology, Monash Health, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jenny Walker
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lauren V Host
- Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - André La Gerche
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David Prior
- Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andrew Burns
- Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kathleen Morrisroe
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The University of Sydney School of Public Health, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital Sydney, New South Wales, Australia
| | - Laura Ross
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Vreeburg YL, Knight DS, Coghlan JG, Ong VH, Denton CP. Recurrent episodes of Takotsubo cardiomyopathy in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:NP7-NP11. [PMID: 38333521 PMCID: PMC10848928 DOI: 10.1177/23971983231188824] [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: 05/30/2023] [Accepted: 07/01/2023] [Indexed: 02/10/2024]
Abstract
Systemic sclerosis is an autoimmune disease characterized by fibrosis and small vessel vasculopathy, which affects various organ systems, such as the heart. Takotsubo cardiomyopathy is a transient cardiomyopathy in reaction to an emotional or physical trigger. There may be clinical and pathogenetic overlap between Takotsubo cardiomyopathy and primary systemic sclerosis heart disease, and some patients with systemic sclerosis have been diagnosed with recurrent Takotsubo cardiomyopathy. Our large systemic sclerosis clinical cohort was reviewed to identify cases diagnosed with Takotsubo cardiomyopathy. The clinical features, laboratory and imaging results were reviewed and evaluated to perform a comparison between cases. We identified five patients with systemic sclerosis, all female (age 68.6 ± 5.7 years), who were diagnosed with Takotsubo cardiomyopathy. Two of these patients had recurrent episodes: one case with a history of multiple episodes and the other with one recurrence. Typical features included repolarization abnormalities on the electrocardiogram and transient left ventricular dysfunction observed using echocardiography or cardiac magnetic resonance imaging. Our findings build upon previous reports and observations that systemic sclerosis may cause Takotsubo cardiomyopathy. To our knowledge, this is the largest case series of Takotsubo syndrome in patients with systemic sclerosis. This association may provide novel insights into the aetiopathogenesis of Takotsubo cardiomyopathy as part of primary systemic sclerosis heart involvement.
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Affiliation(s)
- Yumiko L Vreeburg
- Centre for Rheumatology and Connective Tissue Diseases, University College London Medical School, London, UK
| | | | - John G Coghlan
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Voon H Ong
- Centre for Rheumatology and Connective Tissue Diseases, University College London Medical School, London, UK
- Department of Rheumatology, Royal Free Hospital, London, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, University College London Medical School, London, UK
- Department of Rheumatology, Royal Free Hospital, London, UK
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De Luca G, Matucci-Cerinic M, Mavrogeni SI. Diagnosis and management of primary heart involvement in systemic sclerosis. Curr Opin Rheumatol 2024; 36:76-93. [PMID: 37962165 DOI: 10.1097/bor.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW In systemic sclerosis (SSc) primary heart involvement (pHI) is frequent, even though often unrecognized due to its occult nature and to the lack of a specific diagnostic algorithm. The purpose of this review is to report the state of the art of the evidence in the current literature, as well as the overall diagnostic modalities and therapeutic strategies for primary heart involvement in SSc. RECENT FINDINGS SSc-pHI is defined by the presence of cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications; it may be sub-clinical and must be confirmed through diagnostic investigations. Novel electrocardiographic analysis and cardiac magnetic resonance (CMR) with mapping techniques have been recently proposed, showing a great utility in the early identification of SSc-pHI and in the noninvasive characterization of myocardial tissue. Immunosuppressive therapy emerged as fundamental to curb myocardial inflammation, and recent preclinical and clinical data support the role of antifibrotic drugs to treat SSc-pHI. SUMMARY our review will help clinicians to properly integrate the available diagnostic modalities for the assessment of SSc-pHI. The ultimate goal is to propose a feasible diagnostic algorithm for the early identification of patients with SSc-pHI, and a schematic therapeutic approach to manage SSc-pHI.
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Affiliation(s)
- Giacomo De Luca
- Vita-Salute San Raffaele University
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sophie I Mavrogeni
- Onassis Cardiac Surgery Center
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Healthcare, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Gargani L, Bruni C, Todiere G, Pugliese NR, Bandini G, Bellando-Randone S, Guiducci S, D’Angelo G, Campochiaro C, De Luca G, Stagnaro C, Lombardi M, Dagna L, Pepe A, Allanore Y, Moggi-Pignone A, Matucci-Cerinic M. Digital Ulcers and Ventricular Arrhythmias as Red Flags to Predict Replacement Myocardial Fibrosis in Systemic Sclerosis. J Clin Med 2023; 13:89. [PMID: 38202095 PMCID: PMC10779804 DOI: 10.3390/jcm13010089] [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: 10/27/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Echocardiography is the first line imaging tool to detect cardiac involvement, but it is not able to routinely detect myocardial fibrosis. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for replacement myocardial fibrosis assessment, but its availability is currently limited. AIM We aimed to assess the clinical and instrumental parameters that would be useful for predicting the presence of LGE-CMR, to achieve a better selection of patients with SSc that could benefit from third-level CMR imaging. METHODS 344 SSc patients underwent a comprehensive echocardiogram and LGE-CMR on the same day; for 189 patients, a 24 h ECG Holter monitoring was available. RESULTS CMR showed non-junctional replacement myocardial fibrosis via LGE in 25.1% patients. A history of digital ulcers (OR 2.188; 95% C.I. 1.069-4.481) and ventricular arrhythmias at ECG Holter monitoring (OR 3.086; 95% C.I. 1.191-7.998) were independent predictors of replacement myocardial fibrosis. CONCLUSIONS CMR can detect patterns of clinical and subclinical cardiac involvement, which are frequent in SSc. A history of digital ulcers and evidence of ventricular arrhythmias at ECG Holter monitoring are red flags for the presence of replacement myocardial fibrosis in CMR. The association between digital ulcers and myocardial fibrosis suggests that a similar pathological substrate of abnormal vascular function may underlie peripheral vascular and cardiac complications.
