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Wade RC, Mkorombindo T, Ling SX, Helgeson ES, MacDonald DM, Pew K, Voelker H, Bittner V, Kunisaki KM, Lammi MR, Dransfield MT. Association between P-pulmonale and respiratory morbidity in COPD: a secondary analysis of the BLOCK-COPD trial. BMC Pulm Med 2023; 23:434. [PMID: 37946165 PMCID: PMC10634074 DOI: 10.1186/s12890-023-02748-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
RATIONALE Pulmonary hypertension (PH) in COPD confers increased risk of exacerbations (ECOPD). Electrocardiogram (ECG) indicators of PH are prognostic both in PH and COPD. In the Beta-Blockers for the Prevention of Acute Exacerbations of COPD (BLOCK-COPD) trial, metoprolol increased risk of severe ECOPD through unclear mechanisms. OBJECTIVE We evaluated whether an ECG indicator of PH, P-pulmonale, would be associated with ECOPD and whether participants with P-pulmonale randomized to metoprolol were at higher risk of ECOPD and worsened respiratory symptoms given the potential detrimental effects of beta-blockers in PH. METHODS ECGs of 501 participants were analyzed for P-pulmonale (P wave enlargement in lead II). Cox proportional hazards models evaluated for associations between P-pulmonale and time to ECOPD (all and severe) for all participants and by treatment assignment (metoprolol vs. placebo). Linear mixed-effects models evaluated the association between treatment assignment and P-pulmonale on change in symptom scores (measured by CAT and SOBQ). RESULTS We identified no association between P-pulmonale and risk of any ECOPD or severe ECOPD. However, in individuals with P-pulmonale, metoprolol was associated with increased risk for ECOPD (aHR 2.92, 95% CI: 1.45-5.85). There was no association between metoprolol and ECOPD in individuals without P-pulmonale (aHR 1.01, 95% CI: 0.77-1.31). Individuals with P-pulmonale assigned to metoprolol experienced worsening symptoms (mean increase of 3.95, 95% CI: 1.32-6.58) whereas those assigned to placebo experienced a mean improvement in CAT score of -2.45 (95% CI: -0.30- -4.61). CONCLUSIONS In individuals with P-pulmonale, metoprolol was associated with increased exacerbation risk and worsened symptoms. These findings may explain the findings observed in BLOCK-COPD.
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Affiliation(s)
- R Chad Wade
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA.
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Takudzwa Mkorombindo
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sharon X Ling
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Erika S Helgeson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - David M MacDonald
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Krystle Pew
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ken M Kunisaki
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew R Lammi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Yan W, Luo Q, Nie Q, Wang H, Wu J. Association between systemic sclerosis and left ventricle dysfunction: Findings from observational studies. Heliyon 2023; 9:e14110. [PMID: 36938434 PMCID: PMC10020007 DOI: 10.1016/j.heliyon.2023.e14110] [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: 10/19/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Objectives Cardiac involvement is common in systemic sclerosis (SSc) patients. In this study, we aimed to systematically evaluate the relationship between SSc and left ventricular dysfunction (LVD), especially the left ventricular diastolic dysfunction, by ultrasound and cardiac magnetic resonance data. Methods We searched The Cochrane Library, PubMed and Embase databases collected studies about comparing LVD parameters in SSc patients and controls from establishment to January 2022. Furthermore, we also performed a two-sample MR using summary statistics from genome-wide association studies (GWAS) important LVD parameters, including left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM) and left ventricular ejection fraction (LVEF). Results Our meta-analysis included 31 eligible studies with 1448 SSc patients. According to the results, SSc patients had lower peak of early diastolic flow velocity/peak of late diastolic flow velocity ratio (E/A ratio), E, trans-mitral early filling peak velocity (E'), and left ventricular end-diastolic diameter (LVEDD) compared to controls. The E/E' ratio, A, left ventricular isovolumetric relaxation time (IVRT), deceleration Time (DT) and left atrial (LA) diameter were higher in SSc patients in comparison with controls. Moreover, we observed that the SSc patients had lower LVEF than controls. And in MR analysis, we also found that SSc was causally correlated with LVEF (OR = 0.9966, 95% CI 0.9935-0.998, P = 0.0398). However, unfortunately, there was no significant correlation between SSC and LVM (OR = 1.0048, 95% CI 0.9919-1.0179, P = 0.4661) and LVEDV (LVEDV OR = 0.9976, 95%CI 0.9888-1.0066, P = 0.6019). Conclusion SSc patients had diastolic/systolic dysfunction. However, MR analysis cannot confirm the genetic relationship between SSc and LVDD because of insufficient data. More research is needed to confirm the causal relationship between the two.
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Affiliation(s)
- Wei Yan
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Qiang Luo
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Qiong Nie
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
| | - Han Wang
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
- Corresponding author.
| | - Jing Wu
- Southwest Jiaotong University, Department of Geriatrics, Southwest Jiaotong University College of Medicine, The Third People's Hospital of Chengdu, No.82, Qinglong Street, Sichuan, China
- Corresponding author.
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Mousseaux E, Agoston-Coldea L, Marjanovic Z, Baudet M, Reverdito G, Bollache E, Kachenoura N, Messas E, Soulat G, Farge D. Diastolic Function Assessment of Left and Right Ventricles by MRI in Systemic Sclerosis Patients. J Magn Reson Imaging 2022; 56:1416-1426. [PMID: 35258133 DOI: 10.1002/jmri.28143] [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: 01/10/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Heart involvement is frequent although often clinically silent in systemic sclerosis (SSc) patients. Early identification of cardiac involvement can be improved by noninvasive methods such as MRI, in addition to transthoracic echocardiography (TTE). PURPOSE To assess the ability of phase-contrast (PC)-MRI to detect subclinical left (LV) and right (RV) ventricular diastolic dysfunction in SSc patients. STUDY TYPE Prospective. POPULATION Thirty-five consecutive SSc patients (49 ± 14 years) and 35 sex- and age-matched healthy controls (48.6 ± 13.5 years) who underwent TTE and MRI in the same week. FIELD STRENGTH/SEQUENCE 5 T/PC-MRI using a breath-hold velocity-encoded gradient echo sequence. ASSESSMENT LV TTE (E/E') and LV and RV PC-MRI indices of diastolic function (LV early and late transmitral [EM , EfM , AM , AfM ] and RV transtricuspid [ET , EfT , AT , AfT ] peak filling flow velocities and flow rates, as well as LV [ E M ' ] and RV [ E T ' ] peak longitudinal myocardial velocities during diastole) were measured. STATISTICAL TESTS Two-tailed t-test, Wilcoxon test, or Fischer test for comparison of variables between SSc and healthy control groups; sensitivity, specificity, receiver-operating-characteristic (ROC) area under the curve (AUC) to assess discriminative ability of variables. A P-value <0.05 was considered statistically significant. RESULTS TTE LV E/E' and MRI EM / E M ' and ET / E T ' were significantly higher in SSc patients than in controls (8.27 ± 1.25 vs. 6.70 ± 1.66; 9.43 ± 2.7 vs. 6.51 ± 1.50; 6.51 [4.70-10.40] vs. 4.13 [3.22-5.75], respectively) and separated SSc patients and healthy controls with good sensitivity (68%, 71%, and 80%), specificity (85%, 94%, and 62%), and AUC (0.787, 0.807, and 0.765). LV EfM was significantly higher in SSc patients than in controls (347.1 ± 113.7 vs. 284.7 ± 94.6) as RVAfT (277 [231-355] vs. 220 [154-253] mL/sec) with impaired relaxation pattern (EfT /AfT , 0.95 [0.87-1.21] vs. 1.12 [0.93-1.47]). DATA CONCLUSION MRI was able to detect LV and RV diastolic dysfunction in SSc patients with good accuracy in the absence of LV systolic dysfunction at echocardiography. Use of MRI can allow to better assess the early impact of myocardial fibrosis related to SSc. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Elie Mousseaux
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France.,Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Lucia Agoston-Coldea
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France.,Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Zora Marjanovic
- Service d'Hématologie, Hôpital Saint Antoine (APHP), Paris, France
| | - Mathilde Baudet
- Cardiology Department, APHP, Lariboisiere Hospital, Paris, France
| | - Guillaume Reverdito
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France.,Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Emilie Bollache
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France
| | - Nadjia Kachenoura
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France
| | - Emmanuel Messas
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France.,Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Gilles Soulat
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France.,Department of Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Dominique Farge
- Unité de Médecine Interne (UF 04): CRMR MATHEC, Maladies Auto-Immunes et Thérapie Cellulaire, Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile-de-France, FAI2R, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France.,Recherche Clinique Appliquée à l'hématologie, Institut de Recherche Saint Louis, Université de Paris, Paris, France.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Vértes V, Porpáczy A, Nógrádi Á, Tőkés-Füzesi M, Hajdu M, Czirják L, Komócsi A, Faludi R. Galectin-3 and sST2: associations to the echocardiographic markers of the myocardial mechanics in systemic sclerosis - a pilot study. Cardiovasc Ultrasound 2022; 20:1. [PMID: 35042522 PMCID: PMC8764793 DOI: 10.1186/s12947-022-00272-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 01/05/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Progressive cardiac fibrosis is the central aspect of the myocardial involvement in systemic sclerosis (SSc). We hypothesized that circulating biomarkers of the cardiac fibrosis may be useful in the early diagnosis of the cardiac manifestation in this disease. Thus, we investigated the potential correlations between the levels of galectin-3, soluble suppression of tumorigenicity-2 (sST2) and the echocardiographic markers of the myocardial mechanics in SSc patients. METHODS Forty patients (57.3 ± 13.7 years, 36 female) were investigated. In addition to the conventional echocardiography, tissue Doppler and speckle tracking-derived strain techniques were used to assess the function of both ventricles and atria. To estimate the correlations between galectin-3 and sST2 levels and the echocardiographic variables, partial correlation method was used with age as correcting factor. RESULTS In age adjusted analysis galectin-3 level showed significant correlation with left ventricular global longitudinal strain (r = 0.460, p = 0.005); grade of left ventricular diastolic dysfunction (r = 0.394, p = 0.013); septal e' (r = - 0.369, p = 0.021); septal E/e' (r = 0.380, p = 0.017) and with the grade of mitral regurgitation (r = 0.323, p = 0.048). No significant correlation was found between sST2 levels and the echocardiographic variables. CONCLUSIONS Galectin-3 levels, but not sST2 levels show significant correlation with the parameters of the left ventricular systolic and diastolic function. Galectin-3 may be a useful biomarker for the screening and early diagnosis of SSc patients with cardiac involvement.
