Diagnostic Approach to Cardiac Involvement in Idiopathic Inflammatory Myopathies

Clinical characteristics of primary biliary cirrhosis - idiopathic inflammatory myopathy overlap syndrome: A single center study

PURPOSE

Primary biliary cirrhosis-idiopathic inflammatory myopathy (PBC-IIM) overlap syndrome (OS) is a rare condition in which cardiac involvement is observed. We aimed to characterize the clinical features and associated factors of PBC-IIM OS patients with cardiac involvement.

METHODS

Patients with PBC-IIM OS that visited our hospital from January 1983 to December 2021 were enrolled. Clinical presentations and laboratory and imaging data were recorded. The clinical data of patients with and without cardiac involvement were compared. According to the first instance of a disease flare, prognostic factors were also studied.

RESULTS

Thirty-four patients with PBC-IIM OS were enrolled. A total of 58.8% of patients presented with muscle weakness at disease onset, which primarily involved skeletal muscle (85.3%). Slight liver dysfunction was discovered in this OS cohort. In patients with cardiac involvement, palpitation (63.6%) and dyspnea (36.4%) were the most common onset symptoms. Arrhythmia was a vital manifestation in OS patients, in which half of OS patients had nonsustained ventricular tachycardia (50.0%, 11/22). Compared with noncardiac involvement, myalgia (4.5%, P = 0.004) and fever (0.0%, P = 0.011) were reported relatively rarely at disease onset in the group with cardiac involvement. The prognosis analysis showed that positivity for anti-Ro52 (HR=0.00, P = 0.034) negatively correlated with relapse in OS patients.

CONCLUSION

PBC-IIM OS has unique features. Typical clinical manifestations and early worsening cardiac indicators can be used to identify cardiac involvement and predict prognosis. Anti-Ro52 may have prognostic value for PBC-IIM OS.

Cardiac involvement in polymyositis and dermatomyositis: diagnostic approaches

Polymyositis (PM) and dermatomyositis (DM) are rare idiopathic inflammatory myopathies (IIM). Myocardial involvement in patients with IIM is an unfavorable prognostic factor and one of the most common cause of mortality in this group of patients. The purpose of this review is to present current knowledge on cardiovascular manifestations observed in IIM. Data published in English until December 2021 were selected. Clinical symptoms suggesting cardiac involvement are non-specific and require a differential diagnosis in accordance with cardiological guidelines. Troponin I is specific to cardiac injury and should be preferred to other markers to evaluate the myocardium in IIM. Abnormalities in electrocardiography are common in IIM, especially non-specific changes of the ST-T segment. In standard echocardiography left ventricular diastolic dysfunction is reported frequently. New diagnostic technologies can reveal clinically silent myocardial abnormalities. However, the prognostic value of subclinical impairment of myocardial function require further studies.

The rise and fall of troponin in a patient with polymyositis

Troponins are an excellent sensitive marker for myocardial ischaemic damage. However, there are several non-ischaemic cardiac and non-cardiac reasons for troponin elevation. Many cases of troponin T elevation and some troponin I cases have been reported in the literature due to inflammatory muscle disease. Here, we report a woman in her 50s who initially presents with fatigue and weakness, and is found to have elevated troponin T. The patient was appropriately worked up for cardiac causes with ECG and echocardiogram. She had positive antinuclear antibodies, antineutrophil cytoplasmic antibody and myositis panel. The elevation of troponins was attributed to polymyositis and treated with methotrexate and prednisone with recovery of patient's symptoms. This article emphasises the struggle of diagnosis in a patient with no reported medical history, having low to moderate risk of silent myocardial infarction.

Identification of key biomarkers associated with immune cells infiltration for myocardial injury in dermatomyositis by integrated bioinformatics analysis

BACKGROUND

Dermatomyositis (DM) is an acquired autoimmune disease that can cause damage to various organs, including the heart muscle. However, the mechanisms underlying myocardial injury in DM are not yet fully understood.

METHODS

In this study, we utilized publicly available datasets from the Gene Expression Omnibus (GEO) database to identify hub-genes that are enriched in the immune system process in DM and myocarditis. Weighted gene co-expression network analysis (WGCNA), differentially expressed genes (DEGs) analysis, protein-protein interaction (PPI), and gene ontology (GO) analysis were employed to identify these hub-genes. We then used the CIBERSORT method to analyze immune cell infiltration in skeletal muscle specimens of DM and myocardium specimens of myocarditis respectively. Correlation analysis was performed to investigate the relationship between key genes and infiltrating immune cells. Finally, we predicted regulatory miRNAs of hub-genes through miRNet and validated their expression in online datasets and clinical samples.