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Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Giancarlo Todiere
- U.O.C. Risonanza Magnetica Specialistica, Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | | | - Giulia Bandini
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
| | - Silvia Bellando-Randone
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Serena Guiducci
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Florence, Italy
| | - Gennaro D’Angelo
- U.O.C. Risonanza Magnetica Specialistica, Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Chiara Stagnaro
- Department of Rheumatology, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Massimo Lombardi
- Multimodality Cardiac Imaging Section, Policlinico San Donato, 20097 Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, 35122 Padua, Italy
| | - Yannick Allanore
- French National Institute of Health and Medical Research (INSERM) U1016, Université de Paris, Hôpital Cochin, 75014 Paris, France
| | - Alberto Moggi-Pignone
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, University of Florence, 50121 Florence, Italy
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
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Foeldvari I, Torok KS, Anton J, Blakley M, Constantin T, Curran M, Cutolo M, Denton C, Fligelstone K, Ingegnoli F, Li SC, Němcová D, Orteu C, Pilkington C, Smith V, Stevens A, Klotsche J, Khanna D, Costa-Reis P, Del Galdo F, Hinrichs B, Kasapcopur O, Pain C, Ruperto N, Zheng A, Furst DE. Proposed Response Parameters for Twelve-Month Drug Trial in Juvenile Systemic Sclerosis: Results of the Hamburg International Consensus Meetings. Arthritis Care Res (Hoboken) 2023; 75:2453-2462. [PMID: 37332054 DOI: 10.1002/acr.25171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 04/03/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Juvenile systemic sclerosis (SSc) is an orphan disease, associated with high morbidity and mortality. New treatment strategies are much needed, but clearly defining appropriate outcomes is necessary if successful therapies are to be developed. Our objective here was to propose such outcomes. METHODS This proposal is the result of 4 face-to-face consensus meetings with a 27-member multidisciplinary team of pediatric rheumatologists, adult rheumatologists, dermatologists, pediatric cardiologists, pulmonologists, gastroenterologists, a statistician, and patients. Throughout the process, we reviewed the existing adult data in this field, the more limited pediatric literature for juvenile SSc outcomes, and data from 2 juvenile SSc patient cohorts to assist in making informed, data-driven decisions. The use of items for each domain as an outcome measure in an open label 12-month clinical trial of juvenile SSc was voted and agreed upon using a nominal group technique. RESULTS After voting, the domains agreed on were global disease activity, skin, Raynaud's phenomenon, digital ulcers, musculoskeletal, cardiac, pulmonary, renal, and gastrointestinal involvement, and quality of life. Fourteen outcome measures had 100% agreement, 1 item had 91% agreement, and 1 item had 86% agreement. The domains of biomarkers and growth/development were moved to the research agenda. CONCLUSION We reached consensus on multiple domains and items that should be assessed in an open label, 12-month clinical juvenile SSc trial as well as a research agenda for future development.
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Affiliation(s)
| | - Kathryn S Torok
- University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jordi Anton
- Hospital Sant Joan de Déu and Universitat de Barcelona, Barcelona, Spain
| | - Michael Blakley
- Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis
| | | | - Megan Curran
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Maurizio Cutolo
- University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | | | | | | | - Suzanne C Li
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | | | | | - Vanessa Smith
- Ghent University, Ghent University Hospital, VIB Inflammation Research Center, and ERN ReCONNET, Ghent, Belgium
| | - Anne Stevens
- Children's Hospital Research Institute and University of Washington, Seattle, and Janssen Pharmaceutical Companies of Johnson & Johnson, Spring House, Pennsylvania
| | | | | | - Patrícia Costa-Reis
- Hospital de Santa Maria, Faculdade de Medicina, and Universidade de Lisboa, Lisbon, Portugal
| | | | | | - Ozgur Kasapcopur
- Cerrahpasa Medical School and Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Clare Pain
- Alder Hey Children's Foundation NHS Trust, Liverpool, UK
| | | | - Alison Zheng
- Chinese Organization for Scleroderma, Chengdu City, Sichuan Province, China
| | - Daniel E Furst
- University of California, Los Angeles, University of Washington, Seattle, and University of Florence, Florence, Italy
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Chhikara S, Kanda A, Ogugua FM, Rouf R, Nouraee C, Bawaskar P, Molitor JA, Shenoy C. The primary cardiomyopathy of systemic sclerosis on cardiovascular magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2023; 24:1661-1671. [PMID: 37364296 DOI: 10.1093/ehjci/jead147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023] Open
Abstract
AIMS Cardiac disease in systemic sclerosis (SSc) may be primary or secondary to other disease manifestations of SSc. The prevalence of the primary cardiomyopathy of SSc is unknown. Cardiovascular magnetic resonance (CMR) imaging can help accurately determine the presence and cause of cardiomyopathy. We aimed to investigate the prevalence, the CMR features, and the prognostic implications of the primary cardiomyopathy of SSc. METHODS AND RESULTS We conducted a retrospective cohort study of consecutive patients with SSc who had a clinical CMR for suspected cardiac involvement. We identified the prevalence, the CMR features of the primary cardiomyopathy of SSc, and its association with the long-term incidence of death or major adverse cardiac events (MACEs): heart failure hospitalization, ventricular assist device implantation, heart transplantation, and sustained ventricular tachycardia. Of 130 patients with SSc, 80% were women, and the median age was 58 years. On CMR, 22% had an abnormal left ventricular ejection fraction, and 40% had late gadolinium enhancement (LGE). The prevalence of the primary cardiomyopathy of SSc was 21%. A third of these patients had a distinct LGE phenotype. Over a median follow-up of 3.6 years after the CMR, patients with the primary cardiomyopathy of SSc had a greater incidence of death or MACE (adjusted hazard ratio 2.01; 95% confidence interval 1.03-3.92; P = 0.041). CONCLUSION The prevalence of the primary cardiomyopathy of SSc was 21%, with a third demonstrating a distinct LGE phenotype. The primary cardiomyopathy of SSc was independently associated with a greater long-term incidence of death or MACE.
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Affiliation(s)
- Sanya Chhikara
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Adinan Kanda
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Fredrick M Ogugua
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Rejowana Rouf
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Cyrus Nouraee
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Parag Bawaskar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
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Weber BN, Garshick M, Abbate A, Youngstein T, Stewart G, Bohula E, Plein S, Mukherjee M. Acute cardiovascular complications of immune-mediated systemic inflammatory diseases. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:792-801. [PMID: 37603839 PMCID: PMC11004858 DOI: 10.1093/ehjacc/zuad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
Immune-mediated systemic inflammatory conditions (IMIDs) are associated with an increased risk of atherosclerosis and adverse cardiovascular (CV) events secondary to pathogenic inflammation and derangements in the innate and adaptive immune responses inherent to the underlying rheumatic diseases. As the intersection of cardio-rheumatology continues to expand, a multi-disciplinary approach must be considered to optimize clinical outcomes and long-term survival. This review will highlight acute cardiac manifestations of systemic inflammatory diseases and propose a clinically relevant framework for diagnosis, management, and the role of integrated multimodality imaging.