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Affiliation(s)
- Vivien Vértes
- grid.9679.10000 0001 0663 9479 Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - Adél Porpáczy
- grid.9679.10000 0001 0663 9479 Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - Ágnes Nógrádi
- grid.9679.10000 0001 0663 9479 Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - Margit Tőkés-Füzesi
- grid.9679.10000 0001 0663 9479Department of Laboratory Medicine, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - Máté Hajdu
- grid.9679.10000 0001 0663 9479 Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - László Czirják
- grid.9679.10000 0001 0663 9479Department of Rheumatology and Immunology, Medical School, University of Pécs, Akác u. 1, H-7632 Pécs, Hungary
| | - András Komócsi
- grid.9679.10000 0001 0663 9479 Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624 Pécs, Hungary
| | - Réka Faludi
- Heart Institute, Medical School, University of Pécs, Ifjúság út 13, H-7624, Pécs, Hungary.
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Impaired Right and Left Ventricular Longitudinal Function in Patients with Fibrotic Interstitial Lung Diseases. J Clin Med 2020; 9:jcm9020587. [PMID: 32098133 PMCID: PMC7073641 DOI: 10.3390/jcm9020587] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Left ventricular (LV) and right ventricular (RV) dysfunction is recognized in idiopathic pulmonary fibrosis (IPF). Little is known about cardiac involvement in non-idiopathic pulmonary fibrosis (no-IPF). This issue can be explored by advanced echocardiography. Methods: Thirty-three clinically stable and therapy-naive fibrotic IPF and 28 no-IPF patients, and 30 healthy controls were enrolled. Exclusion criteria were autoimmune systemic diseases, coronary disease, heart failure, primary cardiomyopathies, chronic obstructive lung diseases, pulmonary embolism, primary pulmonary hypertension. Lung damage was evaluated by diffusion capacity for carbon monoxide (DLCOsb). All participants underwent an echo-Doppler exam including 2D global longitudinal strain (GLS) of both ventricles and 3D echocardiographic RV ejection fraction (RVEF). Results: We observed LV diastolic dysfunction in IPF and no-IPF, and LV GLS but not LV EF reduction only in IPF. RV diastolic and RV GLS abnormalities were observed in IPF versus both controls and no-IPF. RV EF did not differ significantly between IPF and no-IPF. DLCOsb and RV GLS were associated in the pooled pulmonary fibrosis population and in the IPF subgroup (β = 0.708, p < 0.001), independently of confounders including pulmonary arterial systolic pressure. Conclusion: Our data highlight the unique diagnostic capabilities of GLS in distinguishing early cardiac damage of IPF from no-IPF patients.
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Miyanaga S, Kubota K, Iwatani N, Higo K, Miyata M, Horizoe Y, Ojima S, Kawasoe S, Kubozono T, Ohishi M. Predictors of exercise-induced pulmonary hypertension in patients with connective tissue disease. Heart Vessels 2019; 34:1509-1518. [DOI: 10.1007/s00380-019-01373-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/01/2019] [Indexed: 01/25/2023]
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7
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Defining primary systemic sclerosis heart involvement: A scoping literature review. Semin Arthritis Rheum 2019; 48:874-887. [DOI: 10.1016/j.semarthrit.2018.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/09/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
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8
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The effect of cold stress on right ventricular functions in patients with systemic sclerosis. MARMARA MEDICAL JOURNAL 2018. [DOI: 10.5472/marumj.472397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Nógrádi Á, Porpáczy A, Porcsa L, Minier T, Czirják L, Komócsi A, Faludi R. Relation of Right Atrial Mechanics to Functional Capacity in Patients With Systemic Sclerosis. Am J Cardiol 2018; 122:1249-1254. [PMID: 30082039 DOI: 10.1016/j.amjcard.2018.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 11/15/2022]
Abstract
Cardiac involvement in systemic sclerosis (SSc) implies a worse prognosis. Little is known about the right atrial (RA) mechanics in this disease, but recent data suggest that it correlates well with the functional capacity of the patients in conditions with known right heart involvement. Thus we aimed to investigate the abnormalities of the RA function as compared with healthy subjects and to assess the potential correlations between RA mechanics and the functional capacity in SSc patients using 2D speckle tracking technique. A total of 70 SSc patients (age: 57 ± 12 years) were investigated. Functional capacity was measured with 6-minute walk test (6MWT). Echocardiographic parameters of the right ventricular (RV) systolic function (TAPSE, RVFAC), parameters of the tricuspid inflow (E, A), and tricuspid annular systolic (S), early- (e') and late- (a') diastolic myocardial velocities were measured. RV wall thickness was obtained. RA reservoir (εR), conduit (εCD), and contractile (εCT) strain were measured. RA stiffness was calculated as ratio of E/e' to εR. Echocardiographic data were compared with an age- and gender-matched group of 25 healthy volunteers. RA εR (49.3 ± 10.7 vs 59.6 ± 9.9%, p = 0.000) and εCD (26.8 ± 8.1 vs 34.3 ± 7.3%, p = 0.000) were significantly lower in SSc patients. No significant difference was found in εCT (22.9 ± 5.8 vs 25.3 ± 5.7%, p = 0.082). RA stiffness was significantly increased in SSc patients (0.11 ± 0.04 vs 0.08 ± 0.02, p = 0.001). 6MWT distance was 391 ± 95m. In stepwise multiple linear regression analysis RV wall thickness (r = -0.289, p = 0.030) and RA stiffness (r = -0.418, p = 0.002) became independent predictors of 6MWT distance. In conclusion, RA εR and εCD are impaired, while RA stiffness is increased in SSc compared with healthy subjects. Speckle tracking-derived RA stiffness is turned out to be one of the main determinants of the functional capacity in SSc patients.
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Affiliation(s)
- Ágnes Nógrádi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Adél Porpáczy
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Lili Porcsa
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Tünde Minier
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - László Czirják
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Faludi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary.
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Impact of Pulmonary Arterial Hypertension on Left Ventricular Function – a Comparative Study between Scleroderma and Coronary Artery Disease. JOURNAL OF INTERDISCIPLINARY MEDICINE 2018. [DOI: 10.2478/jim-2018-0028] [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] Open
Abstract
Abstract
Background: The impact of pulmonary arterial hypertension (PAH) on left ventricular performance in patients with scleroderma is still unknown. This study aims to perform a comparative echocardiographic analysis of left ventricular function between two different etiological varieties of PAH, namely PAH caused by systemic sclerosis as a representative of systemic inflammatory diseases and PAH caused by myocardial ischemia.
Material and method: We conducted a prospective observational study on 82 patients, of which 36 were with documented PAH, with the systolic pressure in the pulmonary artery above 35 mmHg, and 46 were patients with normal pulmonary artery pressure. The study population was divided into two groups, based on the etiology of PAH: group 1 included patients diagnosed with scleroderma (n = 48); group 2 included patients with coronary artery disease (n = 35). Patients from each group were divided into two subgroups based on the diagnosis of PAH: subgroup 1A – subjects with scleroderma and associated PAH (n = 20); subgroup 1B – subjects with scleroderma without PAH (n = 28); subgroup 2A – ischemic patients with associated PAH (n = 16); and subgroup 2B – patients with ischemic disease without PAH (n = 19).
Results: A significant difference between LVEF values in patients with PAH versus those without PAH in the ischemic group (p = 0.023) was recorded. Compared to scleroderma subjects, ischemic patients presented significantly lower values of LVEF in both PAH and non-PAH subgroups (p <0.0001 and p <0.0001, respectively). Linear regression analysis between sPAP and LVEF revealed a significant negative correlation only for the ischemia group (r = −0.52, p = 0.001) and the scleroderma 2B subgroup (r = −0.51, p = 0.04). Tissue Doppler analysis of left ventricular function revealed a significant impact of PAH on left ventricular diastolic performance in the ischemic group.
Conclusions: Compared to patients with coronary artery disease, those with scleroderma present a less pronounced deterioration of LVEF in response to pulmonary arterial hypertension.
