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Cullivan S, Cronin E, Gaine S. Pulmonary Hypertension in Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:411-418. [PMID: 38531379 DOI: 10.1055/s-0044-1782607] [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: 03/28/2024]
Abstract
Systemic sclerosis is a multisystem connective tissue disease that is associated with substantial morbidity and mortality. Visceral organ involvement is common in patients with systemic sclerosis and occurs independently of skin manifestations. Pulmonary hypertension (PH) is an important and prevalent complication of systemic sclerosis. The clinical classification of PH cohorts conditions with similar pathophysiological mechanisms into one of five groups. While patients with systemic sclerosis can manifest with a spectrum of pulmonary vascular disease, notable clinical groups include group 1 pulmonary arterial hypertension (PAH) associated with connective tissues disease, PAH with features of capillary/venous involvement, group 2 PH associated with left heart disease, and group 3 PH associated with interstitial lung disease. Considerable efforts have been made to advance screening methods for PH in systemic sclerosis including the DETECT and ASIG (Australian Scleroderma Interest Group) composite algorithms. Current guidelines recommend annual assessment of the risk of PAH as early recognition may result in attenuated hemodynamic impairment and improved survival. The treatment of PAH associated with systemic sclerosis requires a multidisciplinary team including a PH specialist and a rheumatologist to optimize immunomodulatory and PAH-specific therapies. Several potential biomarkers have been identified and there are several promising PAH therapies on the horizon such as the novel fusion protein sotatercept. This chapter provides an overview of PH in systemic sclerosis, with a specific focus on group 1 PAH.
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Affiliation(s)
- Sarah Cullivan
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eleanor Cronin
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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2
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Ben Shimol J. Perimenopause in women with rheumatologic diseases: a spotlight on an under-addressed transition. Climacteric 2024; 27:115-121. [PMID: 37990992 DOI: 10.1080/13697137.2023.2276201] [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: 06/22/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023]
Abstract
Abundant research has been published describing the effects invoked during menopause across different organ systems. Changing levels of estrogen and progesterone result in bidirectional alterations of immune cell pathways. Overall, the net trend dampens immunoregulation and promotes inflammation. In paradigmatic rheumatologic diseases, the combined effect is far from predictable. While some features may abate during menopause, studies have shown a general increased frequency toward disease exacerbation. Similarly, while impossible to isolate the ramifications of menopause in women with fibromyalgia, a tendency toward enhanced symptoms is unquestionably apparent. Furthermore, the comorbidities accrued by increasing age and the consequences of long-term medication use may also confound this picture. Periodic rheumatologic visits are warranted, with clinical assessments directed toward a multi-disciplinary approach. Ultimately, while an arsenal of effective tools is available for caring for these women and their underlying conditions, more studies are needed to better clarify how the different stages surrounding perimenopause affect subpopulations with rheumatic diseases and fibromyalgia-related disorders so that clinical course can be predicted and addressed prior to the emergence of symptomatology.
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Affiliation(s)
- J Ben Shimol
- Department of Rheumatology, Barzilai University Medical Center, Ashqelon, Israel
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3
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Xanthouli P, Echampati I, Lorenz HM, Heussel CP, Benjamin N. Respiratory involvement in connective tissue diseases. Eur J Intern Med 2024; 120:11-16. [PMID: 37845118 DOI: 10.1016/j.ejim.2023.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Abstract
Pulmonary involvement is doubtless one the most fatal organ manifestations of the autoimmune rheumatic diseases (ARD) and involves the parenchyma, the vessels, the respiratory system itself, but also the muscles and the pleura. Close and regular screening assessments, identification of risk factors, clinical signs associated with the existence of lung disease should alarm the involved physicians treating these patients. The accurate classification is essential, as different treatment options are nowadays available. Pulmonary manifestations of ARD will be analyzed in this review article with special emphasis on interstitial lung disease and pulmonary hypertension.
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Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany; Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany; Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research, Germany.
| | - Ishan Echampati
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research, Germany
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Claus Peter Heussel
- Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research, Germany; Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH at Heidelberg University Hospital, Heidelberg, Germany; Diagnostic and Interventional Radiology, Ruprecht-Karls-University, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research, Germany
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4
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [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: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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5
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Nihtyanova SI, Schreiber BE, Ong VH, Wells AU, Coghlan JG, Denton CP. Dynamic Prediction of Pulmonary Hypertension in Systemic Sclerosis Using Landmark Analysis. Arthritis Rheumatol 2023; 75:449-458. [PMID: 36122180 DOI: 10.1002/art.42349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) is a serious complication of systemic sclerosis (SSc). In this study, we explored the prediction of short-term risk for PH using serial pulmonary function tests (PFTs) and other disease features. METHODS SSc patients in whom disease onset occurred ≥10 years prior to data retrieval and for whom autoantibody specificity and PFT data were available were included in this study. Mixed-effects modeling was used to describe changes in PFTs over time. Landmarking was utilized to include serial assessments and stratified Cox proportional hazards regression analysis with landmarks as strata was used to develop the PH prediction models. RESULTS We analyzed data from 1,247 SSc patients, 16.3% of whom were male and 35.8% of whom had diffuse cutaneous SSc. Anticentromere, antitopoisomerase, and anti-RNA polymerase antibodies were observed in 29.8%, 22.0%, and 11.4% of patients, respectively, and PH developed in 13.6% of patients. Over time, diffusing capacity for carbon monoxide (DLco) and carbon monoxide transfer coefficient (Kco) declined in all SSc patients (up to 1.5% per year) but demonstrated much greater annual decline (up to 4.5% and 4.8%, respectively) in the 5-7 years preceding PH diagnosis. Comparisons between multivariable models including either DLco, Kco, or forced vital capacity (FVC)/DLco ratio, demonstrated that both absolute values and change over the preceding year in those measurements were strongly associated with the risk of PH (hazard ratio [HR] 0.93 and 0.76 for Kco and its change; HR 0.90 and 0.96 for DLco and its change; and HR 1.08 and 2.01 for FVC/DLco ratio and its change; P < 0.001 for all). The Kco-based model had the greatest discriminating ability (Harrell's C-statistic 0.903). CONCLUSION Our findings strongly support the importance of PFT trends over time in identifying patients at risk of developing PH.
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Affiliation(s)
- Svetlana I Nihtyanova
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK, and GSK, London, UK
| | | | - Voon H Ong
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - John G Coghlan
- Pulmonary Hypertension Service, Royal Free Hospital, London, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
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6
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 418] [Impact Index Per Article: 418.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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7
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 988] [Impact Index Per Article: 494.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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8
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Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension. Sci Rep 2022; 12:5289. [PMID: 35347225 PMCID: PMC8960788 DOI: 10.1038/s41598-022-09353-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/11/2022] [Indexed: 11/08/2022] Open
Abstract
To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 ± 20.6% vs 93.6 ± 20.6%, P < 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 ± 5.2 mm vs 19.9 ± 6.7 mm, P < 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P < 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P < 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment.