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Affiliation(s)
- Brittany N Weber
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Michael Garshick
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, and Division of Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College NHS Healthcare Trust, London, UK
| | - Garrick Stewart
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Erin Bohula
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, USA
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9
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Petelytska L, Bonomi F, Cannistrà C, Fiorentini E, Peretti S, Torracchi S, Bernardini P, Coccia C, De Luca R, Economou A, Levani J, Matucci-Cerinic M, Distler O, Bruni C. Heterogeneity of determining disease severity, clinical course and outcomes in systemic sclerosis-associated interstitial lung disease: a systematic literature review. RMD Open 2023; 9:e003426. [PMID: 37940340 PMCID: PMC10632935 DOI: 10.1136/rmdopen-2023-003426] [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: 06/23/2023] [Accepted: 10/02/2023] [Indexed: 11/10/2023] Open
Abstract
Objective The course of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is highly variable and different from continuously progressive idiopathic pulmonary fibrosis (IPF). Most proposed definitions of progressive pulmonary fibrosis or SSc-ILD severity are based on the research data from patients with IPF and are not validated for patients with SSc-ILD. Our study aimed to gather the current evidence for severity, progression and outcomes of SSc-ILD.Methods A systematic literature review to search for definitions of severity, progression and outcomes recorded for SSc-ILD was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in Medline, Embase, Web of Science and Cochrane Library up to 1 August 2023.Results A total of 9054 papers were reviewed and 342 were finally included. The most frequent tools used for the definition of SSc-ILD progression and severity were combined changes of carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC), isolated FVC or DLCO changes, high-resolution CT (HRCT) extension and composite algorithms including pulmonary function test, clinical signs and HRCT data. Mortality was the most frequently reported long-term event, both from all causes or ILD related.Conclusions The studies presenting definitions of SSc-ILD 'progression', 'severity' and 'outcome' show a large heterogeneity. These results emphasise the need for developing a standardised, consensus definition of severe SSc-ILD, to link a disease specific definition of progression as a surrogate outcome for clinical trials and clinical practice.PROSPERO registration number CRD42022379254.Cite Now.
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Affiliation(s)
- Liubov Petelytska
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department Internal Medicine #3, Bogomolets National Medical University, Kiiv, Ukraine
| | - Francesco Bonomi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Carlo Cannistrà
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Elisa Fiorentini
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Silvia Peretti
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Sara Torracchi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Pamela Bernardini
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Carmela Coccia
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Riccardo De Luca
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Alessio Economou
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Juela Levani
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Hospital, Milan, Italy
| | - Oliver Distler
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Cosimo Bruni
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
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10
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Fairley JL, Ross L, Quinlivan A, Hansen D, Paratz E, Stevens W, Kistler PM, McLellan A, La Gerche A, Nikpour M. Sudden cardiac death, arrhythmias and abnormal electrocardiography in systemic sclerosis: A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 62:152229. [PMID: 37354723 DOI: 10.1016/j.semarthrit.2023.152229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To calculate the frequency of sudden cardiac death(SCD), arrhythmia and conduction defects in SSc. METHODS MEDLINE/EMBASE were searched to January 2023. English-language studies reporting the incidence/frequency of SCD, arrhythmia and electrocardiography(ECG) abnormalities in SSc were included. Odds ratios(OR), estimations of annual incidence or pooled frequencies were calculated. RESULTS Seventy-nine studies(n = 13,609 participants with SSc) were included in the meta-analysis. Methodology and outcomes were heterogeneous. Ten studies included cohorts with known/suspected SSc-associated heart involvement(SHI), generally defined as clinically-manifest cardiac disease/abnormal cardiac investigations. The incidence of SCD in SHI was estimated to be 3.3% annually(n = 4 studies, 301PY follow-up). On ambulatory ECG, 18% of SHI cohorts had non-sustained ventricular tachycardia(NSVT; n = 4, 95%CI3.2-39.3%), 70% frequent premature ventricular complexes (PVCs; n = 1, 95%CI34.8-93.3%), and 8% atrial fibrillation (AF; n = 1, 95%CI4.2-13.6%). Nineteen studies included participants without SHI, defined as normal cardiac investigations/absence of cardiac disease. The estimated incidence of SCD was approximately 2.9% annually (n = 1, 67.5PY). Compared to healthy controls, individuals without SHI demonstrated NSVT 13.3-times more frequently (n = 2, 95%CI2-102), and paroxysmal supraventricular tachycardia 7-times more frequently (n = 4, 95%CI3-15). Other ambulatory ECG abnormalities included NSVT in 9% (n = 7, 95%CI6-14%), >1000 PVCs/24 h in 6% (n = 2, 95%CI1-13%), and AF in 7% (n = 5, 0-21%). Fifty studies included general SSc cohorts unselected for cardiac disease. The incidence of SCD was estimated to be 2.0% annually(n = 4 studies, 1646PY). Unselected SSc cohorts were 10.5-times more likely to demonstrate frequent PVCs (n = 2, 95%CI 2-59) and 2.5-times more likely to have an abnormal electrocardiography (n = 2, 95%CI1-4). CONCLUSIONS The incidence of SCD in SSc is estimated to be 1.0-3.3% annually, at least 10-fold higher than general population estimates. Arrhythmias including NSVT and frequent PVCs appear common, including amongst those without known/suspected SHI.
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Affiliation(s)
- Jessica L Fairley
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Laura Ross
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alannah Quinlivan
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dylan Hansen
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Paratz
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Wendy Stevens
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The University of Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Australia
| | - Alex McLellan
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andre La Gerche
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
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11
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Gokcen N. Serum markers in systemic sclerosis with cardiac involvement. Clin Rheumatol 2023; 42:2577-2588. [PMID: 37335406 DOI: 10.1007/s10067-023-06663-z] [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: 05/02/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
Cardiac involvement in systemic sclerosis is a common clinical entity that may range from subclinical to life-threatening complications. The classification of cardiac involvement may be expressed as either primary or secondary involvement. Primary systemic sclerosis heart involvement (SSc-pHI) refers to cardiac pathologies primarily ascribed to systemic sclerosis rather than concomitant conditions like ischemic heart disease and pulmonary hypertension. The timely recognition of cardiac involvement holds significant clinical relevance. Therefore, numerous screening or diagnostic tools have been evaluated to forecast the likelihood of cardiac involvement, particularly in the absence of clinically evident cardiac symptoms. Of these modalities, serum biomarkers are often preferred due to their expeditiousness and non-invasive nature. Hence, the crucial goal of this narrative review is to review serum biomarkers that can be a valuable or promising tool in diagnosing cardiac involvement, especially SSc-pHI, in the early stages or predicting disease prognosis.
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Affiliation(s)
- Neslihan Gokcen
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Turkey.