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Liu A, Philip J, Vinnakota KC, Van den Bergh F, Tabima DM, Hacker T, Beard DA, Chesler NC. Estrogen maintains mitochondrial content and function in the right ventricle of rats with pulmonary hypertension. Physiol Rep 2017; 5:5/6/e13157. [PMID: 28320896 PMCID: PMC5371553 DOI: 10.14814/phy2.13157] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 01/16/2017] [Indexed: 12/15/2022] Open
Abstract
The typical cause of death in pulmonary hypertension (PH) is right ventricular (RV) failure, with females showing better survival rates than males. Recently, metabolic shift and mitochondrial dysfunction have been demonstrated in RV failure secondary to PH In light of evidence showing that estrogen protects mitochondrial function and biogenesis in noncardiovascular systems, we hypothesized that the mechanism by which estrogen preserves RV function is via protection of mitochondrial content and oxidative capacity in PH We used a well-established model of PH (Sugen+Hypoxia) in ovariectomized female rats with/without estrogen treatment. RV functional measures were derived from pressure-volume relationships measured via RV catheterization in live rats. Citrate synthase activity, a marker of mitochondrial density, was measured in both RV and LV tissues. Respiratory capacity of mitochondria isolated from RV was measured using oxygraphy. We found that RV ventricular-vascular coupling efficiency decreased in the placebo-treated SuHx rats (0.78 ± 0.10 vs. 1.50 ± 0.13 in control, P < 0.05), whereas estrogen restored it. Mitochondrial density decreased in placebo-treated SuHx rats (0.12 ± 0.01 vs. 0.15 ± 0.01 U citrate synthase/mg in control, P < 0.05), and estrogen attenuated the decrease. Mitochondrial quality and oxidative capacity tended to be lower in placebo-treated SuHx rats only. The changes in mitochondrial biogenesis and function paralleled the expression levels of PGC-1α in RV Our results suggest that estrogen protects RV function by preserving mitochondrial content and oxidative capacity. This provides a mechanism by which estrogen provides protection in female PH patients and paves the way to develop estrogen and its targets as a novel RV-specific therapy for PH.
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Affiliation(s)
- Aiping Liu
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jennifer Philip
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kalyan C Vinnakota
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Francoise Van den Bergh
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Timothy Hacker
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Daniel A Beard
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin .,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Cardiac involvement in undifferentiated connective tissue disease at risk for systemic sclerosis (otherwise referred to as very early–early systemic sclerosis): a TDI study. Clin Exp Med 2017; 18:237-243. [DOI: 10.1007/s10238-017-0477-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Lamia B, Muir JF, Molano LC, Viacroze C, Benichou J, Bonnet P, Quieffin J, Cuvelier A, Naeije R. Altered synchrony of right ventricular contraction in borderline pulmonary hypertension. Int J Cardiovasc Imaging 2017; 33:1331-1339. [PMID: 28317064 DOI: 10.1007/s10554-017-1110-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 03/04/2017] [Indexed: 01/06/2023]
Abstract
Imaging studies have shown that pulmonary hypertension (PH) is associated with inhomogenous right ventricular (RV) regional contraction, or dyssynchrony, and that this is of prognostic relevance. This study aimed at the identification and functional significance of RV dyssynchrony in borderline PH defined by a mean pulmonary artery pressure between (mPAP) 20 and 25 mmHg. RV dyssynchrony was measured by 2-dimensional speckle tracking echocardiography in 17 patients with pulmonary arterial hypertension (PAH), 13 patients with borderline PH and 14 controls. Dyssynchrony was defined as the R-R interval-corrected standard deviation of the times to peak-systolic strain for the basal and medium segments of the RV. All the PH patients underwent a right heart catheterization. RV dyssynchrony amounted to 69 ± 34 ms in PAH, 47 ± 23 ms in borderline PH and 8 ± 6 ms in controls, all different from each other (p < 0.05). RV dyssynchrony in borderline PH was the only parameter of RV systolic dysfunction in 11 of 13 (85%) of the patients. RV dyssynchrony was accompanied by postsystolic shortening and correlated to RV fractional area change, not to mPAP or pulmonary vascular resistance. RV dyssynchrony occurs in borderline PH and may reflect early RV-arterial uncoupling.
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Affiliation(s)
- Bouchra Lamia
- Department of Pulmonology and Respiratory Critical Care, Pulmonary hypertension competence center, Normandie Univ, UNIROUEN, EA 3830, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University Hospital, 76000, Rouen, France. .,Department of Pulmonology, Le Havre Hospital Complexe, BP 84, 76083, Le Havre Cedex, France. .,Department of Cardiology, Le Havre Hospital Complexe, BP 84, 76083, Le Havre Cedex, France.
| | - Jean-François Muir
- Department of Pulmonology and Respiratory Critical Care, Pulmonary hypertension competence center, Normandie Univ, UNIROUEN, EA 3830, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University Hospital, 76000, Rouen, France
| | - Luis-Carlos Molano
- Department of Pulmonology and Respiratory Critical Care, Rouen University Hospital, 76000, Rouen, France
| | - Catherine Viacroze
- Department of Pulmonology and Respiratory Critical Care, Rouen University Hospital, 76000, Rouen, France
| | - Jacques Benichou
- Department of Biostatistics, Normandie Univ, UNIROUEN, Rouen University Hospital, 76000, Rouen, France
| | - Philippe Bonnet
- Department of Cardiology, Le Havre Hospital Complexe, BP 84, 76083, Le Havre Cedex, France
| | - Jean Quieffin
- Department of Pulmonology, Le Havre Hospital Complexe, BP 84, 76083, Le Havre Cedex, France
| | - Antoine Cuvelier
- Department of Pulmonology and Respiratory Critical Care, Pulmonary hypertension competence center, Normandie Univ, UNIROUEN, EA 3830, Institute for Research and Innovation in Biomedicine (IRIB), Rouen University Hospital, 76000, Rouen, France
| | - Robert Naeije
- Department of Physiology, Faculty of Medicine, Free University of Medicine, Brussels, Belgium
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Nordin A, Svenungsson E, Björnådal L, Elvin K, Larsson A, Jensen-Urstad K. Troponin I and echocardiography in patients with systemic sclerosis and matched population controls. Scand J Rheumatol 2016; 46:226-235. [DOI: 10.1080/03009742.2016.1192217] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A Nordin
- Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - L Björnådal
- Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - K Elvin
- Unit of Clinical Immunology, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - A Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - K Jensen-Urstad
- Department of Clinical Physiology, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Right atrial morphology and function in patients with systemic sclerosis compared to healthy controls: a two-dimensional strain study. Clin Rheumatol 2016; 35:1733-42. [DOI: 10.1007/s10067-016-3279-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/12/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
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16
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Meune C, Khanna D, Aboulhosn J, Avouac J, Kahan A, Furst DE, Allanore Y. A right ventricular diastolic impairment is common in systemic sclerosis and is associated with other target-organ damage. Semin Arthritis Rheum 2016; 45:439-45. [DOI: 10.1016/j.semarthrit.2015.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/28/2015] [Accepted: 07/01/2015] [Indexed: 11/30/2022]
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17
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Karna SK, Rohit MK, Wanchu A. Right ventricular thickness as predictor of global myocardial performance in systemic sclerosis: A Doppler tissue imaging study. Indian Heart J 2015; 67:521-8. [PMID: 26702679 PMCID: PMC4699958 DOI: 10.1016/j.ihj.2015.06.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/13/2015] [Accepted: 06/12/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Cardiopulmonary involvement in systemic sclerosis (SSc) is a poor prognostic factor, due to pulmonary hypertension and right ventricular dysfunction. We assessed the echocardiographic parameters of right ventricular (RV) function in SSc and correlated echocardiographic findings to clinical features of the disease. METHODS Thirty patients with SSc (cases) and 30 healthy, age-matched subjects (controls) were studied. Echocardiography, including tissue Doppler imaging, was used to evaluate cardiac function. RESULTS Pulmonary hypertension could be documented in only 5 cases by Doppler echo, using Bernoulli principle. RV diastolic function was significantly deranged in cases. RV systolic function and left ventricle (LV) diastolic function were also significantly deranged in the cases. RV thickness was increased in patients with SSc. There were no significant differences in the echocardiographic variables between diffuse and limited subtypes of SSc. Myocardial performance index (MPI) of both ventricles were increased in cases. We could demonstrate RV thickness as the single most important predictor of MPI of both ventricles with sensitivity of 82% and specificity of 72% for RV-MPI and 63% for LV-MPI. Diastolic function was not found to be affected by disease duration or Rodnan skin score. CONCLUSION Patients with SSc exhibit abnormal RV and LV diastolic functions as well as abnormal RV systolic function. RV wall thickness was found to be simple and the single best predictor of global myocardial performance. RV dysfunction may be a response to intermittent pulmonary arterial hypertension, lung parenchymal involvement, or secondary to LV diastolic dysfunction in SSc.