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9
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Syed Gaggatur N, Sange AH, Srinivas N, Sarnaik MK, Modi S, Pisipati Y, Vaidya S, Sange I. Systemic Sclerosis: Highlighting Respiratory Complications and Significance of Early Screening. Cureus 2021; 13:e17291. [PMID: 34552830 PMCID: PMC8448757 DOI: 10.7759/cureus.17291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/30/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease that leads the patient to have a diverse clinical presentation encompassing several systems and a worse prognosis, mainly when complications arise. Most SSc-related deaths are caused by pulmonary hypertension (PH) and interstitial lung disease (ILD). This article focuses on pulmonary artery hypertension (PAH) and ILD as pulmonary consequences of SSc. We examined the grave effects regarding SSc's respiratory complications, which are concealed by the disease's clinical heterogeneity. In this article, we briefly reviewed the discussion of clinical features and management and the mortality associated with the sequelae. We further addressed the benefits and significance of screening for the disease and associated respiratory complications in SSc patients in this study.
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Affiliation(s)
| | - Aliya H Sange
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Natasha Srinivas
- Research, B. G. S. Global Institute of Medical Sciences, Bangalore, IND
| | | | - Srimy Modi
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Yasaswi Pisipati
- Internal Medicine, M. S. Ramaiah Medical College, Bangalore, IND
| | - Sarayoo Vaidya
- Internal Medicine, M. S. Ramaiah Medical College, Bangalore, IND
| | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, K. J. Somaiya Medical College, Mumbai, IND
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10
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Vilela VS, Dias MM, Salgado ÂA, da Silva BRA, Lopes AJ, Bessa EJC, Bruno LP, da Costa CH, Levy RA, Rufino R. Pulmonary hypertension in systemic sclerosis: diagnosis by systematic screening and prognosis after three years follow-up. BMC Pulm Med 2021; 21:251. [PMID: 34325685 PMCID: PMC8323291 DOI: 10.1186/s12890-021-01618-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/26/2021] [Indexed: 12/25/2022] Open
Abstract
Background Systemic sclerosis (SSc) is a rare disease, and the presence of pulmonary hypertension can be a determining factor in prognosis. The aim of this study was to evaluate the diagnosis, profile, and prognosis of systemic sclerosis pulmonary hypertension (SSc-PH) diagnosed by systematic screening in a Brazilian population.
Methods A cohort of SSc patients underwent systematic screening for SSc-PH. Patients were referred for right heart catheterization (RHC) according to transthoracic echocardiogram or a combination of diagnostic tools. The clinical, immunological, and hemodynamic features and prognosis after 3 years were evaluated.
Results Twenty patients underwent RHC. SSc pulmonary arterial hypertension (SSc-PAH) was the most common group of SSc-PH. These patients had long disease duration, high urate levels and highly elevated mean pulmonary arterial pressure (mPAP) and peripheral vascular resistance (PVR) on hemodynamics. Patients with mPAP > 20– < 25 mmHg had hemodynamic features of intermediate disease. Patients with SSc-PH associated to interstitial lung disease (SSc-ILD-PH) had signs of vasculopathy on hemodynamics. In patients with no-SSc-PH, the survival at 1, 2, and 3 years was 96%, 92% and 92%, respectively and in patients with SSc-PH it was 86.7%, 60% and 53.3%, respectively. Conclusions Patients identified with SSc-PAH and SSc-ILD-PH in our screening had severe clinical and hemodynamic features. Mortality remains high in SSc-PH but was more related to Bo-PAH and SSc-ILD-PH, while in SSc-PAH, the prognosis was better. Trial registration: Current Controlled Trials ISRCTN 72968188, July 8th, 2021. Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01618-z.
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Affiliation(s)
- Verônica Silva Vilela
- Rheumatology Discipline, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Marcio Macri Dias
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Ângelo Antunes Salgado
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Bruno Rangel Antunes da Silva
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Agnaldo José Lopes
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Elizabeth Jauhar Cardoso Bessa
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Leonardo Palermo Bruno
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Cláudia Henrique da Costa
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil
| | - Roger Abramino Levy
- Rheumatology Discipline, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil.,Immunology and Specialty Medicine, GSK, 1250 Collegville Rd, Collegeville, PA, 19426, USA
| | - Rogério Rufino
- Cardiology Discipline, Thorax Diseases Department, State University of Rio de Janeiro, Hospital Universitário Pedro Ernesto, Third Floor, Boulevard 28 de Setembro 77, Rio de Janeiro, 20551-031, Brazil.
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Naranjo M, Hassoun PM. Systemic Sclerosis-Associated Pulmonary Hypertension: Spectrum and Impact. Diagnostics (Basel) 2021; 11:911. [PMID: 34065226 PMCID: PMC8161029 DOI: 10.3390/diagnostics11050911] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a catastrophic complication of one of the most common and devastating autoimmune diseases. Once diagnosed, it becomes the leading cause of mortality among this patient population. Screening modalities and risk assessments have been designed and validated by various organizations and societies in order to identify patients early in their disease course and promptly refer them to expert centers for a hemodynamic assessment and formal diagnosis. Moreover, several large multicenter clinical trials have now included patients with SSc-PAH to assess their response to therapy. Despite an improved understanding of the condition and significant advances in supportive and targeted therapy, outcomes have remained far from optimal. Therefore, rigorous phenotyping and search for novel therapies are desperately needed for this devastating condition.
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Affiliation(s)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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12
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Endocan and Circulating Progenitor Cells in Women with Systemic Sclerosis: Association with Inflammation and Pulmonary Hypertension. Biomedicines 2021; 9:biomedicines9050533. [PMID: 34064667 PMCID: PMC8150353 DOI: 10.3390/biomedicines9050533] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 01/24/2023] Open
Abstract
Background: Systemic sclerosis (SSc) is characterized by early vasculopathy and fibrosis in the skin, lungs, and other tissues. Vascular manifestations of SSc include Raynaud’s phenomenon, digital ulcers, and pulmonary artery hypertension (PAH). PAH is the second most common cause of mortality in SSc. Circulating CD34+ cells associated with cardiovascular health status in several conditions, including chronic immune-inflammatory disease. CD34+ cell numbers have been found inconstantly reduced in SSc. Endocan, a proteoglycan expressed by endothelial cells, was recently suggested as a marker of vascular stress. We tested the relationships among CD34+ cells, endocan, inflammatory markers, vitamin D levels, and clinical parameters in SSc patients with PAH. METHODS: Standard echocardiography was performed. Vitamin D levels, CD34+ cells, inflammatory markers, endocan plasma levels were determined in 36 female SSc patients (24 diffuse/12 limited) and 36 matched controls (HC). RESULTS: We found no difference in CD34+ and vitamin D levels in SSc as compared to controls; ESR, CRP, fibrinogen, endocan, sPAP were higher in SSc with respect to controls. We found a correlation between endocan and: CD34+ cells (r: −0.540, p = 0.002), pulmonary arterial pressure (sPAP) (r: 0.565, p < 0.001), tricuspid annular plane excursion (TAPSE) (r: −0.311, p < 0.01), and E/A ratio (r: −0.487, p < 0.001), but not with ejection fraction (r: −0.057, p = 0.785) in SSc. CD34+ cells correlate with fibrinogen (r: −0.619, p < 0.001), sPAP (r: −0.404, p = 0.011), E/A (r: 0.470, p < 0.005 in SSc. CONCLUSION: CD34+ cell number was significantly correlated with endocan levels and with sPAP in SSc; endocan and CD34+ progenitor cells might be suggested as a potential marker of disease status.