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12
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Bruni C, Buch MH, Djokovic A, De Luca G, Dumitru RB, Giollo A, Galetti I, Steelandt A, Bratis K, Suliman YA, Milinkovic I, Baritussio A, Hasan G, Xintarakou A, Isomura Y, Markousis-Mavrogenis G, Mavrogeni S, Gargani L, Caforio ALP, Tschöpe C, Ristic A, Plein S, Behr E, Allanore Y, Kuwana M, Denton CP, Furst DE, Khanna D, Krieg T, Marcolongo R, Pepe A, Distler O, Sfikakis P, Seferovic P, Matucci-Cerinic M. Consensus on the assessment of systemic sclerosis-associated primary heart involvement: World Scleroderma Foundation/Heart Failure Association guidance on screening, diagnosis, and follow-up assessment. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:169-182. [PMID: 37744047 PMCID: PMC10515996 DOI: 10.1177/23971983231163413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 02/24/2023] [Indexed: 09/26/2023]
Abstract
Introduction Heart involvement is a common problem in systemic sclerosis. Recently, a definition of systemic sclerosis primary heart involvement had been proposed. Our aim was to establish consensus guidance on the screening, diagnosis and follow-up of systemic sclerosis primary heart involvement patients. Methods A systematic literature review was performed to investigate the tests used to evaluate heart involvement in systemic sclerosis. The extracted data were categorized into relevant domains (conventional radiology, electrocardiography, echocardiography, cardiac magnetic resonance imaging, laboratory, and others) and presented to experts and one patient research partner, who discussed the data and added their opinion. This led to the formulation of overarching principles and guidance statements, then reviewed and voted on for agreement. Consensus was attained when the mean agreement was ⩾7/10 and of ⩾70% of voters. Results Among 2650 publications, 168 met eligibility criteria; the data extracted were discussed over three meetings. Seven overarching principles and 10 guidance points were created, revised and voted on. The consensus highlighted the importance of patient counseling, differential diagnosis and multidisciplinary team management, as well as defining screening and diagnostic approaches. The initial core evaluation should integrate history, physical examination, rest electrocardiography, trans-thoracic echocardiography and standard serum cardiac biomarkers. Further investigations should be individually tailored and decided through a multidisciplinary management. The overall mean agreement was 9.1/10, with mean 93% of experts voting above 7/10. Conclusion This consensus-based guidance on screening, diagnosis and follow-up of systemic sclerosis primary heart involvement provides a foundation for standard of care and future feasibility studies that are ongoing to support its application in clinical practice.
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Affiliation(s)
- Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital (AOUC), University of Florence, Florence, Italy
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Maya H Buch
- Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Aleksandra Djokovic
- Department of Cardiology, University Clinical Hospital Center Bezanijska kosa, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology Allergology and Rare diseases, IRCSS San Raffaele Hospital, Milan, Italy
| | - Raluca B Dumitru
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Alessandro Giollo
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Ilaria Galetti
- Federation of European Scleroderma Associations (FESCA), Saint Maur, Belgium
| | - Alexia Steelandt
- Rheumatology Department, Paris University, Cochin Hospital, Paris, France
| | - Konstantinos Bratis
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Yossra Atef Suliman
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assuit University Hospital, Assuit, Arab Republic of Egypt
| | - Ivan Milinkovic
- Department of Cardiology, University Clinical Hospital Center Bezanijska kosa, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Anna Baritussio
- Cardiology and Cardioimmunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Ghadeer Hasan
- Department of Medicine, Rutgers Robert Wood Johnson Medical Centre, New Brunswick, NJ, USA
| | | | - Yohei Isomura
- Department of Allergy and Rheumatology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Sophie Mavrogeni
- Onassis Cardiac Surgery Centre and Kapodistrian University of Athens, Athens, Greece
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Alida LP Caforio
- Cardiology and Cardioimmunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité—University Medicine Berlin, Berlin, Germany
| | - Arsen Ristic
- Department of Cardiology, University Clinical Hospital Center Bezanijska kosa, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sven Plein
- Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Elijah Behr
- Cardiovascular Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George’s University of London, London, UK
| | - Yannick Allanore
- Rheumatology Department, Paris University, Cochin Hospital, Paris, France
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Daniel E Furst
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital (AOUC), University of Florence, Florence, Italy
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Thomas Krieg
- Department of Dermatology, Translational Matrix Biology, University Hospital Cologne, Cologne, Germany
| | - Renzo Marcolongo
- Cardiology and Cardioimmunology Outpatient Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alessia Pepe
- Institute of Radiology and Department of Medicine, University of Padova, Padova, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Petros Sfikakis
- First Department of Propaedeutic and Internal Medicine and Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Petar Seferovic
- Department of Cardiology, University Clinical Hospital Center Bezanijska kosa, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marco Matucci-Cerinic
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Careggi University Hospital (AOUC), University of Florence, Florence, Italy
- Unit of Immunology, Rheumatology Allergology and Rare diseases, IRCSS San Raffaele Hospital, Milan, Italy
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13
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Rotondo C, Sciacca S, Rella V, Busto G, Colia R, Cantatore FP, Corrado A. Subclinical coronary atherosclerosis, detected by computer tomography with coronary calcium score, and the occurrence of major cardiovascular events at 5 years of follow-up in a cohort of patients with systemic sclerosis. Eur J Intern Med 2023; 115:62-69. [PMID: 37316356 DOI: 10.1016/j.ejim.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/21/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Spreading data describe cardiovascular disease (CVD) as a growing cause of hospitalization in systemic sclerosis (SSc) patients. Although interstitial lung disease and pulmonary arterial hypertension (PAH) remain the principal causes of mortality, the presence of CVD has been shown to further increase mortality in SSc patients. Few and contrasting data are available on cardiovascular impairment, particularly of subclinical coronary arteries disease, in SSc patients. The aims of this study were: 1) to determine the demographic, clinical, and cardiovascular differences between the groups of SSc patients with and without subclinical coronary atherosclerosis (SCA) assessed by coronary calcium score; 2) to verify the performance of cardiovascular risk scores in SSc for detection of SCA major cardiovascular events (MCVE); 3) to evaluate the risk factors associated to MCVE in 5 years of follow-up in this study group of patients. METHODS Sixty-seven SSc patients were enrolled in this study. SCA was assessed using quantification of coronary calcium score by computerized tomography, reported as Agatson. Evaluation of common cardiovascular risk scores, carotid plaques by Doppler ultrasonography, the history of peripheral artery disease (PAD), lipid profiles, and clinical and laboratiristic characteristics of SSc were assessed at baseline visits for each patient. Factors associated with the presence of SCA were assessed by multivariate logistic analysis. A five years prospective study was performed for the evaluation of MCVE occurrence and its possible predictors. RESULTS The prevalence of SCA was 42% (Agatston scores of 266.04 ± 455.9 units) in our group of SSc patients. Patients with SCA were principally older (p = 0.0001) and had higher rates of CENP-B antibodies (57% vs 26%; p = 0.009), pulmonary arterial hypertension (PAH) (25% vs 3%; p = 0.008), dysphagia (86% vs 61%; p = 0.027), and users of statins (36% vs 8%; p = 0.004), carotid plaque (82% vs 13%; p = 0.0001), PAD (79% vs 18%; p = 0.0001), and metabolic syndrome (25% vs 0%; p = 0.002) than patients without SCA. Metabolic syndrome (OR: 8.2, p = 0.0001), presence of a PAD (OR: 5.98, p = 0.031), and carotid plaque (OR: 5.49, p = 0.010) were the main factors associated with SCA in SSc patients, by multivariate regression analysis. MCVE occurred in 7 patients. By multivariate COX regression analysis unique predictor of MCVE in 5 years of follow-up in our SSc patients was the presence of PAH (HR: 10.33, p = 0.009). Of note, the contemporary presence of PAH and SCA (defined as "not pure" pattern of PAH) was observed in 71% of patients with the occurrence of MCVE CONCLUSION: This study evidenced the high presence of the new "not pure" pattern of PAH, which could worsen the outcome in SSc in a medium-term (5 years) observation period. Furthermore, our data confirmed a higher cardiovascular impairment in SSc due to the presence of both SCA, mainly associated with typical cardiovascular risk factors, and PAH, life-threatening complications of SSc, that is the principal cause of the occurrence of MCVE in our SSc patients. A careful assessment of cardiovascular involvement in SSc and a more aggressive therapeutic strategy for preventing CAD and treating PAH should be highly suggested to reduce MCVE in SSc patients.