RESULTS

Using integrated bioinformatics analysis, we identified 10 and 5 hub-genes that were enriched in the immune system process in the database of DM and myocarditis respectively. The subsequent intersections between hub-genes were IFIT3, OAS3, ISG15, and RSAD2. We found M2 macrophages increased in DM and myocarditis compared to the healthy control, associating with the expression of IFIT3, OAS3, ISG15, and RSAD2 in DM and myocarditis positively. Gene function enrichment analysis (GSEA) showed that IFIT3, OAS3, ISG15, and RSAD2 were mainly enriched in type I interferon (IFN) signaling pathway, cellular response to type I interferon, and response to type I interferon. Finally, we verified that the expression of miR-146a-5p was significantly higher in the DM with myocardial injury than those without myocardial injury (p = 0.0009).

CONCLUSION

Our findings suggest that IFIT3, OAS3, ISG15, and RSAD2 may play crucial roles in the underlying mechanism of myocardial injury in DM. Serum miR-146a-5p could be a potential biomarker for myocardial injury in DM.

Cardiac involvement in anti-MDA5 dermatomyositis: a case-based review

Among myositis-specific antibodies, anti-melanoma differentiation-associated gene 5 (anti-MDA5) is one of the antibodies with a unique spectrum that is expressed principally in clinically amyopathic dermatomyositis (CADM) and, to a lesser extent, in dermatomyositis (DM). In addition to muscle and classical skin involvement, patients with anti-MDA5 DM/CADM are characterized by the expression of rapidly progressive interstitial lung diseases, vasculopathic lesions, and non-erosive arthritis. Although cardiac involvement has been described in other inflammatory myopathies, such as myocarditis, pericarditis, and conduction disorders, in anti-MDA5 DM/CADM patients, heart disease is infrequent. We report a case of a young male presenting with constitutional symptoms, polyarthritis, skin ulcers, and mild muscle weakness who developed an episode of high ventricular rate atrial fibrillation during his hospitalization. The anti-MDA5 DM diagnosis was supported by increased muscular enzymes, positive anti-MDA5 and anti-Ro52 antibodies, and the presence of organizing pneumonia. He was treated with high-dose glucocorticoids, rituximab, and beta-blocker drugs and received pharmacological cardioversion, which improved his myopathy symptoms and stabilized his heart rhythm. Here, we describe eight similar cases of anti-MDA5 DM/CADM with cardiac involvement. The case presented and the literature reviewed reveal that although rare, physicians must be aware of cardiac disease in patients with suggestive symptoms to guarantee early assessment and treatment, thereby reducing life-treating consequences.

Defining cardiac involvement in idiopathic inflammatory myopathies: a systematic review

OBJECTIVE

Recent advances in cardiac magnetic resonance imaging (CMR) and other diagnostic techniques have made it easier to identify subclinical cardiac inflammation and dysfunction in the idiopathic inflammatory myopathies (IIM). Herein, we systematically review the literature regarding cardiac involvement in IIM.

METHODS

We searched Medline and EMBASE from 1990-2020 using keywords related to IIM and cardiac disease. We included English language studies in adults with any immune-mediated, inflammatory muscle pathology.

RESULTS

We identified 10425 potentially relevant abstracts, of which 29 were included. Most frequently these included patients with polymyositis or dermatomyositis without symptomatic myocarditis. Five categories of cardiac investigation were used in these patients: cardiac enzyme testing, electrocardiography (ECG), transthoracic echocardiography (TTE), CMR and nuclear medicine testing. Patients with clinical myocarditis had universally abnormal cardiac troponin levels and ECG. Elevated cardiac troponin T was more common than troponin I (cTnI) and may correlate with disease activity, whereas cTnI was more specific for cardiac involvement. Non-specific ECG changes were common. The major finding on TTE was abnormal ejection fraction. Gross systolic dysfunction was unusual, but subclinical systolic dysfunction was reported in several studies. Abnormal diastolic function was common and may be associated with disease duration. Late gadolinium enhancement (reflecting regional necrosis or scar) and abnormal myocardial mapping parameters (reflecting myocardial inflammation, fibrosis and oedema) were frequently identified on CMR, suggesting significant subclinical myocardial pathology (despite typically normal ejection fraction).