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Affiliation(s)
- S K Karna
- Assistant Professor, Department of Cardiology, Pramukhswami Medical College, Anand, Gujarat 388325, India.
| | - M K Rohit
- Additional Professor, Department of Cardiology, PGIMER, Chandigarh 160012, India
| | - A Wanchu
- Associate Professor, Division of Arthritis and Rheumatic Diseases, Oregon Health and Science University, Portland, OR 97239, USA
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Murch SD, La Gerche A, Roberts TJ, Prior DL, MacIsaac AI, Burns AT. Abnormal right ventricular relaxation in pulmonary hypertension. Pulm Circ 2015; 5:370-5. [PMID: 26064464 DOI: 10.1086/681268] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 12/06/2014] [Indexed: 12/21/2022] Open
Abstract
Left ventricular diastolic dysfunction is a well-described complication of systemic hypertension. However, less is known regarding the effect of chronic pressure overload on right ventricular (RV) diastolic function. We hypothesized that pulmonary hypertension (PHT) is associated with abnormal RV early relaxation and that this would be best shown by invasive pressure measurement. Twenty-five patients undergoing right heart catheterization for investigation of breathlessness and/or suspected PHT were studied. In addition to standard measurements, RV pressure was sampled with a high-fidelity micromanometer, and RV pressure/time curves were analyzed. Patients were divided into a PHT group and a non-PHT group on the basis of a derived mean pulmonary artery systolic pressure of 25 mmHg. Eleven patients were classified to the PHT group. This group had significantly higher RV minimum diastolic pressure ([Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]) and RV end-diastolic pressure (RVEDP; [Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]), and RV τ was significantly prolonged ([Formula: see text] vs. [Formula: see text] ms, [Formula: see text]). There were strong correlations between RV τ and RV minimum diastolic pressure ([Formula: see text], [Formula: see text]) and between RV τ and RVEDP ([Formula: see text], [Formula: see text]). There was a trend toward increased RV contractility (end-systolic elastance) in the PHT group ([Formula: see text] vs. [Formula: see text] mmHg/mL, [Formula: see text]) and a correlation between RV systolic pressure and first derivative of maximum pressure change ([Formula: see text], [Formula: see text]). Stroke volumes were similar. Invasive measures of RV early relaxation are abnormal in patients with PHT, whereas measured contractility is static or increasing, which suggests that diastolic dysfunction may precede systolic dysfunction. Furthermore, there is a strong association between measures of RV relaxation and RV filling pressures.
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Affiliation(s)
- Stuart D Murch
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andre La Gerche
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Timothy J Roberts
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - David L Prior
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andrew I MacIsaac
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andrew T Burns
- Department of Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; and University of Melbourne, Department of Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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Abstract
PURPOSE OF REVIEW This review summarizes recent advances in pulmonary hypertension, a leading cause of morbidity and mortality in scleroderma (SSc). RECENT FINDINGS Although WHO Group I pulmonary arterial hypertension (PAH) is the most common cause of pulmonary hypertension, all WHO Groups can occur. PAH is now a criterion for the diagnosis of SSc. Results of recent research have resulted in greater insight into the epidemiology of SSc-pulmonary hypertension with regard to prevalence, incidence and clinical risk factors. There is also greater understanding of the role of inflammation in the pathogenesis of SSc-PAH. Advances have also been made in the evaluation and screening of patients with SSc-PAH, and early detection has been shown to improve survival in a disease that typically has worse outcomes than other forms of PAH. Finally, recommendations have been made with regard to goal-directed therapy. SUMMARY Although there have been many recent advances in SSc-pulmonary hypertension, further research is needed in order to prevent/cure this deadly complication.
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Gerede DM, Turhan S, Hural R, Acıbuca A, Kucuksahin O, Ozcan OU, Goksuluk H, Vurgun VK, Erol C. Evaluation of global function of the heart in scleroderma patients. Echocardiography 2014; 32:912-9. [PMID: 25250771 DOI: 10.1111/echo.12774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Scleroderma is a connective tissue disease characterized by diffuse vascular lesions and fibrosis of the skin and major organs including lungs, kidneys, and heart. When cardiac involvement is clinically evident, it is recognized as a poor prognostic factor. The early detection of cardiac involvement in scleroderma would be desirable both for implementation of preventive measures in the early stages of the disease and for optimal treatment. METHODS Left (LV) and right (RV) ventricular function were examined in 31 scleroderma patients and 21 healthy controls. Conventional and tissue Doppler echocardiography was used to evaluate systolic and diastolic function. Systolic indices including systolic (S) velocity, isovolumetric acceleration (IVA), ejection time (ET), and isovolumetric contraction time (IVCT) were measured. Early diastolic (E) velocity, late diastolic (A) velocity, E/A and E'/A' ratios, isovolumetric relaxation time (IVRT), and deceleration time (DT) were the diastolic measurements obtained. Myocardial performance index (Tei index) calculated by 2 different methods was used to assess global ventricular function. RESULTS In our study; mitral S velocity, biventricular ET, E', E/A, E'/A', RV IVA, LV IVA, and tricuspid S velocity were significantly lower in scleroderma patients. Mitral DT, IVCT, and biventricular IVRT, were significantly higher in scleroderma patients (P < 0.0001). In addition, RV and LV Tei indices were significantly increased in scleroderma patients compared with the control group (P < 0.0001 and P < 0.001, respectively). CONCLUSIONS In scleroderma patients, global function was depressed prior to the onset of clinical symptoms. Biventricular diastolic and systolic function abnormalities were also observed.
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Affiliation(s)
| | - Sibel Turhan
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Refika Hural
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Aynur Acıbuca
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Orhan Kucuksahin
- Department of Rheumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Ozgur Ulas Ozcan
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Huseyin Goksuluk
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Veysel Kutay Vurgun
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Cetin Erol
- Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
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Ciurzyński M, Bienias P, Irzyk K, Kostrubiec M, Szewczyk A, Demkow U, Siwicka M, Kurnicka K, Lichodziejewska B, Pruszczyk P. Heart diastolic dysfunction in patients with systemic sclerosis. Arch Med Sci 2014; 10:445-54. [PMID: 25097573 PMCID: PMC4107251 DOI: 10.5114/aoms.2014.43739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 07/24/2013] [Accepted: 10/14/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There are limited data on left (LV) and right ventricular (RV) diastolic function in systemic sclerosis (SSc) patients especially in relation to biomarkers of matrix remodeling. The aim of the study was to analyze LV and RV myocardial diastolic function in SSc patients at baseline and after at least 1 year of follow-up and its relation to serum tissue inhibitors of metalloproteinase 1 (TIMP-1) level. MATERIAL AND METHODS We prospectively studied 111 SSc patients (101 female, 10 male, age 54.2 ±13.8 years) and 21 age-matched controls (18 female, 3 male, age 49.3 ±10.5 years). After at least 1 year of observation (3.0 ±1.1 years) we reevaluated 69 of the SSc patients. Transthoracic echocardiography (Philips, iE33) for assessment of LV and RV diastolic function was performed and TIMP-1 serum level was measured. RESULTS Impaired LV relaxation was observed in 38 (34%) SSc patients and in 1 (5%) of the controls (p < 0.001). The mean E/A ratio was lower in patients with SSc than in controls (p = 0.002) and significantly decreased after the follow-up period (p = 0.02). Impaired RV relaxation was detected in 25 (22.5%) SSc patients and in 1 (5%) control subject (p < 0.001) but did not deteriorate after follow-up. Mean serum level of TIMP-1 was significantly elevated in the follow-up group compared to baseline examination (p = 0.0001). Serum TIMP-1 level correlated positively with E/E', both septal and lateral (r = 0.4, p = 0.002 and r = 0.32, p = 0.01). CONCLUSIONS The LV and RV relaxation is impaired in SSc patients. Moreover, left ventricular diastolic function deteriorated after the follow-up period. The TIMP-1 serum levels correlate with echocardiographic parameters, providing a potent link for LV diastolic function and matrix remodeling in patients with SSc.
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Affiliation(s)
- Michał Ciurzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Bienias
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Irzyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Urszula Demkow
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Maria Siwicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
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Tedford RJ, Mudd JO, Girgis RE, Mathai SC, Zaiman AL, Housten-Harris T, Boyce D, Kelemen BW, Bacher AC, Shah AA, Hummers LK, Wigley FM, Russell SD, Saggar R, Saggar R, Maughan WL, Hassoun PM, Kass DA. Right ventricular dysfunction in systemic sclerosis-associated pulmonary arterial hypertension. Circ Heart Fail 2013; 6:953-63. [PMID: 23797369 DOI: 10.1161/circheartfailure.112.000008] [Citation(s) in RCA: 193] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Systemic sclerosis–associated pulmonary artery hypertension (SScPAH) has a worse prognosis compared with idiopathic pulmonary arterial hypertension (IPAH), with a median survival of 3 years after diagnosis often caused by right ventricular (RV) failure. We tested whether SScPAH or systemic sclerosis–related pulmonary hypertension with interstitial lung disease imposes a greater pulmonary vascular load than IPAH and leads to worse RV contractile function. METHODS AND RESULTS We analyzed pulmonary artery pressures and mean flow in 282 patients with pulmonary hypertension (166 SScPAH, 49 systemic sclerosis–related pulmonary hypertension with interstitial lung disease, and 67 IPAH). An inverse relation between pulmonary resistance and compliance was similar for all 3 groups, with a near constant resistance×compliance product. RV pressure–volume loops were measured in a subset, IPAH (n=5) and SScPAH (n=7), as well as SSc without PH (n=7) to derive contractile indexes (end-systolic elastance [Ees] and preload recruitable stroke work [Msw]), measures of RV load (arterial elastance [Ea]), and RV pulmonary artery coupling (Ees/Ea). RV afterload was similar in SScPAH and IPAH (pulmonary vascular resistance=7.0±4.5 versus 7.9±4.3 Wood units; Ea=0.9±0.4 versus 1.2±0.5 mm Hg/mL; pulmonary arterial compliance=2.4±1.5 versus 1.7±1.1 mL/mm Hg; P>0.3 for each). Although SScPAH did not have greater vascular stiffening compared with IPAH, RV contractility was more depressed (Ees=0.8±0.3 versus 2.3±1.1, P<0.01; Msw=21±11 versus 45±16, P=0.01), with differential RV-PA uncoupling (Ees/Ea=1.0±0.5 versus 2.1±1.0; P=0.03). This ratio was higher in SSc without PH (Ees/Ea=2.3±1.2; P=0.02 versus SScPAH). CONCLUSIONS RV dysfunction is worse in SScPAH compared with IPAH at similar afterload, and may be because of intrinsic systolic function rather than enhanced pulmonary vascular resistive and pulsatile loading.