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Affiliation(s)
- C Rotondo
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - S Sciacca
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - V Rella
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy
| | - G Busto
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - R Colia
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy
| | - F P Cantatore
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - A Corrado
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
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14
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Kato M, Ninagawa K, Atsumi T. Comment on: Beneficial effects of nintedanib on cardiomyopathy in patients with systemic sclerosis: a pilot study: reply. Rheumatology (Oxford) 2023; 62:e278-e279. [PMID: 36707999 DOI: 10.1093/rheumatology/kead037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/29/2023] Open
Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Keita Ninagawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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15
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Ninagawa K, Kato M, Tsuneta S, Ishizaka S, Ujiie H, Hisada R, Kono M, Fujieda Y, Ito YM, Atsumi T. Beneficial effects of nintedanib on cardiomyopathy in patients with systemic sclerosis: a pilot study. Rheumatology (Oxford) 2023; 62:2550-2555. [PMID: 36458921 DOI: 10.1093/rheumatology/keac674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/29/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Nintedanib is an inhibitor of tyrosine kinases that has been shown to slow the progression of interstitial lung disease (ILD), including ILD associated with SSc. The aim of this study was to explore the effect of nintedanib on cardiomyopathy associated with systemic sclerosis (SSc). METHODS Twenty consecutively hospitalized patients with SSc-ILD were enrolled and prospectively followed. The rate of change at 6 months in cardiac magnetic resonance (CMR) parametric mapping, including myocardial extracellular volume, was primarily evaluated. Other endpoints included changes in CMR functional parameters, echocardiographic parameters, modified Rodnan skin score, serum biomarkers and pulmonary function test. RESULTS Nintedanib was administered in 10 patients, whereas the other 10 were treated without nintedanib or watched, according to ILD severity and progression. Baseline values of CMR parametric mapping were not different between the two groups. The rate of change at 6 months in myocardial extracellular volume was highly different, almost divergent, between the nintedanib group and the control group (-1.62% vs +2.00%, P = 0.0001). Among other endpoints, the change in right ventricular ejection fraction was significantly different between the two groups (P = 0.02), with a preferential change in the nintedanib group. CONCLUSION Our data indicate beneficial signals of nintedanib on cardiomyopathy associated with SSc. The anti-fibrotic effect of nintedanib might not be limited to the lung.
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Affiliation(s)
- Keita Ninagawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satonori Tsuneta
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Ujiie
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Michihito Kono
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoichi M Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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16
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Penglase R, Girgis L, Englert H, Brennan X, Jabbour A, Kotlyar E, Ma D, Moore J. Cardiotoxicity in autologous haematopoietic stem cell transplantation for systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:87-100. [PMID: 37287946 PMCID: PMC10242691 DOI: 10.1177/23971983221145639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/15/2022] [Indexed: 09/20/2023]
Abstract
Autologous haematopoietic stem cell transplantation is now well-established as an effective treatment for severe systemic sclerosis with clear demonstration of favourable end-organ and survival outcomes. Treatment-related cardiotoxicity remains the predominant safety concern and contraindicates autologous haematopoietic stem cell transplantation in patients with severe cardiopulmonary disease. In this review, we describe the cardiovascular outcomes of autologous haematopoietic stem cell transplantation recipients, discuss the potential mechanisms of cardiotoxicity and propose future mitigating strategies.
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Affiliation(s)
- Ross Penglase
- Department of Rheumatology, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Laila Girgis
- Department of Rheumatology, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Helen Englert
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Xavier Brennan
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Andrew Jabbour
- University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Eugene Kotlyar
- University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - David Ma
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - John Moore
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
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Matsumori A. Myocarditis and Autoimmunity. Expert Rev Cardiovasc Ther 2023. [PMID: 37243585 DOI: 10.1080/14779072.2023.2219895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Autoimmune myocarditis may develop due to heterogeneous causes. Myocarditis is often caused by viral infections, but it can also be caused by systemic autoimmune diseases. Immune checkpoint inhibitors and virus vaccines induce immune activation, and they can cause the development of myocarditis, as well as several immune-related adverse events. The development of myocarditis is dependent on the genetic factors of the host, and the major histocompatibility complex (MHC) may be an important determinant of the type and severity of the disease. However, non-MHC immunoregulatory genes may also play a role in determining susceptibility. AREA COVERED This review summarizes the current knowledge of the etiology, pathogenesis, diagnosis and treatment of autoimmune myocarditis with a particular focus on viral infection and autoimmunity, and biomarkers of myocarditis. EXPERT OPINION An endomyocardial biopsy may not be the gold standard for the diagnosis of myocarditis. Cardiac magnetic resonance imaging is useful in diagnosing autoimmune myocarditis. Recently identified biomarkers of inflammation and myocyte injury are promising for the diagnosis of myocarditis when measured simultaneously. Future treatments should focus on the appropriate diagnosis of the etiologic agent, as well as on the specific stage of the evolution of immune and inflammatory processes.