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Brown ZR, Nikpour M. Screening for pulmonary arterial hypertension in systemic sclerosis: Now or never! Eur J Rheumatol 2020; 7:S187-S192. [PMID: 33164734 PMCID: PMC7647680 DOI: 10.5152/eurjrheum.2020.19114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 03/30/2020] [Indexed: 02/05/2023] Open
Abstract
Systemic sclerosis (SSc), a chronic multisystem autoimmune disease characterized by fibrosis of the skin and internal organs and vasculopathy, has a high burden of mortality. One of the major contributors to mortality in patients with SSc is pulmonary arterial hypertension (PAH), which affects up to 10% of individuals and results in up to 15 years of life loss. Best practice recommendations are for asymptomatic patients with SSc and SSc-spectrum disorder to be screened annually for the early detection of SSc-PAH. Recently published data from large registries have shown improvements in the long-term outcomes in patients who are diagnosed with SSc-PAH because of systematic annual screening. This review will address the current clinical and research implications of the screening for the early detection of SSc-PAH.
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Affiliation(s)
- Zoe R. Brown
- Department of Medicine, The University of Melbourne, Victoria, Australia
- Clinic of Rheumatology, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne, Victoria, Australia
- Clinic of Rheumatology, St. Vincent’s Hospital, Melbourne, Victoria, Australia
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14
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Bruni C, De Luca G, Lazzaroni MG, Zanatta E, Lepri G, Airò P, Dagna L, Doria A, Matucci-Cerinic M. Screening for pulmonary arterial hypertension in systemic sclerosis: A systematic literature review. Eur J Intern Med 2020; 78:17-25. [PMID: 32540411 DOI: 10.1016/j.ejim.2020.05.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/04/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
Pulmonary arterial hypertension (PAH) carries a high morbidity and mortality burden in Systemic Sclerosis (SSc). Therefore, PAH screening and early detection are pivotal. A systematic literature review (SLR) to search for all screening tools and modalities for SSc-PAH was performed in reference to right heart catheterization as diagnostic gold standard. Papers from 2 previously published SLRs and derived from a systematic search on Pubmed, EMBASE, Web of Science for papers published from 03/10/2017 to 31/12/2018 were manually included. A total of 199 papers were reviewed and 32 were extracted, with a low bias risk according to QUADAS2. Echocardiography, pulmonary function tests, clinical features and serum biomarkers were the most frequently tools used for screening, with different parameters combined in a variable fashion, as single item or as part of composite algorithms. Among the composite algorithms, the DETECT score, ESC/ERS 2009 or 2015 guidelines, ASIG and ITINER-air algorithms were the most commonly used in a wide range of patients. In different cohorts, DETECT and ASIG showed higher sensitivity and negative predictive value than ESC/ERS 2009. In conclusion, the literature shows echocardiography as the leading screening tool for SSc-PAH. In particular, systolic pulmonary arterial pressure (sPAP) and tricuspid regurgitation velocity (TRV), both as single items or part of composite algorithms, including also serum biomarkers, clinical and functional items, are the most frequent parameters evaluated.
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Affiliation(s)
- Cosimo Bruni
- Dept. Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Viale Pieraccini 18, Florence, 50139, Italy.
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Maria-Grazia Lazzaroni
- Dept. of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Gemma Lepri
- Dept. Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Viale Pieraccini 18, Florence, 50139, Italy
| | - Paolo Airò
- Dept. of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Marco Matucci-Cerinic
- Dept. Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Viale Pieraccini 18, Florence, 50139, Italy
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15
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Wangkaew S, Pota P, Prasertwittayakij N, Phrommintikul A. Incidence, predictors, and survival of pulmonary hypertension determined by echocardiography in Thai patients with early systemic sclerosis (SSc): inception cohort study. Clin Rheumatol 2020; 40:973-980. [PMID: 32683661 DOI: 10.1007/s10067-020-05296-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We investigated the incidence, predictors, and survival of pulmonary hypertension (PH) determined by Doppler echocardiography in Thai patients with early SSc (systemic sclerosis), in which the majority were diffuse cutaneous SSc (DcSSc) with anti-topoisomerase I-positive. METHODS We used an inception cohort study of patients with early SSc seen at the Rheumatology Clinic, Maharaj Nakorn Chiang Mai Hospital. All patients were assessed for clinical data and underwent Doppler echocardiography at the study entry and then annually. RESULTS A total of 133 patients (81 female, 106 DcSSc, 103 anti-topoisomerase I-positive) with a mean disease duration of 11.9 months were recruited. During the mean observational period of 4.2 years, 14 patients developed PH concurrent with ILD and 6 with left heart disease. The incidence rate for the development of PH was 3.95 per 100 person years. The multivariate Cox regression analysis indicated higher NYHA class (HR 6.90, 95% CI 2.28-20.94, p = 0.001), telangiectasia (HR 4.18, 95% CI 1.25-13.92, p = 0.020), and enlarged LA diameter (HR 1.16, 95% CI 1.05-1.28, p = 0.005) as predictors of PH. Raynaud's phenomenon (HR 0.22, 95% CI 0.06-0.84, p = 0.026) and high oxygen saturation (HR 0.80, 95% CI 0.65-0.99, p = 0.047) were protective factors. The survival rate after PH diagnosis at 1, 3, and 5 years were 88.9%, 82.3%, and 48.0%, respectively. CONCLUSIONS In this study cohort, the majority had early DcSSc, the incidence of PH was modest, and all cases developed concomitantly with ILD or left heart disease, resulting in poor survival. The presence of higher NYHA class, telangiectasia, and enlarged LA diameter was predictors of secondary PH. Further study regarding the treatment strategies for PH associated with ILD and left heart disease in SSc is needed. Key Points • In this cohort of early SSc in which the main subtype was DcSSc, the incidence of PH was modest and all PH was secondary PH associated with ILD and left heart disease, resulting in poor survival. • The presence of higher NYHA functional class, telangiectasia, and enlarged LA diameter was baseline predictors of developing secondary PH. • Effective treatment strategies for secondary PH due to ILD and cardiac involvement in SSc patients are urgently needed.