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MESH Headings
- Adult
- Aged
- Analysis of Variance
- Arterial Pressure
- Cardiac Catheterization
- Chi-Square Distribution
- Compliance
- Familial Primary Pulmonary Hypertension
- Female
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Linear Models
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/physiopathology
- Male
- Middle Aged
- Myocardial Contraction
- Nonlinear Dynamics
- Predictive Value of Tests
- Prognosis
- Pulmonary Artery/physiopathology
- Pulmonary Circulation
- Risk Factors
- Scleroderma, Systemic/complications
- United States
- Vascular Resistance
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right
- Ventricular Pressure
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Tissue Doppler imaging in systemic sclerosis: a 3-year longitudinal study. Semin Arthritis Rheum 2013; 43:673-80. [PMID: 24262931 DOI: 10.1016/j.semarthrit.2013.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 09/21/2013] [Accepted: 10/10/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To investigate by standard echocardiography and pulsed-tissue Doppler imaging (TDI) the course of systemic sclerosis (SSc) heart disease and its correlation with epidemiological, clinical, and serological features of the disease and drug treatment. METHODS A total of 74 consecutive patients (69 females, between the ages of 19 and 71 years, and disease duration 1-43 years) and 71 controls underwent cardiac assessment at baseline and at 3-year follow-up. RESULTS At baseline, compared to controls, patients showed post-Bonferroni correction, impaired left (LV) and right ventricular (RV) diastolic function (Em/Am 0.85 ± 0.4 vs 1.5 ± 0.7, p = 0.0003; Et/At 0.9 ± 0.3 vs 1.3 ± 0.4, p = 0.0003), subtle LV and RV systolic dysfunction (Sm 13.7 ± 2.7 vs 15.4 ± 3.2cm/s, p = 0.031; St < 11.5cm/s in 16/74 patients vs 0 controls, p = 0.0031), and higher pulmonary artery systolic pressure (sPAP) (26.1 ± 6.0 vs 24.1 ± 5.1, p = 0.040). At 3-year follow-up, SSc patients showed a further deterioration of biventricular diastolic and systolic function and a further sPAP increase. At multiple regression analysis of baseline data, Em/Am < 1 was detected in 55/74 patients vs 25/71 controls (p < 0.0001) and was associated with age (p = 0.030); Et/At < 1 was detected in 16/74 patients vs 7/71 controls (p < 0.0001), was associated with NYHA class ≥ II (p = 0.033), late capillaroscopic pattern (p = 0.029), and a baseline cardiac Medsger severity score ≥ 1 (p = 0.029). TDI evidence of new abnormalities in RV and/or LV diastolic function was associated with a baseline cardiac Medsger severity score ≥ 1 (p = 0.01). Neither diastolic or systolic abnormalities nor sPAP changes correlated with treatment. CONCLUSIONS Our study confirms that SSc patients exhibit biventricular systolic and diastolic dysfunction and increased sPAP and reveals further deterioration at 3-year follow-up.
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Tissue Doppler assessment of right ventricular function in female patients with limited form of systemic sclerosis. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2013.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Hilde JM, Skjørten I, Grøtta OJ, Hansteen V, Melsom MN, Hisdal J, Humerfelt S, Steine K. Right Ventricular Dysfunction and Remodeling in Chronic Obstructive Pulmonary Disease Without Pulmonary Hypertension. J Am Coll Cardiol 2013; 62:1103-1111. [DOI: 10.1016/j.jacc.2013.04.091] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/23/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
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Right Ventricular End-Diastolic Wall Stress: Does It Impact on Right Atrial Size, and Does It Differ in Right Ventricular Pressure vs Volume Loading Conditions? Can J Cardiol 2013; 29:858-65. [DOI: 10.1016/j.cjca.2012.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/23/2012] [Accepted: 06/28/2012] [Indexed: 11/18/2022] Open
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Di Cesare E, Battisti S, Di Sibio A, Cipriani P, Giacomelli R, Liakouli V, Ruscitti P, Masciocchi C. Early assessment of sub-clinical cardiac involvement in systemic sclerosis (SSc) using delayed enhancement cardiac magnetic resonance (CE-MRI). Eur J Radiol 2013; 82:e268-73. [PMID: 23510727 DOI: 10.1016/j.ejrad.2013.02.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 12/06/2012] [Accepted: 02/06/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Systemic sclerosis heart involvement (SHI) is one of systemic sclerosis (SSc) most frequent complications, both in diffuse (dcSSc) and limited (lcSSc) cutaneous forms of disease. Nowadays, SHI is a major factor decreasing SSc survival rate because, when clinically evident, is associated with 70% of mortality at 5 years. SHI shows different forms, primary and/or secondary. Primary myocardial SHI is characterized by fibrosis. Aim of our study is to assess the presence and pattern of fibrosis as detected by cardiac magnetic resonance (CMR) in systemic sclerosis. METHODS In this study, we used CE-MRI (contrast enhanced-MRI) in 58 female SSc patients. Images were evaluated to obtain functional parameters and to see presence, location and pattern (nodular, linear or diffuse) of myocardial LE, sign of fibrosis. CE-MRI findings were correlated with patients clinical setting. RESULTS Myocardial fibrosis was detected in 25 of 58 patients (43%). The main finding observed in 16 of these 25 patients was a late enhancement showing a linear pattern, without coronary distribution and sparing the sub-endocardial myocardial layers. A patchy nodular enhancement pattern was observed in 9 patients (36%). Patients with linear pattern presented dcSSc, on the contrary patients with nodular LE displayed the lcSSc form. CONCLUSIONS This study shows that CE-MRI is a reliable technique to detect SHI earlier than other methods. SHI increase passive myocardial stiffness, proportional to collagen deposition degree, leading to cardiac remodelling with possible development of heart failure, even with normal ejection fraction. An early treatment of SHI might improve SSc patients outcome.
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Affiliation(s)
- Ernesto Di Cesare
- Department of Radiology, University of L'Aquila, Via Vetoio 1, 67100 L'Aquila, Italy.
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Abstract
PURPOSE OF REVIEW When present clinically, cardiac involvement in systemic sclerosis (SSc) is a major risk factor for death. It is therefore vitally important to understand the epidemiology, screening, diagnosis, and treatment of the cardiac manifestations of SSc. RECENT FINDINGS The epidemiology of cardiac involvement in SSc has been the subject of several recent studies. Most importantly, the prevalence of overt left ventricular (LV) systolic dysfunction and its associated risk factors have been defined, and patients with diffuse cutaneous SSc appear to be most susceptible to direct cardiac involvement. From a diagnostic and screening standpoint, tissue Doppler echocardiography and natriuretic peptides have provided fresh insight into subclinical cardiac dysfunction in SSc. Newer techniques, such as speckle-tracking echocardiography, diffuse myocardial fibrosis imaging, and absolute myocardial perfusion imaging, are poised to further advance our knowledge. Lastly, there is now consistent observational data to suggest a central role for calcium channel blockers in the treatment of microvascular ischemia and prevention of overt LV systolic dysfunction, although randomized controlled trials are lacking. SUMMARY Recent studies have improved our understanding of cardiac involvement in SSc. Nevertheless, key questions regarding screening, diagnosis, and treatment remain. Novel diagnostic techniques and multicenter studies should yield important new data, which will hopefully ultimately result in improved outcomes.
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Cuttica MJ, Shah SJ, Rosenberg SR, Orr R, Beussink L, Dematte JE, Smith LJ, Kalhan R. Right heart structural changes are independently associated with exercise capacity in non-severe COPD. PLoS One 2011; 6:e29069. [PMID: 22220201 PMCID: PMC3248404 DOI: 10.1371/journal.pone.0029069] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/20/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) occurs frequently and results in functional limitation in advanced COPD. Data regarding the functional consequence of PH in less severe COPD are limited. Whether echocardiographic evidence of right sided heart pathology is associated with functional outcomes in patients with non-severe COPD is unknown. METHODS We evaluated pulmonary function, six minute walk distance, and echocardiography in 74 consecutive patients with non-severe COPD. We performed multivariable linear regression to evaluate the association between right heart echocardiographic parameters and six minute walk distance adjusting for lung function, age, sex, race, and BMI. MAIN RESULTS The mean six minute walk distance was 324±106 meters. All subjects had preserved left ventricular (LV) systolic function (LV ejection fraction 62.3%±6.1%). 54.1% had evidence of some degree of diastolic dysfunction. 17.6% of subjects had evidence of right ventricular enlargement and 36.5% had right atrial enlargement. In univariate analysis RV wall thickness (β = -68.6; p = 0.002), log right atrial area (β = -297.9; p = 0.004), LV mass index (β = -1.3; p = 0.03), E/E' ratio (β = -5.5; p = 0.02), and degree of diastolic dysfunction (β = -42.8; p = 0.006) were associated with six minute walk distance. After adjustment for co-variables, the associations between right atrial area (log right atrial area β = -349.8; p = 0.003) and right ventricular wall thickness (β = -43.8; p = 0.04) with lower six minute walk distance remained significant independent of forced expiratory volume in one second (FEV1). LV mass index, E/E' ratio, and degree of diastolic dysfunction were not independent predictors of six minute walk distance. CONCLUSION In patients with non-severe COPD right sided cardiac structural changes are associated with lower six minute walk distance independent of lung function. These findings may indicate that echocardiographic evidence of pulmonary hypertension is present in patients with non-severe COPD and has important functional consequences.