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Affiliation(s)
- Akira Matsumori
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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18
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Meloni A, Gargani L, Bruni C, Cavallaro C, Gobbo M, D'Agostino A, D'Angelo G, Martini N, Grigioni F, Sinagra G, De Caterina R, Quaia E, Mavrogeni S, Cademartiri F, Matucci-Cerinic M, Pepe A. Additional value of T1 and T2 mapping techniques for early detection of myocardial involvement in scleroderma. Int J Cardiol 2023; 376:139-146. [PMID: 36731634 DOI: 10.1016/j.ijcard.2023.01.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/16/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND We evaluated the prevalence of myocardial involvement by native T1 and T2 mapping, the diagnostic performance of mapping in addition to conventional Lake Louise Criteria (LLC), as well as correlations between mapping findings and clinical or conventional cardiovascular magnetic resonance (CMR) parameters in systemic sclerosis (SSc) patients. METHODS Fifty-five SSc patients (52.31 ± 13.24 years, 81.8% female) and 55 age- and sex-matched healthy subjects underwent clinical, bio-humoral assessment, and CMR. The imaging protocol included: T2-weighted, early post-contrast cine sequences, native T1 and T2 mapping by a segmental approach, and late gadolinium enhancement (LGE) technique. RESULTS Global myocardial T1 and T2 values were significantly higher in SSc patients than in healthy subjects. An increase in native T1 and/or T2 was present in the 62.1% of patients with normal conventional CMR techniques (negative LGE and T2-weighted images). Respectively, 13.5% and 59.6% of patients fulfilled original and updated LLC (overall agreement = 53.9%). Compared with patients with normal native T1, patients with increased T1 (40.0%) featured significantly higher left ventricular end-diastolic volume index and cardiac index, biventricular stroke volume indexes, and global heart T2 values, and more frequently had a history of digital ulcers. Biochemical and functional CMR parameters were comparable between patients with normal and increased T2 (61.8%). CONCLUSION T1 and T2 mapping are sensitive parameters that should be included in the routine clinical assessment of SSc patients for detecting early/subclinical myocardial involvement.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy; Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Camilla Cavallaro
- Cardiovascular Department, University Campus Bio-Medico, Roma, Italy
| | - Marco Gobbo
- Cardiovascular Department, Azienda Sanitaria Universitaria di Trieste, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andreina D'Agostino
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Gennaro D'Angelo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nicola Martini
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria di Trieste, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy.
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19
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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20
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Matas-García A, Guillén-Del-Castillo A, Kisluk B, Selva-O'Callaghan A, Espinosa G, Prieto-González S, Moreno Lozano P, Garrabou G, Grau-Junyent JM, Simeon-Aznar CP, Milisenda JC. Clinico-pathological phenotypes of systemic sclerosis-associated myopathy: analysis of a large multicentre cohort. Rheumatology (Oxford) 2023; 62:SI82-SI90. [PMID: 35713496 DOI: 10.1093/rheumatology/keac361] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The objective of this study was to analyse the clinico-serological and histological phenotypes of patients with SSc with associated myopathy. METHODS From November 2002 to September 2020, 52 patients with SSc underwent a muscle biopsy for suspected myopathy. We established two subgroups according to the histological findings based on the presence of isolated fibrosis or fibrosis together with significant inflammation. These patterns were designated as fibrosing and inflammatory, respectively. Clinical data, antibody profile, electrophysiologic studies, muscle biopsy findings and data regarding treatment, mortality and survival were compared between the two groups. RESULTS Fourteen biopsies had a fibrosing pattern, whereas 26 showed an inflammatory pattern that could be classified (according to the predominant pattern) into DM (n = 7), necrotizing myopathy (n = 4) and non-specific myositis (n = 15). Additionally, 12 muscle biopsies were reported as neurogenic atrophy (n = 2), or normal muscle or minimal changes (n = 10). Compared with the inflammatory group, SSc patients with the fibrosing pattern presented a higher prevalence of ischaemic heart disease (38.5% vs 3.8%, P = 0.011), conduction abnormalities or arrhythmias (61.5% vs 26.9%, P = 0.036), anti-topo I antibodies (42.9% vs 11.5%, P = 0.044), greater median ESR (53.5 mm/h vs 32.5 mm/h, P = 0.013), with poor response to treatment and a higher mortality (42.9% vs 3.8%, P = 0.004) and lower cumulative survival (P = 0.035). CONCLUSIONS Patients with SSc-associated myopathy require a comprehensive approach that encompasses clinical, serological and histopathological aspects, given their outcome predictive capacity. At least two different phenotypes can be drawn, considering clinico-pathological features. Significant differences are delineated between both a fibrotic and an inflammatory phenotype.
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Affiliation(s)
- Ana Matas-García
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
| | - Alfredo Guillén-Del-Castillo
- Systemic Autoimmune Diseases Unit, Internal Medicine Service, Hospital Universitari Vall d'Hebron (HVH), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Boris Kisluk
- Rheumathology Service, Hospital Escuela Eva Perón, Santa Fe, Argentina
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Internal Medicine Service, Hospital Universitari Vall d'Hebron (HVH), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Sergio Prieto-González
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
| | - Pedro Moreno Lozano
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
| | - Glòria Garrabou
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
| | - Josep María Grau-Junyent
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
| | - Carmen Pilar Simeon-Aznar
- Systemic Autoimmune Diseases Unit, Internal Medicine Service, Hospital Universitari Vall d'Hebron (HVH), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - José C Milisenda
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona (HCB), Universidad de Barcelona and Center for Biomedical Research on Rare Diseases (CIBERER)
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21
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Zanatta E, Huscher D, Ortolan A, Avouac J, Airò P, Balbir-Gurman A, Siegert E, Matucci Cerinic M, Cozzi F, Riemekasten G, Hoffmann-Vold AM, Distler O, Gabrielli A, Heitmann S, Hunzelmann N, Montecucco C, Morovic-Vergles J, Ribi C, Doria A, Allanore Y. Phenotype of limited cutaneous systemic sclerosis patients with positive anti-topoisomerase I antibodies: data from the EUSTAR cohort. Rheumatology (Oxford) 2022; 61:4786-4796. [PMID: 35348643 DOI: 10.1093/rheumatology/keac188] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/09/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To characterize patients with positive anti-topoisomerase I (ATA) in lcSSc. METHODS SSc patients enrolled in the EUSTAR cohort with a disease duration of ≤3 years at database entry were considered. We assessed the risk of major organ involvement in the following groups: ATA-lcSSc vs ACA-lcSSc and vs ANA without specificity (ANA)-lcSSc, and ATA-lcSSc vs ATA-dcSSc. Cox regression models with time-dependent covariates were performed with the following outcomes: new-onset interstitial lung disease (ILD), ILD progression [forced vital capacity (FVC) decline ≥10% and ≥5% vs values at ILD diagnosis), primary myocardial involvement (PMI), pulmonary hypertension (PH), any organ involvement and all-cause mortality. RESULTS We included 1252 patients [194 ATA-lcSSc (15.5%)], with 7.7 years (s.d. 3.5) of follow-up. ILD risk was higher in ATA-lcSSc vs ACA- and ANA-lcSSc and similar to ATA-dcSSc, although with less frequent restrictive lung disease. The risk of FVC decline ≥10% (35% of ATA-lcSSc) was lower in ATA-lcSSc than in ATA-dcSSc, whereas FVC decline ≥5% occurs similarly between ATA-lcSSc (58% of patients) and other SSc subsets, including ATA-dcSSc. The risk of PMI was similar in ATA-lcSSc and ANA-lcSSc but lower than in ACA-lcSSc; no difference in PH and mortality risk was observed among lcSSc subsets. The risk of any organ involvement, PMI and PH was lower and the mortality tended to be lower in ATA-lcSSc vs ATA-dcSSc. CONCLUSION ATA-lcSSc patients have a high risk of ILD, albeit with a lower risk of progression compared with ATA-dcSSc, supporting careful screening for ILD in this subgroup.