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Affiliation(s)
- Suparaporn Wangkaew
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
| | - Panupong Pota
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | | | - Arintaya Phrommintikul
- Division of Cardiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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16
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Jiang Y, Turk MA, Pope JE. Factors associated with pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). Autoimmun Rev 2020; 19:102602. [PMID: 32659476 DOI: 10.1016/j.autrev.2020.102602] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) is a lethal complication affecting 8-15% of patients. Screening tests such as echocardiography and pulmonary function tests allow for triaging patients for diagnosis by right heart catheterization. Understanding risk factors of SSc-PAH could help differentiate high-risk patients. METHODS A systematic review was conducted to determine associations with SSc-PAH, including clinical/disease characteristics, antibodies, labs and biomarkers. The frequencies of publications featuring each risk/association were reported. RESULTS Among 2654 articles, 984 duplicates and 1578 irrelevant articles were removed, leaving 92 articles for manual screening. After excluding 55 papers with small sample sizes, publications from identical cohorts, not English language, or PAH not ascertained by RHC, 37 articles were eligible. A total of 43 factors for SSc-PAH were identified within seven categories. Several associations were due to PAH and risk factors such as dynpnea, right heart failure, and short 6-minute walk distance. Patient characteristics (14), pulmonary physiology (6), antibody profiles (6) and genetics/epigenetics (6) had the most numerous and diverse factors, while biomarkers (4) and other labs (2) features were infrequent. Low carbon monoxide (DLCO) (6), older age (4), longer disease duration (4), positive anticentromere antibodies (ACA) (4), telangiectasias (4), high brain natriuretic peptide (4) were frequent associations. CONCLUSIONS Risk factors for SSc-PAH such as ACA, older age, longer disease duration limited cutaneous SSc subset and presence of ILD may enrich screening programs. Genes and other antibody profiles are inconsistent and requires further validation.
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Affiliation(s)
- Yuxuan Jiang
- Department of Biochemistry, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada
| | | | - Janet E Pope
- Department of Rheumatology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada; Division of Rheumatology, St. Joseph's Healthcare London, London, ON, Canada.
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17
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Successful Use of Hyperbaric Oxygen as Adjunctive Therapy for a Nonhealing Venous Ulcer in a Patient with Systemic Sclerosis and Pulmonary Arterial Hypertension: A Case Report and Review of the Literature. Case Rep Pulmonol 2020; 2020:4750375. [PMID: 32181042 PMCID: PMC7060445 DOI: 10.1155/2020/4750375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/07/2020] [Indexed: 11/18/2022] Open
Abstract
Skin ulcers are a common complication of systemic sclerosis (SSc) that can significantly impact the quality of life. There have been recent reports on the use of hyperbaric oxygen therapy (HBO2T) in the management of nonhealing systemic sclerosis skin ulcers. The effect of HBO2T on pulmonary arterial hypertension (PAH), another common and potentially life-threatening complication of SSc, is unclear with literature on the subject lacking. We present the case of a 65-year-old female with limited SSc complicated by severe PAH and a nonhealing left lower extremity venous ulcer. HBO2T was successfully used as an adjunct in her management resulting in complete resolution of the venous ulcer and improved quality of life without any adverse effects on her pulmonary arterial hypertension.
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18
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Saygin D, Domsic RT. Pulmonary Arterial Hypertension In Systemic Sclerosis: Challenges In Diagnosis, Screening And Treatment. Open Access Rheumatol 2019; 11:323-333. [PMID: 31920409 PMCID: PMC6939800 DOI: 10.2147/oarrr.s228234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/15/2019] [Indexed: 12/31/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem autoimmune disease characterized by vasculopathy, fibrosis and immune system activation. Pulmonary hypertension and interstitial lung disease account for majority of SSc-related deaths. Diagnosis of SSc-PAH can be challenging due to nonspecific clinical presentation which can lead to delayed diagnosis. Many screening algorithms have been developed to detect SSc-associated pulmonary arterial hypertension (SSc-PAH) in early stages. Currently used PAH-specific medications are largely extrapolated from IPAH studies due to smaller number of patients with SSc-PAH. In this review, we discuss the current state of knowledge in epidemiology and risk factors for development of SSc-PAH, and challenges and potential solutions in the diagnosis, screening and management of SSc-PAH.
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Affiliation(s)
- Didem Saygin
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Poindron V, Chatelus E, Canuet M, Gottenberg JE, Arnaud L, Gangi A, Gavand PE, Guffroy A, Korganow AS, Germain P, Sibilia J, El Ghannudi S, Martin T. T1 mapping cardiac magnetic resonance imaging frequently detects subclinical diffuse myocardial fibrosis in systemic sclerosis patients. Semin Arthritis Rheum 2019; 50:128-134. [PMID: 31301817 DOI: 10.1016/j.semarthrit.2019.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES cardiac involvement is the second most frequent systemic sclerosis (SSc) related cause of death. It remains mostly asymptomatic in the early stage and is underdiagnosed with routine screening. Cardiac magnetic resonance imaging (CMR) could improve cardiac assessment of patients and noteworthily, new sequences allow the detection of diffuse myocardial fibrosis (DMF) by native T1 mapping. The aim of this study was to determine the prevalence of cardiac involvement by CMR native T1 mapping and its correlation with echocardiography data and non-cardiac manifestations in SSc patients. METHODS patients fulfilling the ACR/EULAR classification criteria for SSc were prospectively included between 2014 and 2016. They underwent CMR at 1.5T, including native T1 and T2 mapping, and Late Gadolinium Enhancement (LGE) as a part of routine follow up. Routine biological tests (mainly BNP and CRP) were centralized in the hospital laboratory. RESULTS seventy-two unselected patients were included. Thirty six patients (50%) had elevated T1 (ET1) (mean T1 1097±14 ms). CMR cardiac functional parameters were similar in ET1 and normal T1 (NT1). Echocardiography was normal in 18 (50%) of ET1. ET1 and NT1 groups were similar for cardiovascular risk factors and ischemic heart disease. ET1 was not correlated with any clinical or echocardiographic parameter or antibody profile. Thirty-six percent of patients with ET1 had no cardiac symptoms, normal echocardiography and CMR LVEF, and no LGE. CONCLUSION native T1 mapping detects left ventricular ET1 (potential DMF) in 50% of patients with SSc and a third of them had a normal conventional screening including standard CMR. In the future, further studies are needed to confirm the benefit of use of native T1 mapping as a part of routine follow up to detect earlier pejorative cardiac involvement in SSc patients.