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Affiliation(s)
- Michael J Cuttica
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois, United States of America.
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Ivanovic BA, Tadic MV, Zlatanovic MM, Damjanov NN, Ostojić PM, Bonaci-Nikolic BN. Which factors impact myocardial function in systemic sclerosis? Echocardiography 2011; 29:307-17. [PMID: 22066854 DOI: 10.1111/j.1540-8175.2011.01560.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of our study was to determine clinical and echocardiographic parameters, which impacted the left (LV) and right ventricular (RV) diastolic and global function in patients with systemic sclerosis (SSc). METHODS The study included 50 SSc patients and 48 age-matched healthy volunteers. All the patients underwent clinical examination, serological tests, pulmonary function testing, and complete two-dimensional echocardiography, which included pulsed and tissue Doppler. We determined the ratio of early diastolic transtricuspid/transmitral and the lateral area of the tricuspid/mitral annulus flow velocities (E/e';(lateral) ). RV and LV global ventricular function was estimated by the Tei index. Pulmonary vascular resistance (PVR) was calculated by using echocardiographic parameters. RESULTS Tricuspid inflow E/A ratio was decreased in the SSc group (P < 0.001), also as e'/a' ratio (P < 0.001), whereas E/e'(tricuspid) was increased (P = 0.001). The RV Tei index was increased in SSc patients (P < 0.001). PVR was significantly higher than in controls (P < 0.001). The multivariate analysis showed that brain natriuretic peptide (BNP) level (β= 0.403, P = 0.016), diffusion capacity for carbon monoxide (DLCO; β= 0.361, P = 0.025), RV systolic pressure (β= 0.449, P = 0.011), and PVR (β= 0.507, P < 0.001) were independently associated with RV diastolic function (tricuspid E/e'(lateral) ). Similar results were achieved for the RV Tei index. Multiple regression showed that BNP level (β= 0.337, P = 0.029), DLCO (β= 0.405, P = 0.011), and PVR (β= 0.449, P = 0.022) were independently associated with LV diastolic function (mitral E/e'(lateral) ). Similar results were obtained for the LV Tei index. CONCLUSION Our study revealed some new noninvasive parameters (BNP, DLCO, and PVR), which are useful for everyday clinical practice for determining of early myocardial involvement in SSc. (Echocardiography, ****;**:1-11).
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Do DH, Therrien J, Marelli A, Martucci G, Afilalo J, Sebag IA. Right Atrial Size Relates to Right Ventricular End-Diastolic Pressure in an Adult Population with Congenital Heart Disease. Echocardiography 2010; 28:109-16. [DOI: 10.1111/j.1540-8175.2010.01277.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Othman KM, Assaf NY, Farouk HM, Aly Hassan IM. Autonomic dysfunction predicts early cardiac affection in patients with systemic sclerosis. CLINICAL MEDICINE INSIGHTS. ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2010; 3:43-54. [PMID: 21124695 PMCID: PMC2989638 DOI: 10.4137/cmamd.s4940] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To detect the early preclinical alterations in cardiac autonomic control as well as altered cardiac function in systemic sclerosis (SSc) patients and their relevance to the clinical features of the disease using noninvasive methods. METHODS 30 SSc patients and 15 healthy controls matched for age and sex underwent clinical examination, serological analysis, and echocardiographic assessment including Doppler flow imaging to evaluate cardiac function, and 24-hour Holter monitoring analyzed for arrhythmia and heart rate variability (HRV) in the time and frequency domains. RESULTS The trans-mitral Doppler of early to atrial wave (E/A) ratio was reversed in five patients (16.6%) and the tricuspid E/A ratio was reversed in 10 patients (33.3%). Holter analysis for SSc patients revealed an increased prevalence of premature ventricular contractions (PVC) ≥ 10/h (P = 0.02), supra-ventricular tachycardias (SVTs) (P = 0.2), and total PVC count (P = 0.0000). Highly significant (P = 0.000) impairment in all HRV parameters was demonstrated in the SSc patients. Total skin thickness score (TSS), Raynaud's phenomenon and anti-scleroderma 70 (anti-SCL70) showed significant positive correlations with all arrhythmia parameters, while showing a significant negative correlation with the impaired ventricular diastolic function and various HRV parameters. No correlation was found between arrhythmia and HRV parameters and disease duration, disease type, or presence of anti-centromere antibodies. CONCLUSION Low heart rate variability, increased TSS and the presence of anti-SCL70 are correlated with preclinical cardiac involvement in SSc patients and may predict the likelihood of malignant arrhythmia and sudden cardiac death. Therefore, noninvasive HRV evaluation before clinical cardiac involvement in these patients might be beneficial when added to the clinical and laboratory assessments in detecting high-risk patients, and may allow for implementation of preventive measures and initiation of appropriate therapy early in the course of the disease.
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Affiliation(s)
| | | | | | - Iman M. Aly Hassan
- Clinical Pathology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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Do we have two hearts? New insights in right ventricular function supported by myocardial imaging echocardiography. Heart Fail Rev 2010; 15:39-61. [PMID: 19866357 DOI: 10.1007/s10741-009-9154-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
RV performance is difficult to evaluate, given its geometry, interrelationship with the left ventricle, and sensitivity to alterations in pulmonary pressure. This article focuses on some of the challenges related to the assessment of RV function in the setting of the RV's unique anatomic, physiologic, conventional and newer echocardiographic aspects, and therapeutic implications. The majority of proposed methods of echocardiographic assessment of RV function are based on volumetric approximations of the RV. Such approaches have inherent limitations, first as volume-related measures such as EF are load dependent, second because of the complex geometry of the RV. The issue of RV geometry is usually overcome using geometry-independent parameters such as tricuspid annular excursion and the Tei index. The recent introduction of real-time three-dimensional echocardiography and myocardial imaging echocardiography (tissue Doppler imaging, 1D-strain and 2D-strain echocardiography) implied a great progress in echocardiography. Tissue Doppler imaging allows the quantitative assessment of RV systolic and diastolic function by means of measurement of myocardial velocities. Strain measurements have been shown to correlate well with sonomicrometry segment length measurements both in the inflow and outflow tract of the RV and under different loading conditions. Other findings have been reported in chronic and acute clinical settings. Standard and novel echocardiographic methods of assessment of RV size and performance can help clinicians in the treatment of acute and chronic RV failure and contribute to a better understanding of the peculiar chamber-related functional mechanisms in the context of ventricular interdependent independency.
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Campo A, Mathai SC, Le Pavec J, Zaiman AL, Hummers LK, Boyce D, Housten T, Champion HC, Lechtzin N, Wigley FM, Girgis RE, Hassoun PM. Hemodynamic predictors of survival in scleroderma-related pulmonary arterial hypertension. Am J Respir Crit Care Med 2010; 182:252-60. [PMID: 20339143 DOI: 10.1164/rccm.200912-1820oc] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Pulmonary arterial hypertension (PAH) related to systemic sclerosis (SSc) has a poorer prognosis compared with other forms of PAH for reasons that remain unexplained. OBJECTIVES To identify risk factors of mortality in a well-characterized cohort of patients with PAH related to systemic sclerosis (SSc-PAH). METHODS Seventy-six consecutive patients with SSc (64 women and 12 men; mean age 61 +/- 11 yr) were diagnosed with PAH by heart catheterization in a single center, starting in January 2000, and followed over time. Kaplan-Meier estimates were calculated and mortality risk factors were analyzed. MEASUREMENTS AND MAIN RESULTS Forty (53%) patients were in World Health Organization functional class III or IV. Mean pulmonary artery pressure was 41 +/- 11 mm Hg, pulmonary vascular resistance (PVR) was 8.6 +/- 5.6 Wood units, and cardiac index was 2.4 +/- 0.7 L/min/m(2). Median follow-up time was 36 months, with 42 deaths observed. Survival estimates were 85%, 72%, 67%, 50%, and 36% at 1, 2, 3, 4, and 5 years, respectively. Multivariate analysis identified PVR (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03-1.18; P < 0.01), stroke volume index (HR, 0.94; 95% CI, 0.89-0.99; P = 0.02), and pulmonary arterial capacitance (HR, 0.43; 95% CI, 0.20-0.91; P = 0.03) as strong predictors of survival. An estimated glomerular filtration rate less than 60 ml/min/1.73 m(2) portended a threefold risk of mortality. CONCLUSIONS Our results suggest that specific components of right ventricular dysfunction and renal impairment contribute to increased mortality in SSc-PAH. Understanding the mechanisms of right ventricular dysfunction in response to increased afterload should lead to improved targeted therapy in these patients.