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Affiliation(s)
- Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Jérôme Avouac
- Service de Rhumatologie, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
| | - Paolo Airò
- Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - Alexandra Balbir-Gurman
- B. Shine Rheumatology Institute Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Elise Siegert
- Department of Rheumatology and Clinical Immunology, Charité-Universitatsmedizin Berlin, Berlin, Germany
| | - Marco Matucci Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence
| | - Franco Cozzi
- Internal Medicine Unit, Ospedale Classificato Villa Salus, Venice, Italy
| | - Gabriela Riemekasten
- Department of Rheumatology, Universitatsklinikum Schleswig Holstein-Campus Lübeck, Lübeck, Germany
| | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Armando Gabrielli
- Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy
| | - Stefan Heitmann
- Department of Rheumatology, Marienhospital Stuttgart, Stuttgart
| | - Nicolas Hunzelmann
- Department of Dermatology, University of Cologne, Köln, Nordrhein-Westfalen, Germany
| | | | - Jadranka Morovic-Vergles
- Division of Clinical Immunology, Allergology and Rheumatology, Department of Internal Medicine, Dubrava University Hospital, Zagreb, Croatia
| | - Camillo Ribi
- Service d'immunologie et Allergie, Département de Médecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Yannick Allanore
- Service de Rhumatologie, Hôpital Cochin, APHP, Université Paris Descartes, Paris, France
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22
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Ferlito A, Campochiaro C, Tomelleri A, Dagna L, De Luca G. Primary heart involvement in systemic sclerosis, from conventional to innovative targeted therapeutic strategies. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:179-188. [PMID: 36211207 PMCID: PMC9537702 DOI: 10.1177/23971983221083772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/08/2022] [Indexed: 10/03/2023]
Abstract
Primary heart involvement is frequent in systemic sclerosis, even though often sub-clinical, and includes cardiac abnormalities that are predominantly attributable to systemic sclerosis rather than other causes and/or complications. A timely diagnosis is crucial to promptly start the appropriate therapy and to prevent the potential life-threatening early and late complications. There is little evidence on how to best manage systemic sclerosis-primary heart involvement as no specific treatment recommendations for heart disease are available, and a shared treatment approach is still lacking. The objective of this review is to summarize the state of the art of current literature and the overall management strategies and therapeutic approaches for systemic sclerosis-primary heart involvement. Novel insights into pathogenic mechanisms of systemic sclerosis-primary heart involvement are presented to facilitate the comprehension of therapeutic targets and novel treatment strategies.
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Affiliation(s)
| | - Corrado Campochiaro
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Tomelleri
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University,
Milan, Italy
- Unit of Immunology, Rheumatology,
Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
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23
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Panopoulos S, Mavrogeni S, Vlachopoulos C, Sfikakis PP. Cardiac magnetic resonance imaging before and after therapeutic interventions for systemic sclerosis-associated myocarditis. Rheumatology (Oxford) 2022; 62:1535-1542. [PMID: 36083014 DOI: 10.1093/rheumatology/keac504] [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: 04/13/2022] [Revised: 07/25/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Cardiac Magnetic Resonance (CMR) imaging is increasingly used to evaluate cardiac involvement in Systemic Sclerosis (SSc). We assessed changes, including inflammatory and/or fibrotic myocardial lesions detected by CMR, following therapeutic interventions for SSc-associated symptomatic myocarditis. METHODS In this retrospective study, myocarditis was diagnosed by CMR (2018 revised Lake Louise criteria) in 14 diffuse and 4 limited SSc patients (16/18 women, aged 56 ± 11 years, disease duration 8 ± 11 years, 17/18 with lung involvement) with cardiac symptoms and abnormal findings in echocardiography (4/18) and/or in 24-h Holter monitoring (12/14). CMR was repeated after 8 ± 3 months following administration of cyclophosphamide (n = 11, combined with corticosteroids in 3 and rituximab in 1), mycophenolate (n = 1), tocilizumab (n = 1), methotrexate/corticosteroids (n = 2), corticosteroids (n = 1) or autologous stem cell transplantation (n = 2). RESULTS Functional cardiac improvement was evident by increases in left (by 5.8%±7.8%, p= 0.006) and right ventricular ejection fraction (by 4.5%±11.4%, p= 0.085) in the second CMR compared with the first. Notably, Late Gadolinium Enhancement, currently considered to denote replacement fibrosis, decreased by 3.1%±3.8% (p= 0.003), resolving in 6 patients. Markers of myocardial oedema, namely T2-ratio and T2-mapping, decreased by 0.27 ± 0.40 (p= 0.013) and 6.0 ± 7 (p= 0.025), respectively. Conversely, both T1-mapping, considered to reflect acute oedema and diffuse fibrosis, and extracellular volume fraction, reflecting diffuse fibrosis, remained unchanged. CONCLUSIONS CMR may distinguish between reversible inflammatory/fibrotic and irreversible fibrotic lesions in SSc patients with active myocarditis, confirming the unique nature of primary cardiac involvement in SSc. Whether, and how, CMR should be used to monitor treatment effects in SSc-associated myocarditis warrants further study.
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Affiliation(s)
- Stylianos Panopoulos
- First Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Charalambos Vlachopoulos
- First Cardiology Department, Hippokration General Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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24
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Cacciapaglia F, Airò P, Fornaro M, Trerotoli P, De Lorenzis E, Corrado A, Lazzaroni MG, Natalello G, Montini F, Altomare A, Urso L, Verardi L, Bosello SL, Cantatore FP, Iannone F. Survival and Prognostic factors from a multicentre large cohort of unselected Italian Systemic Sclerosis patients. Rheumatology (Oxford) 2022; 62:1552-1558. [PMID: 36074979 DOI: 10.1093/rheumatology/keac512] [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: 04/20/2022] [Revised: 08/03/2022] [Accepted: 08/23/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Survival and death prognostic factors of systemic sclerosis (SSc) patients varied during the last decades. We aimed to update the 5- and 10-year survival rates and identify prognostic factors in a multicentre cohort of Italian SSc patients diagnosed after 2009. METHODS Patients who received a diagnosis of SSc after January 1st, 2009, and were longitudinally followed up in 4 Italian Rheumatologic Centres were retrospectively assessed up to December 31st, 2020. Overall survival of SSc patients was described using the Kaplan-Meier method. Predictors of mortality at 10-year follow-up were assessed by the Cox-regression model. A comparison of our cohort with the Italian general population was performed by determining the standardized mortality ratio (SMR). RESULTS A total of 912 patients (91.6% females, 20% dcSSc) were included. Overall survival rates at 5 and 10 years were 94.4%, and 89.4% respectively. The SMR was 0.96 (95% CI 0.81-1.13), like that expected in the Italian general population. Pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) associated with pulmonary hypertension (PH) significantly reduced survival (p< 0.0001). Main death predictors were male gender (HR = 2.76), diffuse cutaneous involvement (HR = 3.14), older age at diagnosis (HR = 1.08), PAH (HR = 3.21), ILD-associated PH (HR = 4.11), comorbidities (HR = 3.53), and glucocorticoid treatment (HR = 2.02). CONCLUSIONS In the last decade, SSc patients have reached similar mortality of that expected in the Italian general population. Male gender, diffuse cutaneous involvement, comorbidities, and PAH with or without ILD represent the main poor prognostic factors.