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Affiliation(s)
- Vincent Poindron
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Clinical Immunology and Internal Medicine, University Hospital of Strasbourg, France.
| | - Emmanuel Chatelus
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Rheumatology, University Hospital of Strasbourg, France
| | - Matthieu Canuet
- Department of Pneumology, University Hospital of Strasbourg, France
| | - Jacques-Eric Gottenberg
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Rheumatology, University Hospital of Strasbourg, France
| | - Laurent Arnaud
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Rheumatology, University Hospital of Strasbourg, France
| | - Afshin Gangi
- Department of Radiology, University Hospital of Strasbourg, France
| | - Pierre-Edouard Gavand
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Clinical Immunology and Internal Medicine, University Hospital of Strasbourg, France
| | - Aurélien Guffroy
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Clinical Immunology and Internal Medicine, University Hospital of Strasbourg, France
| | - Anne-Sophie Korganow
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Clinical Immunology and Internal Medicine, University Hospital of Strasbourg, France
| | - Philippe Germain
- Department of Radiology, University Hospital of Strasbourg, France
| | - Jean Sibilia
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Rheumatology, University Hospital of Strasbourg, France
| | - Soraya El Ghannudi
- Department of Radiology, University Hospital of Strasbourg, France; Department of Nuclear Medicine, University Hospital of Strasbourg, France; ICube, UMR 7357, University of Strasbourg, France
| | - Thierry Martin
- National Referral Center for Systemic Autoimmune Diseases RESO, University Hospital of Strasbourg, France; Clinical Immunology and Internal Medicine, University Hospital of Strasbourg, France
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20
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Allanore Y, Gharibdoost F, Jamshidi AR, Javinani A, Avouac J, Rastkar E, Hooshmandi S, Kavosi H. Comparison of the clinical phenotype of systemic sclerosis patients in Iran and France in two university centers. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:149-159. [PMID: 35382390 PMCID: PMC8922647 DOI: 10.1177/2397198318809224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/30/2018] [Indexed: 06/29/2024]
Abstract
OBJECTIVES Systemic sclerosis is a severe and rare chronic auto-immune multisystem disorder characterized by vasculopathy and skin stiffness. Ethnic and geographical origin can influence the outcomes. In this study, we compared the phenotypic characteristics of Iranian and French patients. METHODS This cross-sectional study was performed on 200 Iranian and 268 French systemic sclerosis patients. Iranian patients collected from the Iranian systemic sclerosis cohort of the Rheumatology Research Center, Shariati hospital, Tehran University of Medical Sciences. The French population was monocentric, and it was constituted by the patients included locally in the EUSTAR database in December 2016. RESULTS The mean age at onset was significantly lower in Iranian patients (35.58 ± 11.68 vs 47.06 ± 13.54, p-value < 0.001). The female-to-male ratio was approximately 5.2:1 and was not different in the two populations. The prevalence of diffuse cutaneous systemic sclerosis was significantly higher in Iranian patients (60.2% vs 42.85%, p-value < 0.001). Calcinosis cutis and joint synovitis were more prevalent in French patients (p-value = 0.013, <0.001). The positivity of anti-topoisomerase antibody was higher in Iranian patients, whereas the anti-centromere antibody predominated in French cases (p-value < 0.001). Restrictive pattern of pulmonary function test was more common in Iranian patients (p-value < 0.001), while estimated pulmonary arterial pressure by echocardiography was higher in French patients (p-value < 0.001). CONCLUSION It seems that systemic sclerosis occurred in younger ages among Iranian female with the predominance of diffuse cutaneous subtype. In addition, lung interstitial disease appeared to be more prevalent and severe in Iranians than French patients.
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Affiliation(s)
- Yannick Allanore
- Department of Rheumatology, Cochin Hospital, Paris Descartes University, Paris, France
| | - Farhad Gharibdoost
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Reza Jamshidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Javinani
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jérôme Avouac
- Department of Rheumatology, Cochin Hospital, Paris Descartes University, Paris, France
| | - Elnaz Rastkar
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sadid Hooshmandi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Kavosi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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21
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Rodríguez-Reyna TS, Rosales-Uvera SG, Kimura-Hayama E, Hernández-Reyes P, Mercado-Velázquez P, Benavides-Suárez SA, Esquinca-González A, Núñez-Álvarez CA. Myocardial fibrosis detected by magnetic resonance imaging, elevated U-CRP and higher mRSS are predictors of cardiovascular complications in systemic sclerosis (SSc) patients. Semin Arthritis Rheum 2019; 49:273-278. [PMID: 30853116 DOI: 10.1016/j.semarthrit.2019.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/10/2019] [Accepted: 02/04/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In previous studies we showed that prevalence of myocardial fibrosis as assessed by late enhancement on cardiac MRI in SSc patients is 45% and is associated to diffuse disease (dcSSc) and lower left ventricle ejection fraction; microvascular damage defined as decreased perfusion on cardiac MRI after adenosine infusion, was also very frequent (79%). Our aim was to identify baseline characteristics associated to the development of cardiovascular outcomes (heart failure, coronary artery disease, arrhythmias, vasculopathy, elevated systolic pulmonary artery pressure and death) in SSc patients with previously documented myocardial fibrosis and microvascular damage. PATIENTS AND METHODS We included 62 SSc patients who participated in the study of prevalence of myocardial fibrosis (2008-2010) and in our local SSc cohort. We performed baseline clinical evaluation, cardiac MRI, coronary CT angiography, transthoracic echocardiogram, and yearly clinical and cardiovascular evaluation that included Medsger's severity scale items, electrocardiogram, echocardiogram, chest X-ray or HRCT and spirometry; we registered presence and severity of internal organ involvement and cardiovascular outcomes. Ordinal variables were analyzed using Chi square test and Fisher test when appropriate, numeric variables were compared using Student's t-test or Mann Whitney U when appropriate, logistic regression and Cox proportional hazard ratio were used to perform multivariable analysis. RESULTS We obtained follow-up information from 62 patients (29 dcSSc, 33 lcSSc), mean follow-up was 43.5 months. Multivariable analysis showed that elevated basal ultrasensitive CRP was associated to mortality (p = 0.004, OR: 11.9, 95% CI 2.1-65.7) and recurrent digital tip ischemic ulcers (p = 0.001, OR 26.8, 95% CI 3,9-181.3) on follow-up. Myocardial fibrosis, particularly in the middle segments (p = 0.01, OR: 11.49, 95% CI 1.6-83), and older age (p = 0.02, OR: 1.11, 95% CI 1.01-1.22) were associated to heart failure on follow-up. Higher maximum mRSS was associated to coronary artery disease (p = 0.02, OR: 1.2, 95% CI 1.02-1.38), while insertion point fibrosis (p = 0.001, OR: 12.5 95% CI 2.7-56.6) was associated to recurrent digital tip ischemic ulcers. CONCLUSIONS This study shows that myocardial fibrosis, elevated ultrasensitive CRP, and higher maximum mRSS are independent predictors of cardiovascular outcomes in SSc patients. Future studies should focus on early preventive and therapeutic strategies for this group of patients.