CONCLUSION

Abnormal cardiac investigations are commonly found in asymptomatic IIM patients, which has potential prognostic and treatment implications.

The diagnostic value of GDF-15 for myocardial involvement in idiopathic inflammatory myopathy

BACKGROUND

Cardiac involvement is a serious complication of idiopathic inflammatory myopathy (IIM). GDF-15 can predict the risk and the prognosis of cardiovascular disease, but its value is unclear in IIM.

OBJECTIVE

To investigate the diagnostic value of GDF-15 for myocardial involvement in IIM.

METHODS

A total of 77 IIM patients from May 2018 to August 2020 were included in this retrospective study. Of these, 43 patients underwent cardiac magnetic resonance (CMR) examination. There were 33 SLE patients and 16 healthy people were used as the control group. The concentration of GDF-15 of these groups was measured by ELISA.

RESULTS

There were significant differences in GDF-15 levels in patients with IIM, SLE and healthy controls (H = 45.291, P<0.001). GDF-15 levels were statistically significant different between IIM patients with the myocardial injury [1484.88(809.07 2835.50) pg/ml] and without myocardial injury [593.26(418.61 784.59) pg/ml, P =0.001]. After adjusted for age, renal function, the risk of myocardial injury in IIM patients increased an average of 0.3% by per increased unit of GDF-15 (odds ratio=1.003, 95% CI: 1.000, 1.007). The level of GDF-15 was positively correlated with extra-cellular volume (ECV) (rs = 0.348, P =0.028). GDF-15 ≥ 929.505 pg/ml (area under the curve=0.856, 95% CI: 0.744, 0.968) predicted myocardial injury in IIM with a sensitivity of 0.75 and specificity of 0.90.

CONCLUSION

GDF-15 could serve as a potential biomarker to predict myocardial injury in IIM patients.

Myocardial involvement characteristics by cardiac MR imaging in patients with polymyositis and dermatomyositis

OBJECTIVE

Myocardial involvement is frequently observed in polymyositis (PM) and dermatomyositis (DM) but typically remains subclinical. This study aimed to investigate characteristics of myocardial involvement and compare differences between patients with PM and DM by cardiac magnetic resonance (CMR) imaging.

METHODS

From March 2017 to December 2019, a total of 17 PM and 27 DM patients were enrolled in this retrospective study. In all patients, clinical assessment and CMR examination were performed. CMR parameters, including left ventricular (LV) morphologic and functional parameters and CMR tissue characterization imaging parameters, such as native T1, T2, extracellular volume (ECV), and late gadolinium enhancement (LGE) were analyzed.

RESULTS

Patients in both PM and DM groups, elevated global native T1 and ECV values were observed. Global ECV values were higher in the PM group when compared to the DM group (33.24 ± 2.97% vs. 30.36 ± 4.20%; P = 0.039). Furthermore, patients in PM and DM groups showed a different positive segment distribution of LGE, native T1 and ECV, whereas the number of positive segments in PM patients was greater compared to that in DM patients. No significant differences in LV morphological and functional parameters were observed between patients in PM and DM groups and most were in normal range.

CONCLUSION

CMR tissue characterization imaging could detect early myocardial involvement in PM and DM patients without overt LV dysfunction. Furthermore, characteristics of myocardial involvement were different between PM and DM patients with more serious seen in PM patients.

Cardiac troponins: are there any differences between T and I?

The most recent international guidelines recommend the measurement of cardiac troponin I (cTnI) and cardiac troponin T (cTnT) using high-sensitivity methods (hs-cTn) for the detection of myocardial injury and the differential diagnosis of acute coronary syndromes. Myocardial injury is a prerequisite for the diagnosis of acute myocardial infarction, but also a distinct entity. The 2018 Fourth Universal Definition of Myocardial Infarction states that myocardial injury is detected when at least one value above the 99th percentile upper reference limit is measured in a patient with high-sensitivity methods for cTnI or cTnT. Not infrequently, increased hs-cTnT levels are reported in patients with congenital or chronic neuromuscular diseases, while the hs-cTnI values are often in the normal range. Furthermore, some discrepancies between the results of laboratory tests for the two troponins are occasionally found in individuals apparently free of cardiac diseases, and also in patients with cardiac diseases. In this review article, authors discuss the biochemical, pathophysiological and analytical mechanisms which may cause discrepancies between hs-cTnI and hs-cTnT test results.