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Affiliation(s)
- Fabio Cacciapaglia
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Paolo Airò
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University, Brescia, Italy
| | - Marco Fornaro
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Paolo Trerotoli
- Medical Statistics, Department of Biomedical and Human Oncologic Science, University of Bari, Bari, Italy
| | - Enrico De Lorenzis
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Ph.D Program in Biomelocular Medicine, Cicle XXXV, University of Verona, Verona, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University, Brescia, Italy
| | - Gerlando Natalello
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Fabio Montini
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Alberto Altomare
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Livio Urso
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
| | - Lucrezia Verardi
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Silvia Laura Bosello
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Francesco Paolo Cantatore
- Ph.D Program in Biomelocular Medicine, Cicle XXXV, University of Verona, Verona, Italy
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantations, Rheumatology Unit, University and AOUC Policlinico of Bari, Bari, Italy
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25
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Caforio ALP, De Luca G, Baritussio A, Seguso M, Gallo N, Bison E, Cattini MG, Pontara E, Gargani L, Pepe A, Campochiaro C, Plebani M, Iliceto S, Peretto G, Esposito A, Tofani L, Moggi-Pignone A, Dagna L, Marcolongo R, Matucci-Cerinic M, Bruni C. Serum Organ-Specific Anti-Heart and Anti-Intercalated Disk Autoantibodies as New Autoimmune Markers of Cardiac Involvement in Systemic Sclerosis: Frequency, Clinical and Prognostic Correlates. Diagnostics (Basel) 2021; 11:2165. [PMID: 34829512 PMCID: PMC8625508 DOI: 10.3390/diagnostics11112165] [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: 10/17/2021] [Revised: 11/09/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Heart involvement (HInv) in systemic sclerosis (SSc) may relate to myocarditis and is associated with poor prognosis. Serum anti-heart (AHA) and anti-intercalated disk autoantibodies (AIDA) are organ and disease-specific markers of isolated autoimmune myocarditis. We assessed frequencies, clinical correlates, and prognostic impacts of AHA and AIDA in SSc. METHODS The study included consecutive SSc patients (n = 116, aged 53 ± 13 years, 83.6% females, median disease duration 7 years) with clinically suspected heart involvement (symptoms, abnormal ECG, abnormal troponin I or natriuretic peptides, and abnormal echocardiography). All SSc patients underwent CMR. Serum AHA and AIDA were measured by indirect immunofluorescence in SSc and in control groups of non-inflammatory cardiac disease (NICD) (n = 160), ischemic heart failure (IHF) (n = 141), and normal blood donors (NBD) (n = 270). AHA and AIDA status in SSc was correlated with baseline clinical, diagnostic features, and outcome. RESULTS The frequency of AHA was higher in SSc (57/116, 49%, p < 0.00001) than in NICD (2/160, 1%), IHF (2/141, 1%), or NBD (7/270, 2.5%). The frequency of AIDA was higher (65/116, 56%, p < 0.00001) in SSc than in NICD (6/160, 3.75%), IHF (3/141, 2%), or NBD (1/270, 0.37%). AHAs were associated with interstitial lung disease (p = 0.04), history of chest pain (p = 0.026), abnormal troponin (p = 0.006), AIDA (p = 0.000), and current immunosuppression (p = 0.01). AHAs were associated with death (p = 0.02) and overall cardiac events during follow-up (p = 0.017). CONCLUSIONS The high frequencies of AHA and AIDA suggest a high burden of underdiagnosed autoimmune HInv in SSc. In keeping with the negative prognostic impact of HInv in SSc, AHAs were associated with dismal prognosis.
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Affiliation(s)
- Alida Linda Patrizia Caforio
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.D.L.); (C.C.); (L.D.); (M.M.-C.)
| | - Anna Baritussio
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Mara Seguso
- Department of Laboratory Medicine, University of Padua, 35122 Padua, Italy; (M.S.); (N.G.); (M.P.)
| | - Nicoletta Gallo
- Department of Laboratory Medicine, University of Padua, 35122 Padua, Italy; (M.S.); (N.G.); (M.P.)
| | - Elisa Bison
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Maria Grazia Cattini
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Elena Pontara
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Luna Gargani
- Institute of Clinical Physiology, National Council of Research, 56124 Pisa, Italy;
| | - Alessia Pepe
- Department of Medicine, Institute of Radiology, University of Padova, 35122 Padova, Italy;
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.D.L.); (C.C.); (L.D.); (M.M.-C.)
| | - Mario Plebani
- Department of Laboratory Medicine, University of Padua, 35122 Padua, Italy; (M.S.); (N.G.); (M.P.)
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy; (A.B.); (E.B.); (M.G.C.); (E.P.); (S.I.)
| | - Giovanni Peretto
- Unit of Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Expirimental Imaging Center, IRCCS San Raffaele Scientific Institute, Ospedale San Raffaele University, 20132 Milan, Italy;
| | - Lorenzo Tofani
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Department of Geriatric Medicine AOUC, University of Florence, 50121 Florence, Italy; (L.T.); (C.B.)
| | - Alberto Moggi-Pignone
- Division of Internal Medicine Unit IV AOUC, Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy;
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.D.L.); (C.C.); (L.D.); (M.M.-C.)
| | - Renzo Marcolongo
- Haematology and Clinical Immunology, Department of Medicine, University of Padua, 35122 Padua, Italy;
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.D.L.); (C.C.); (L.D.); (M.M.-C.)
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Department of Geriatric Medicine AOUC, University of Florence, 50121 Florence, Italy; (L.T.); (C.B.)
| | - Cosimo Bruni
- Division of Rheumatology, Department of Experimental and Clinical Medicine, Department of Geriatric Medicine AOUC, University of Florence, 50121 Florence, Italy; (L.T.); (C.B.)
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