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Affiliation(s)
- Tatiana S Rodríguez-Reyna
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15. Col. Belisario Dominguez Sección XVI, Tlalpan, Mexico City 14080, Mexico.
| | - Sandra G Rosales-Uvera
- Radiology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico
| | | | - Pablo Hernández-Reyes
- Cardiology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico
| | - Pamela Mercado-Velázquez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15. Col. Belisario Dominguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
| | - Sergio A Benavides-Suárez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15. Col. Belisario Dominguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
| | - Alexia Esquinca-González
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15. Col. Belisario Dominguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
| | - Carlos A Núñez-Álvarez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15. Col. Belisario Dominguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
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Jeon CH. Early Detection of Pulmonary Hypertension in Connective Tissue Disease. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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García-Hernández FJ, Castillo-Palma MJ, Tolosa-Vilella C, Guillén-Del Castillo A, Rubio-Rivas M, Freire M, Vargas-Hitos JA, Todolí-Parra JA, Rodríguez-Carballeira M, Espinosa-Garriga G, Colunga-Argüelles D, Ortego-Centeno N, Trapiella-Martínez L, Rodero-Roldán MM, Pla-Salas X, Perales-Fraile I, Pons-Martín Del Campo I, Chamorro AJ, Fernández-de la Puebla Giménez RA, Madroñero-Vuelta AB, Ruíz-Muñoz M, Fonollosa-Pla V, Simeón-Aznar CP. Pulmonary hypertension in Spanish patients with systemic sclerosis. Data from the RESCLE registry. Clin Rheumatol 2018; 38:1117-1124. [PMID: 30535994 DOI: 10.1007/s10067-018-4390-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 11/12/2018] [Accepted: 11/30/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Our objective was to evaluate the pulmonary hypertension (PH) data for Spanish patients with systemic sclerosis (SSc), define the PH types and determine the associated factors. METHOD Descriptive study of PH-related data from the multicentre RESCLE registry. Estimated systolic pulmonary artery pressure (esPAP), measured via echocardiogram was considered elevated if ≥ 35 mmHg. Left heart disease (LHD) and interstitial lung disease (ILD) were identified. When performed, data from right heart catheterisation (RHC) were collected. RESULTS esPAP was elevated in 350 of 808 patients (43.3%). One hundred and forty-four patients (17.8%) were considered to have PH (88 via RHC and the rest due to elevated esPAP along with evidence of significant LHD or ILD): PAH 3.7%, secondary to ILD 8.3%, secondary to LHD 2.8% and unclassified 3%. Prevalence of elevated esPAP was greater in diffuse SSc (dSSc) than in limited scleroderma (lSSc) (50.5 vs. 42.2%, p 0.046). In the group with elevated esPAP, a lower prevalence of anti-centromere antibodies (41.9% vs. 52.3%, p 0.006) and a greater prevalence of anti-topoisomerase-1 antibodies (ATA) (25.1% vs. 18.6%, p 0.04) were observed compared to the group with normal esPAP. Patients with elevated esPAP had a lower rate of digital ulcers (50.6% vs. 60.2%, p 0.007) and esophageal involvement (83.6% vs. 88.7%, p 0.07) and higher rate of renal crisis (4.6% vs. 1.8%, p 0.066). CONCLUSIONS Prevalence of PAH was lower than expected (3.7%). Probability of having elevated esPAP was higher among patients with dSSc and among those with ATA.
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Affiliation(s)
| | - María J Castillo-Palma
- Department of Internal Medicine, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Carles Tolosa-Vilella
- Department of Internal Medicine, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Spain
| | - Alfredo Guillén-Del Castillo
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Manuel Rubio-Rivas
- Department of Internal Medicine, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Mayka Freire
- Systemic Autoimmune Diseases and Thrombosis Unit, Department of Internal Medicine, Complejo Hospitalario Universitario de Vigo, Pontevedra, Galicia, Spain
| | - José A Vargas-Hitos
- Department of Internal Medicine, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - José A Todolí-Parra
- Department of Internal Medicine, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Gerard Espinosa-Garriga
- Systemic Autoimmune Diseases Unit, Instituto Clínic de Medicina y Dermatología, Hospital Universitario Clínic, Barcelona, Spain
| | | | - Norberto Ortego-Centeno
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Campus de la Salud, Complejo Universitario de Granada, Granada, Spain
| | - Luis Trapiella-Martínez
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital de Cabueñes, Gijón, Spain
| | - María M Rodero-Roldán
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Xavier Pla-Salas
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Consorci Hospitalari de Vic, Barcelona, Spain
| | - Isabel Perales-Fraile
- Department of Internal Medicine, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
| | | | - Antonio J Chamorro
- Department of Internal Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | | | - Manuel Ruíz-Muñoz
- Department of Internal Medicine, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Vicent Fonollosa-Pla
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Carmen P Simeón-Aznar
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Update of screening and diagnostic modalities for connective tissue disease-associated pulmonary arterial hypertension. Semin Arthritis Rheum 2018; 48:1059-1067. [PMID: 30415942 DOI: 10.1016/j.semarthrit.2018.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/06/2018] [Accepted: 10/09/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH) has high morbidity and mortality in connective tissue diseases (CTDs), especially systemic sclerosis (SSc). In this systematic review, we provide an update on screening measures for early detection of PAH in CTD. METHODS Manuscripts published between July 2012 and October 2017, which incorporated screening measures to identify patients with PAH by right heart catheterization, were identified. Risk of bias was assessed using the QUADAS-2 tool. RESULTS The systematic review resulted in 1514 unique citations and 22 manuscripts were included for final review; the majority of manuscripts had a lower risk of bias based on the QUADAS-2 tool. There were 16 SSc cohort studies and 6 case-control studies (SSc 4, SLE 2). Four SSc cohort studies evaluated transthoracic echocardiography (TTE) only. Eight SSc cohort studies evaluated composite measures including ASIG, DETECT, and a combination of tricuspid regurgitation velocity (TRV) and PFT variables. DETECT and ASIG had greater sensitivity and negative predictive value (NPV) compared to the 2009 ESC/ERS guidelines in different cohorts. The addition of PFT variables, such as DLCO or FVC/ DLCO ratio, to TRV, resulted in greater sensitivity and NPV compared to TRV alone. CONCLUSION Current screening for PAH in CTDs is centered on SSc. Data continues to support the use of TTE and provides additional evidence for use of composite measures.