Identification of characteristics of overt myocarditis in adult patients with idiopathic inflammatory myopathies

Background

Myocarditis is a rare complication of idiopathic inflammatory myopathies (IIMs), which is usually underestimated because of limited applications of endomyocardial biopsy and cardiovascular magnetic resonance (CMR) in clinical routines.

Methods

From January 2014 to January 2019, 62 patients with initial untreated IIMs were enrolled, including 31 cases with myocarditis (case group) and 31 cases without cardiac involvement (control group). Myocarditis secondary to IIMs was defined based on definitions of IIMs. All medical data were retrieved from electrical medical records of PUMCH. The differences between two groups in symptoms, serum levels of cardiac troponin I (cTnI), creatine kinase-isozyme and N-terminal pro-brain natriuretic peptide (NT-proBNP) were analyzed. The comparisons of arrhythmia, left ventricular ejection fraction (LVEF) and restrictive diastolic dysfunction between two groups were conducted in the analysis of electrocardiogram and electrocardiogram. Besides, CMR data were analyzed to explore the characteristics of CMR in the identification of myocarditis. Meanwhile, 31 patients with myocarditis were divided into two subgroups based on the activity of anti-mitochondrial antibody M2 (AMA-M2), and the differences between two subgroups in the above tests were also analyzed.

Results

Compared with control group, patients with myocarditis exhibited shorter disease durations (defined as the period from onset symptoms of IIM to diagnosis of IIM), more symptoms associated with IIMs, more manifestations of heart failure, and higher frequency of positive AMA-M2 antibody (P<0.05). Patients with myocarditis exhibited elevated levels of cTnI, creatine kinase-isozyme and NT-proBNP compared with control group. In case group, the area under the curve indicating myocarditis for CK-MB, cTnI, and NT-proBNP was 0.654, 0.915 and 0.973, with optimal cut-off values of 24.4 µg/L, 0.1 ng/L and 531 pg/L, respectively. Ventricular arrhythmia, atrial arrhythmia, abnormal Q wave and left anterior fascicular block (LAFB) were showed in 76.7%, 53.3%, 74.2% and 51.6% of patients in case group (P<0.01). Patients of case group were featured as decreased LVEF and restrictive diastolic dysfunction compared with control group (P<0.05). Analyzing CMR data of patients of case group, the basal segments (74.2%) and mid-cavity segments (71.0%) were the most frequently involved areas of late gadolinium-enhancement (LGE), while intramural LGE (54.8%) and subendocardial LGE (51.6%) were reported more commonly than subepicardial LGE (19.4%). In patients with myocarditis and positive AMA-M2 antibody, LVEF and right ventricular ejection factor (RVEF) were decreased, and more cases presented diffuse LGE than those with negative AMA-M2 antibody (P<0.05).

Conclusions

Symptoms of heart failure and arrhythmias, elevated levels of cTnI and NT-proBNP, and positive AMA-M2 antibody play an important role in the identification of myocarditis in IIMs. Most frequently involved areas of LGE were found in the ventricular septal, basal and mid-cavity segments, as well as in the sub-endocardium and intramural myocardium. Diffuse LGE is common in the detection, which is correlated with AMA-M2 antibody in patients with myocarditis related to IIMs.

Interleukin-33/suppression of tumorigenicity 2 (IL-33/ST2) axis in idiopathic inflammatory myopathies and its association with laboratory and clinical parameters: a pilot study