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Affiliation(s)
- Aránzazu Campo
- MD, Division of Pulmonary and Critical Care Medicine, 1830 E Monument St, Fifth Floor, Baltimore, MD 21205, USA
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DIMITROULAS THEODOROS, GIANNAKOULAS GEORGIOS, PAPADOPOULOU KLIO, KARVOUNIS HARALAMBOS, DIMITROULA HARA, KOLIAKOS GEORGIOS, KARAMITSOS THEODOROS, PARCHARIDOU DESPOINA, SETTAS LOUKAS. Early Detection of Cardiac Involvement in Systemic Sclerosis Assessed by Tissue-Doppler Echocardiography: Relationship with Neurohormonal Activation and Endothelial Dysfunction. J Rheumatol 2010; 37:993-9. [DOI: 10.3899/jrheum.090931] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Cardiopulmonary complications are common in patients with systemic sclerosis (SSc). We assessed cardiac involvement in patients with SSc using echocardiography and investigated the association of N-terminal pro-brain natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) with echocardiographic measures of myocardial function in sera of patients with SSc who had no symptoms of heart failure.Methods.We prospectively studied 52 patients with SSc (mean age 55.7 ± 10.1 yrs, 51 women), with conventional and tissue-Doppler echocardiography. Plasma NT-proBNP and ADMA levels were measured in all patients. Data were compared with those obtained from 25 healthy controls comparable for age and sex.Results.Patients with SSc had impaired left ventricular (LV) and right ventricular diastolic function expressed by inverted ratio of peak early to peak late transmitral (Mit E/A) and transtricuspid velocity and increased left atrial diameter compared with controls. Peak systolic mitral lateral annular motion velocity and peak early diastolic mitral lateral annular motion velocity (LV Em) were lower, while LV E/Em ratio was higher, in patients with SSc compared to controls. ADMA was significantly related with LV Em and E/Em ratio. NT-proBNP was associated with Mit E, Mit E/A ratio and mitral deceleration time. Significant correlation was also observed between NT-proBNP and ADMA levels.Conclusion.Depressed cardiac function is common, even in asymptomatic patients with SSc. NT-proBNP and ADMA are significantly correlated with echocardiographic abnormalities, providing a potent link for cardiac function, neuroendocrine derangement, and endothelial dysfunction in patients with SSc who have cardiac disease.
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Natriuretic Peptides in Systemic Sclerosis-related Pulmonary Arterial Hypertension. Semin Arthritis Rheum 2010; 39:278-84. [DOI: 10.1016/j.semarthrit.2009.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Revised: 03/10/2009] [Accepted: 03/30/2009] [Indexed: 11/18/2022]
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Schattke S, Knebel F, Grohmann A, Dreger H, Kmezik F, Riemekasten G, Baumann G, Borges AC. Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study. Cardiovasc Ultrasound 2010; 8:3. [PMID: 20096122 PMCID: PMC2822748 DOI: 10.1186/1476-7120-8-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 01/22/2010] [Indexed: 11/13/2022] Open
Abstract
Background Isovolumetric acceleration (IVA) is a novel tissue Doppler parameter for the assessment of systolic function. The aim of this study was to evaluate IVA as an early parameter for the detection of right ventricular (RV) systolic dysfunction in patients with systemic sclerosis (SSc) without pulmonary hypertension. Methods 22 patients and 22 gender- and age-matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) and speckle tracking strain to assess RV function. Results Tricuspid annular plane systolic excursion (TAPSE) (23.2 ± 4.1 mm vs. 26.5 ± 2.9 mm, p < 0.006), peak myocardial systolic velocity (Sm) (11.6 ± 2.3 cm/s vs. 13.9 ± 2.7 cm/s, p = 0.005), isovolumetric contraction velocity (IVV) (10.3 ± 3 cm/s vs. 14.8 ± 3 cm/s, p < 0.001) and IVA (2.3 ± 0.4 m/s2 vs. 4.1 ± 0.8 m/s2, p < 0.001) were significant lower in the patient group. IVA was the best parameter to predict early systolic dysfunction with an area under the curve of 0.988. Conclusion IVA is a useful tool with high-predictive power to detect early right ventricular systolic impairment in patients with SSc and without pulmonary hypertension.
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Affiliation(s)
- Sebastian Schattke
- Universitätsmedizin Berlin, Medical Clinic for Cardiology and Angiology, Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany.
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Remy-Jardin M, Hachulla AL, Pontana F, Faivre JB, Remy J. Sémiologie des atteintes du cœur droit en pathologie pulmonaire. ACTA ACUST UNITED AC 2009; 90:1819-29. [DOI: 10.1016/s0221-0363(09)73285-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Poanta L, Dadu R, Tiboc C, Rednic S, Dumitrascu D. Systolic and diastolic function in patients with systemic sclerosis. Eur J Intern Med 2009; 20:378-82. [PMID: 19524178 DOI: 10.1016/j.ejim.2008.10.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 09/22/2008] [Accepted: 10/24/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical and epidemiological findings indicate that symptomatic heart disease in patients with systemic sclerosis (SSc) predicts poor prognosis, but cardiac involvement may occur years before clinical manifestation. The aim of this study was to evaluate the cardiac function in patients with SSc and to correlate the echocardiographic parameters with others that quantify the diseases' severity. METHODS Twenty consecutive patients with SSc were investigated with transthoracic echocardiography (TTE). Two dimensional, pulsed Doppler and pulsed tissue Doppler imaging (TDI) techniques were used, in all the patients, to assess the systolic and diastolic function for left ventricle (LV). Correlations were made between echocardiographic measurements and some clinical and serological features of the patients. RESULTS None of the patients had any clinical signs of cardiac involvement, nor ECG or TTE systolic function impairment; there are significant differences between systemic sclerosis patients and control group for peak A velocity (0.75+/-0.22 vs 0.57+/-0.32, P=0.05), E/A ratio (1.14+/-0.22 vs 1.48+/-0.26, P=0.01), E/Ea ratio (8.25+/-1.57 vs 7+/-2.2, P=0.05), which account for filling impairment of LV. There are also significant correlations between some other parameters, like the mean duration of Raynaud's phenomenon and E/Ea ratio (r=0.48, P<0.05). CONCLUSIONS The analysis of SSc heart disease, mainly at a preclinical level, is important in all the cases as an asymptomatic patient may have diastolic dysfunction which can be treated and should be closely observed.
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Affiliation(s)
- Laura Poanta
- University of Medicine and Pharmacy Iuliu Hatieganu, 2nd Medical Department, Cluj Napoca, Romania.
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López-Candales A, Rajagopalan N, Gulyasy B, Edelman K, Bazaz R. Differential strain and velocity generation along the right ventricular free wall in pulmonary hypertension. Can J Cardiol 2009; 25:e73-7. [PMID: 19279990 DOI: 10.1016/s0828-282x(09)70045-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND In contrast to the homogeneously distributed deformation properties within the left ventricle, the right ventricular (RV) free wall (RVFW) shows a more inhomogeneous distribution. It has been demonstrated that pulmonary hypertension (PH) results in significant RVFW mechanical delay. OBJECTIVE To assess the effect of the degree of pulmonary arterial systolic pressure on the RVFW strain gradient and on myocardial velocity generation. METHODS Peak longitudinal strain and velocity data were collected from three different segments (basal, mid- and apical) of the RVFW in 17 normal individuals and 31 PH patients. RESULTS A total of 144 RV wall segments were analyzed. RVFW strain values in individuals without PH were higher in the mid and apical segments than in the basal segment. In contrast, RVFW strain in PH patients was higher in basal segments and diminished toward the apex. In terms of RVFW velocities, both groups showed decremental values from basal to apical segments. Basal and mid-RVFW velocities were significantly lower in PH patients than in individuals without PH. CONCLUSIONS PH results in significant alterations of strain and velocity generation that occurs along the RVFW. Of these abnormalities, the reduction in strain from the mid and apical RVFW segments was most predictive of PH. It is important to be aware of these differences in strain generation when studying the effect of PH on the right ventricle. Additional studies are required to determine whether these differences are due to RV remodelling.
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Fayssoil A, Abasse S, Nardi O. Analyse échocardio-graphique du ventricule droit. Med Sci (Paris) 2009; 25:513-8. [DOI: 10.1051/medsci/2009255513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Celermajer DS, Marwick T. Echocardiographic and right heart catheterization techniques in patients with pulmonary arterial hypertension. Int J Cardiol 2008; 125:294-303. [PMID: 17689753 DOI: 10.1016/j.ijcard.2007.04.184] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The cardiovascular assessment of patients with suspected pulmonary arterial hypertension (PAH) involves Doppler echocardiography and often subsequent confirmation by right heart catheterization (RHC). However, there appears to be limited consensus on the appropriate technique(s) for assessing PAH, and thus no clear, comprehensive guidelines exist for assessment of PAH. The aim of this paper is to review the Doppler echocardiographic and RHC techniques for the diagnosis and/or assessment of PAH. METHOD We searched Medline (1966 to August 2006) and EMBASE (1980 to August 2006) bibliographic databases to allow identification of all potentially relevant studies and review articles. In addition, the reference lists of included articles were scanned to identify relevant references and unpublished reports missed by the search strategy. RESULTS Our findings show that recommendations for the echocardiographic assessment of PAH at rest or with exercise are heterogeneous. Clinical practice guidelines provide limited details. Although more specific information regarding echocardiographic techniques can be obtained from individual research articles, the techniques employed and the methods used to calculate specific hemodynamic variables do not appear to be consistent throughout the literature. RHC techniques for the confirmation of PAH are more consistent, albeit less frequently reported. The literature search identified several articles where indications and considerations for the catheterization of patients with PAH are discussed, together with safety considerations and principles for the accurate assessment of hemodynamic variables. CONCLUSION Although clinical practice guidelines and numerous research studies provide details of echocardiographic measures in patients with PAH, greater consensus and standardisation of measurement techniques is required. A minimum dataset for the evaluation of PAH by these techniques is suggested.