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Niklas K, Niklas A, Mularek-Kubzdela T, Puszczewicz M. Prevalence of pulmonary hypertension in patients with systemic sclerosis and mixed connective tissue disease. Medicine (Baltimore) 2018; 97:e11437. [PMID: 29995796 PMCID: PMC6076033 DOI: 10.1097/md.0000000000011437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) are 2 conditions in which pulmonary hypertension (PH) can develop.We retrospectively analyzed the probability of PH in case of 83 patients (69 SSc and 14 MCTD). The European Society of Cardiology/European Respiratory Society (ESC/ERS) echocardiographic guidelines of 2015 were used for the evaluation.On the basis of an echocardiography, the patients were divided into 2 subgroups: patients with elevated probability of PH (EP) (n = 16) versus the group with a low probability of PH (LP) (n = 67). Of the 16 patients in the EP group, 15 were SSc patients and 1 was an MCTD patient, respectively, that is, 21.7% and 7.1% of all patients. Of the 16 patients with EP, 10 with SSc had right-heart catheterization, which excluded PH in 7 patients; hence, PH was estimated to be 11.6% in the SSc group. The distribution of the individual causes of PH was arterial PH 2.9%, PH associated with interstitial lung disease 4.3%, PH associated with left ventricular disease 1.5%, and PH of unknown origin 2.9%. Further, there was a significant difference between EP and LP in the incidence of the right bundle branch block in standard electrocardiography, left atrial and right ventricular dimension, tricuspid annular plane systolic excursion, and Doppler-derived tricuspid lateral annular systolic velocity (S') in echocardiography.Echocardiography, particularly those evaluating the parameters included in the ESC/ERS guidelines of 2015, appears to be a useful tool in the detection of patients with a high PH probability. Additional tissue Doppler echocardiography seems to be a good option.
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26
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Joven BE, Escribano P, Andreu JL, Loza E, Jimenez C, de Yebenes MJG, Ruiz-Cano MJ, Carmona L, Carreira PE. 2013 ACR/EULAR systemic sclerosis classification criteria in patients with associated pulmonary arterial hypertension. Semin Arthritis Rheum 2018; 47:870-876. [DOI: 10.1016/j.semarthrit.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/11/2017] [Accepted: 10/11/2017] [Indexed: 01/27/2023]
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Sundaram SM, Chung L. An Update on Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: a Review of the Current Literature. Curr Rheumatol Rep 2018; 20:10. [PMID: 29488016 DOI: 10.1007/s11926-018-0709-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review will summarize the most current literature on the clinical impact, epidemiology, risk factors, screening recommendations, predictors of outcomes, and treatment options in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc). RECENT FINDINGS PAH continues to be a major cause of morbidity and mortality in SSc. Many risk factors and predictors of outcomes have been identified in patients with SSc including clinical, hemodynamic, and laboratory parameters. Screening for PAH in SSc patients is important and screening algorithms have been developed. Despite many available treatment options for PAH, prognosis remains poor. Awareness of risk factors, early detection, and up-front combination treatment are important considerations in SSc-PAH and may lead to improved outcomes. Further research to develop better biomarkers and therapies is needed to continue to improve survival and outcomes in patients with SSc-PAH.
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Affiliation(s)
- Sneha M Sundaram
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University, 1000 Welch Road, Suite 201, Palo Alto, CA, 94304, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA.
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Clinical Characteristics of Systemic Sclerosis With Interstitial Lung Disease. Arch Rheumatol 2018; 33:322-327. [PMID: 30632529 DOI: 10.5606/archrheumatol.2018.6630] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/20/2017] [Indexed: 12/18/2022] Open
Abstract
Objectives This study aims to compare the clinical characteristics of systemic sclerosis (SSc) patients with or without interstitial lung disease (ILD), and figure out whether the differences can be useful to suspect ILD in SSc. Patients and methods We retrospectively collected the clinical data of 108 patients with SSc (13 males, 95 females; mean age 50.1±13.5 years; range 14 to 78 years) and compared them according to the presence of ILD. ILD was confirmed by chest computed tomography, and pulmonary arterial hypertension was suspected when right ventricular systolic pressure was ≥40 mmHg based on echocardiography. Results Of the 108 patients, 49 (45.4) had diffuse type and 59 (54.6) had limited type SSc. Disease duration, percentages of positive anti-scleroderma 70 (anti-Scl70) antibody and anti-centromere antibody, white blood cell, platelet, erythrocyte sedimentation rate (ESR), and presence of pulmonary hypertension differed significantly. On multivariate logistic analysis, positive titer of anti-Scl70 antibody (odds ratio [OR]=15.65, p<0.001), platelet (OR=1.01, p=0.026), ESR (OR=1.02, p=0.037) and pulmonary hypertension (OR=21.97, p=0.003) were associated with ILD in patients with SSc. Conclusion In SSc patients with ILD, disease duration was longer and positive titer of anti-Scl70 antibody was more frequent, positive titer of anti- centromere antibody was less frequent, and white blood cell and platelet counts, ESR levels, and incidence of possible pulmonary hypertension were significantly higher than in those without ILD. Positive titer of anti-Scl70 antibody, platelet, ESR, and combination of pulmonary hypertension were independently associated with the presence of ILD in SSc patients.