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Affiliation(s)
- David S Celermajer
- Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
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Pignone A, Mori F, Pieri F, Oddo A, Galeota G, Fiori G, Del Rosso A, Perfetto F, Becucci A, Livi R, Tempestini A, Benvenuti C, Gramigna L, Fedi R, Generini S, Minelli M, Cinelli M, Guiducci S, Arcangeli C, Conforti ML, Bernardo P, Cerinic MM. Exercise Doppler echocardiography identifies preclinic asymptomatic pulmonary hypertension in systemic sclerosis. Ann N Y Acad Sci 2007; 1108:291-304. [PMID: 17893993 DOI: 10.1196/annals.1422.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In systemic sclerosis (SSc), the involvement of the interstitium or vascular system of the lung may lead to pulmonary arterial hypertension (PAH). PAH is often asymptomatic or oligosymptomatic in early SSc and, when it becomes symptomatic, pulmonary vascular system is already damaged. Exercise echocardiography (ex-echo), measuring pulmonary artery pressure (PAP) during exercise and allowing to differentiate physiologic from altered PAP responses, may identify subclinical PAH. Our aims were (a) to evaluate by ex-echo the change of PAP in patients with SSc without lung involvement; and (b) to correlate PAP during exercise (ex-PAP) values to clinical and biohumoral parameters of PAH. Twenty-seven patients with limited SSc (ISSc) without interstitial lung involvement were studied. Patients underwent rest and exercise two-dimensional and Doppler echocardiography by supine cycloergometer. Systolic PAP was calculated using the maximum systolic velocity of the tricuspid regurgitant jet at rest and during exercise values of systolic PAP exceeding 40 mmHg at ex-echo were considered as abnormal, and biohumoral markers potentially related to PAH were assessed. Eighteen of 27 SSc patients presented an ex-PAP > 40 mmHg, while in 9 of 27 patients ex-PAP values remained < 40 mmHg (48.8 +/- 4.5 mmHg versus 36.2 +/- 3.1 mmHg; P < 0.001). Other echocardiographic and ergometric parameters, clinical tests, and biohumoral markers were not different in the two groups. Ex-PAP significantly correlated with D-dimer (P = 0.0125; r2 = 0.2029). Ex-echo identifies a cluster of SSc patients with subclinical PAH that may develop PAH. This group should be followed up and may be considered for specific therapies to prevent disease evolution.
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Affiliation(s)
- Alberto Pignone
- Department of Medicine, Division of Rheumatology, University of Florence, Florence, Italy
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Gondi S, Dokainish H. Right Ventricular Tissue Doppler and Strain Imaging: Ready for Clinical Use? Echocardiography 2007; 24:522-32. [PMID: 17456072 DOI: 10.1111/j.1540-8175.2007.00430.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Although tissue Doppler (TD) imaging of the left ventricle is now commonly used in clinical settings, TD imaging of the right ventricle (RV) is not routinely practiced. Yet, there are significant data on clinical uses of RV TD imaging, including established normal values using both color and spectral TD. In acute left ventricular (LV) inferior wall myocardial infarction, depressed RV TD velocities have been shown to correlate with the presence of RV impairment, and with patient outcome. In patients with LV heart failure, TD imaging has been correlated to RV ejection fraction by radionuclide angiography, and is an independent predictor of outcome. In patients with congenital heart disease, RV TD has been especially valuable for assessing RV function, and has been correlated to invasive hemodynamic indices, and RV ejection fraction by magnetic resonance imaging. The RV performance (Tei) index has been calculated and validated using TD-derived, rather than conventional pulsed Doppler time intervals. RV TD indices have been shown to be useful in the detection of subclinical and clinical disease in morbid obesity, chronic pulmonary, and systemic disease. TD-derived RV strain imaging can detect segmental myocardial dysfunction, overcoming limitations to conventional TD imaging resulting from tethering. For both TD velocity and strain imaging, however, appreciation of the limitations of these techniques is necessary for their appropriate use. Given its rapid acquisition times, reproducibility, and ease of addition to standard transthoracic echocardiographic protocols, RV TD and strain imaging are important additional modalities in the comprehensive echo-Doppler assessment of RV function.
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Affiliation(s)
- Sreedevi Gondi
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas 77030, USA
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Buch MH, Denton CP, Furst DE, Guillevin L, Rubin LJ, Wells AU, Matucci-Cerinic M, Riemekasten G, Emery P, Chadha-Boreham H, Charef P, Roux S, Black CM, Seibold JR. Submaximal exercise testing in the assessment of interstitial lung disease secondary to systemic sclerosis: reproducibility and correlations of the 6-min walk test. Ann Rheum Dis 2007; 66:169-73. [PMID: 16868020 PMCID: PMC1798506 DOI: 10.1136/ard.2006.054866] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2006] [Indexed: 11/03/2022]
Abstract
BACKGROUND The 6-min walk test (6MWT) is increasingly used as an outcome measure in interstitial lung disease (ILD). AIM To evaluate the usefulness of the 6MWT in a cohort of patients with ILD secondary to systemic sclerosis (SSc) and to correlate with established physiological parameters. METHODS 163 patients with SSc-ILD were recruited for a multicentre, randomised, double-blind clinical trial. Available data at protocol screening included repeated 6MWTs, pulmonary function testing with diffusing capacity, Doppler echocardiography and high-resolution computed tomography of the thorax. Borg Dyspnoea Index was evaluated before and after 6MWT. RESULTS Mean (standard deviation (SD)) distance walked during walk test 1 was 396.6 (84.55) m compared with 399.5 (86.28) m at walk test 2. The within-subject, intertest correlation as determined by Pearson's correlation coefficient testing was 0.95 (p<0.001). However, only weak correlations of 6MWT with percentage forced vital capacity and the Borg Dyspnoea Index were observed, and no correlation was observed with percentage diffusing capacity. CONCLUSION These data confirm the high reproducibility of the 6MWT in patients with SSc-ILD and therefore the validity of the test in this cohort. The lack of correlation of 6MWT with standard physiological parameters of ILD suggests a multifactorial basis for limited exercise capacity in patients with SSc and calls into question the utility of the 6MWT as a measure of outcome in future studies on SSc-ILD.
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Affiliation(s)
- M H Buch
- University of Michigan Scleroderma Program, 3918 Taubman Centre, Box 0358, 1500 E Medical Center Drive, Ann Arbor, MI 48109-0358, USA
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Silveira-Torre LH. [Cardiac involvement in systemic sclerosis]. REUMATOLOGIA CLINICA 2006; 2 Suppl 3:S31-S36. [PMID: 21794385 DOI: 10.1016/s1699-258x(06)73105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Systemic sclerosis (SS) can involve the pericardium, myocardium, conduction system, and cardiac valves. The presence of overt clinical signs of cardiac disease is a poor prognostic sign. Clinical manifestations include dyspnea, palpitations, chest pain, syncope, and symptoms of right heart failure. Prevalence of clinically symptomatic pericardial disease is 5-16%. However, ecocardiographic prevalence is 5.4- 41% and at autopsy is 33-77.5%. Patchy fibrosis is the characteristic myocardial finding in SS. Contraction band necrosis is the typical pathological finding. Important complications of fibrosis include left ventricular hypertrophy, as well as systolic and diastolic dysfunction of both ventricles. Early detection of these abnormalities is very important, mainly of the diastolic dysfunction, since it occurs before the systolic dysfunction and can predict important cardiac damage. Association of skeletal myositis with myocardial disease has been described. Patients with skeletal myositis are more likely to develop congestive heart failure, sustained symptomatic arrythmias, and cardiac sudden death. Coronary arteries are normal in systemic sclerosis, but there is no endomyocardial vessel involvement. There is an increased prevalence of arrhytmias, mainly premature atrial and ventricular contractions, as well as conduction system disease. Cardiac valvular involvement is minor in systemic sclerosis; mitral valve is the most frequently affected. Other abnormalities described in this disease include peripheral large vessels stiffness and secondary cardiac involvement due to pulmonary and systemic arterial hypertension. Cardiac involvement confers a high morbi-mortality risk in systemic sclerosis.
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Affiliation(s)
- Luis H Silveira-Torre
- Departamento de Bioquímica. Instituto Nacional de Cardiología Ignacio Chávez. México DF. México
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Meune C, Allanore Y. Abnormal Right Ventricular Diastolic Function May Not Be the Only Early Marker of Myocardial Involvement in Systemic Sclerosis. Chest 2006; 130:302. [PMID: 16840422 DOI: 10.1378/chest.130.1.302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Montagnana M, Lippi G, Volpe A, Salvagno GL, Biasi D, Caramaschi P, Cesare Guidi G. Evaluation of cardiac laboratory markers in patients with systemic sclerosis. Clin Biochem 2006; 39:913-7. [PMID: 16713594 DOI: 10.1016/j.clinbiochem.2006.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Revised: 03/07/2006] [Accepted: 03/22/2006] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Myocardial involvement is frequent in systemic sclerosis, but symptoms are usually delayed and non-specific, thus often misrecognized. The aim of this study was the evaluation of the early subclinical cardiac involvement in patients with systemic sclerosis by means of non-invasive laboratory cardiac markers. DESIGN AND METHODS Cardiac troponin T (cTnT), ischemia modified albumin (IMA) and NT-prohormone-brain natriuretic peptide (NT-proBNP) were measured in 40 female patients with systemic sclerosis and in 40 matched healthy controls. RESULTS Patients with systemic sclerosis displayed significantly increased concentrations of serum IMA (106 versus 93.5 kunits/l, P < 0.0001) and NT-proBNP (89 versus 37 pg/ml, P < 0.0001), whereas no significant differences could be observed in both IMA and NT-proBNP values in limited versus diffuse pattern of disease. CONCLUSIONS The increased levels of NT-proBNP and IMA could be considered a sign of early myocardial involvement, warranting further heart examination and a regular follow-up.
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Affiliation(s)
- Martina Montagnana
- Istituto di Chimica e Microscopia Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Ospedale Policlinico G.B. Rossi, Verona, Italy.
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