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Morrisroe K, Stevens W, Sahhar J, Ngian GS, Rabusa C, Ferdowsi N, Hill C, Proudman S, Nikpour M. Quantifying the direct public health care cost of systemic sclerosis: A comprehensive data linkage study. Medicine (Baltimore) 2017; 96:e8503. [PMID: 29310332 PMCID: PMC5728733 DOI: 10.1097/md.0000000000008503] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/01/2017] [Accepted: 10/08/2017] [Indexed: 11/27/2022] Open
Abstract
To quantify the direct healthcare cost of systemic sclerosis (SSc) and identify its determinants. Healthcare use was captured through data linkage, wherein clinical and medication data for SSc patients from the state of Victoria enrolled in the Australian Scleroderma Cohort Study were linked with the Victorian hospital admissions and emergency presentations data sets, and the Medicare Benefits Schedule which contains all government subsidized ambulatory care services, for the period 2011-2015. Medication cost was determined from the Pharmaceutical Benefits Scheme. Costs were extrapolated to all Australian SSc patients based on SSc prevalence of 21.1 per 100,000 and an Australian population of 24,304,682 in 2015. Determinants of healthcare cost were estimated using logistic regression. Total healthcare utilization cost to the Australian government extrapolated to all Australian SSc patients from 2011 to 2015 was Australian Dollar (AUD)$297,663,404.77, which is an average annual cost of AUD$59,532,680.95 (US Dollar [USD]$43,816,040.08) and annual cost per patient of AUD$11,607.07 (USD$8,542.80). Hospital costs, including inpatient hospitalization and emergency department presentations, accounted for the majority of these costs (44.4% of total), followed by medication cost (31.2%) and ambulatory care cost (24.4%). Pulmonary arterial hypertension (PAH) and gastrointestinal (GIT) involvement were the major determinants of healthcare cost (OR 2.3 and 1.8, P = .01 for hospitalizations; OR 2.8 and 2.0, P = .01 for ambulatory care; OR 7.8 and 1.6, P < .001 and P = .03 for medication cost, respectively). SSc is associated with substantial healthcare utilization and direct economic burden. The most costly aspects of SSc are PAH and GIT involvement.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne)
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Joanne Sahhar
- Department of Medicine, Monash University, Clayton and Monash Health, Victoria
| | - Gene-Siew Ngian
- Department of Medicine, Monash University, Clayton and Monash Health, Victoria
| | - Candice Rabusa
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Nava Ferdowsi
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
| | - Catherine Hill
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville Road, Woodville
- Discipline of Medicine, University of Adelaide, SA, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace
- Discipline of Medicine, University of Adelaide, SA, Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital (Melbourne)
- Department of Rheumatology, St Vincent's Hospital (Melbourne)
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Degano B, Soumagne T, Delaye T, Berger P, Perez T, Guillien A, Pellegrin JL, Launay D, Magy-Bertrand N, Agard C, Tiev KP, Hua-Huy T, Tardiff C, Diaz V, Chambellan A, Dinh-Xuan AT. Combined measurement of carbon monoxide and nitric oxide lung transfer does not improve the identification of pulmonary hypertension in systemic sclerosis. Eur Respir J 2017; 50:50/4/1701008. [DOI: 10.1183/13993003.01008-2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
Abstract
Screening is important to determine whether patients with systemic sclerosis (SSc) have pulmonary hypertension because earlier pulmonary hypertension treatment can improve survival in these patients. Although decreased transfer factor of the lung for carbon monoxide (TLCO) is currently considered the best pulmonary function test for screening for pulmonary hypertension in SSc, small series have suggested that partitioning TLCO into membrane conductance (diffusing capacity) for carbon monoxide (DMCO) and alveolar capillary blood volume (VC) through combined measurement of TLCO and transfer factor of the lung for nitric oxide (TLNO) is more effective to identify pulmonary hypertension in SSc patients compared with TLCO alone. Here, the objective was to determine whether combined TLCO–TLNO partitioned with recently refined equations could more accurately detect pulmonary hypertension than TLCO alone in SSc.For that purpose, 572 unselected consecutive SSc patients were retrospectively recruited in seven French centres.Pulmonary hypertension was diagnosed with right heart catheterisation in 58 patients. TLCO, TLNO and VC were all lower in SSc patients with pulmonary hypertension than in SSc patients without pulmonary hypertension. The area under the receiver operating characteristic curve for the presence of pulmonary hypertension was equivalent for TLCO (0.82, 95% CI 0.79–0.85) and TLNO (0.80, 95% CI 0.76–0.83), but lower for VC (0.75, 95% CI 0.71–0.78) and DMCO (0.66, 95% CI 0.62–0.70).Compared with TLCO alone, combined TLCO–TLNO does not add capability to detect pulmonary hypertension in unselected SSc patients.
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Pros and Cons of Echocardiography in the Screening, Diagnosis and Follow-up of Patients with Systemic Sclerosis Pulmonary Arterial Hypertension – a Rheumatologist's Perspective. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose Our objective was to review the evidence regarding echocardiography in patients with systemic sclerosis (SSc) and possible pulmonary hypertension (PH). Methods The literature was reviewed. In addition, a survey was conducted of 315 rheumatologists/internists with a self-declared interest in SSc, to determine their preferred use of echocardiograms. Results The most relevant literature findings come from two studies, the DETECT study and one from the Australian Scleroderma Interest Group. In both these studies, it appears that the use of non-echocardiographic variables such as pulmonary function tests (PFTs) and values of serum N-terminal pro-brain natriuretic peptide (NT-proBNP), are adequate on their own in suggesting which patients are at high risk of PH. Echocardiograms added very little information and in fact may confuse the picture by appearing to be normal when in fact underlying PH is present. With regard to the survey, 157 physicians (49.8%) responded. Of those, 67% felt that an echocardiogram should be ordered on every patient with SSc every year. Ninety-five percent (95%) said the reason was to screen for the development of significant PH, 65% said the reason was to screen for the development of significant intrinsic cardiac disease and 38% said that the reason was to adhere to accepted international recommendations. Conclusions Despite popular belief and current recommendations, in the opinion of the author, echocardiograms are not necessary in every SSc patient every year. Cheaper tests such as PFTs and NT-proBNP are adequate in most cases to suggest when a right heart catheterization should be performed.
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Morrisroe K, Stevens W, Sahhar J, Rabusa C, Nikpour M, Proudman S. Epidemiology and disease characteristics of systemic sclerosis-related pulmonary arterial hypertension: results from a real-life screening programme. Arthritis Res Ther 2017; 19:42. [PMID: 28270192 PMCID: PMC5341425 DOI: 10.1186/s13075-017-1250-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/27/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc). Annual screening with echocardiogram (ECHO) is recommended. We present the methodological aspects of a PAH screening programme in a large Australian SSc cohort, the epidemiology of SSc-PAH in this cohort, and an evaluation of factors influencing physician adherence to PAH screening guidelines. METHODS Patient characteristics and results of PAH screening were determined in all patients enrolled in a SSc longitudinal cohort study. Adherence to PAH screening guidelines was assessed by a survey of Australian rheumatologists. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of risk factors with PAH. RESULTS Among 1636 patients with SSc, 194 (11.9%) had PAH proven by right-heart catheter. Of these, 160 were detected by screening. The annual incidence of PAH was 1.4%. Patients with PAH diagnosed on subsequent screens, compared with patients in whom PAH was diagnosed on first screen, were more likely to have diffuse SSc (p = 0.03), be in a better World Health Organisation (WHO) Functional Class at PAH diagnosis (p = 0.01) and have less advanced PAH evidenced by higher mean six-minute walk distance (p = 0.03), lower mean pulmonary arterial pressure (p = 0.009), lower mean pulmonary vascular resistance (p = 0.006) and fewer non-trivial pericardial effusions (p = 0.03). Adherence to annual PAH screening using an ECHO-based algorithm was poor among Australian rheumatologists, with less than half screening their patients with SSc of more than ten years disease duration. CONCLUSION PAH is a common complication of SSc. Physician adherence to PAH screening recommendations remains poor. Identifying modifiable barriers to screening may improve adherence and ultimately patient outcomes.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Wendy Stevens
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Joanne Sahhar
- Monash University and Monash Health, 246 Clayton Road, Clayton, 3168 Victoria Australia
| | - Candice Rabusa
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
- Departments of Rheumatology and Medicine, The University of Melbourne at St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, 3065 Victoria Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, North Terrace, SA 5000 Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA 5000 Australia
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