Idiopathic inflammatory myopathies (IIM) are rare connective tissue diseases, which can lead to internal organ involvement. IL-33/ST2 pathway is involved in the pathogenesis of numerous diseases including autoimmune disorders. IL-33 fulfils cardioprotective function, while soluble ST2 (sST2) is a decoy receptor that reduces protective impact of IL-33. The aim of the study was to evaluate the concentrations of sST2 and IL-33 in sera of patients with IIM and evaluate its associations with the clinical course of the disease. Patients with IIM as well as age- and sex-matched healthy controls were recruited. Concentrations of sST2 and IL-33 were assessed with ELISA in sera of both patients and controls. Patients were asked to fill in the questionnaires concerning clinical symptoms and physical functioning. Concentrations of sST2 and IL-33 were correlated with the results of laboratory tests and clinical symptoms. Concentrations of sST2 were significantly higher in IIM group than in healthy subjects (median sST2 in IIM 26.51 vs in healthy controls 21.39; p = 0.03). In the majority of patients, IL-33 concentrations did not exceed the detection limit. Anti-SRP-positive patients presented significantly higher concentrations of sST2 as compared to anti-SRP-negative patients (p = 0.04). In patients with anti-Ro52 antibodies, sST2 concentrations were significantly lower than in anti-Ro52-negative patients (p = 0.02). Concentrations of sST2 correlated with the degree of disability evaluated with Health Assessment Questionnaire. sST2 is increased in patients with IIM and its concentration correlates with the degree of disability. In patients with anti-SRP antibodies, levels of sST2 are exceptionally high.

Cardiovascular complications in patients with idiopathic inflammatory myopathies: does heart matter in idiopathic inflammatory myopathies?

This review presents a detailed study of original researches and previously published reviews concerning cardiovascular involvement in idiopathic inflammatory myopathies (IIM). We aimed to summarize the current knowledge on the cardiac involvement in IIM, evaluate its impact on mortality and indicate areas still awaiting to be investigated. We searched MEDLINE database (until January 2019) and the reference lists of articles. Selection criteria included only published data, available in English, both original researches and reviews. Articles related to cardiovascular involvement in IIM were selected and analysed. The references were also screened, and relevant articles were included. Cardiovascular involvement is frequent in IIM but typically remains subclinical. Among far less prevalent symptomatic forms, congestive heart failure is the most common. Myocardium and conduction system seems to be predominantly affected. High rate of left ventricular diastolic dysfunction was observed. Non-specific changes of ST-T segment were the most common abnormalities in electrocardiography. Patients with IIM were more frequently affected by atrial fibrillation as compared with other autoimmune diseases. Increased risk of myocardial infarction was observed; furthermore, patients often develop comorbidities that enhance cardiovascular risk. Since cardiovascular disorders remain one of the major causes of death and subclinical involvement is frequent, active screening is justified. Growing availability of the novel imaging techniques may facilitate diagnosis. Correlation between myocardial involvement and the type of autoantibodies and impact of different therapeutic options on the progression of cardiovascular lesions require further studies.

The Brazilian Society of Rheumatology recommendations on investigation and diagnosis of systemic autoimmune myopathies

BACKGROUND

This research is recommended by the Myopathy Committee of the Brazilian Society of Rheumatology for the investigation and diagnosis of systemic autoimmune myopathies. BODY: A systematic literature review was performed in the Embase, Medline (PubMed) and Cochrane databases, including studies published until October 2018. PRISMA was used for the review, and the articles were evaluated, based on the Oxford levels of evidence. Ten recommendations were developed addressing different aspects of systemic autoimmune myopathy investigation and diagnosis.

CONCLUSIONS

The European League Against Rheumatism/ American College of Rheumatology (EULAR/ACR) classification stands out for the diagnosis of systemic autoimmune myopathies. Muscular biopsy is essential, aided by muscular magnetic resonance images and electroneuromyography in complementary research. Analysis of the factors related to prognosis with the evaluation of extramuscular manifestations, and comorbidities and intense investigation regarding differential diagnoses are mandatory.

Polymyositis and dermatomyositis - challenges in diagnosis and management

Polymyositis (PM) and dermatomyositis (DM) are different disease subtypes of idiopathic inflammatory myopathies (IIMs). The main clinical features of PM and DM include progressive symmetric, predominantly proximal muscle weakness. Laboratory findings include elevated creatine kinase (CK), autoantibodies in serum, and inflammatory infiltrates in muscle biopsy. Dermatomyositis can also involve a characteristic skin rash. Both polymyositis and dermatomyositis can present with extramuscular involvement. The causative factor is agnogenic activation of immune system, leading to immunologic attacks on muscle fibers and endomysial capillaries. The treatment of choice is immunosuppression. PM and DM can be distinguished from other IIMs and myopathies by thorough history, physical examinations and laboratory evaluation and adherence to specific and up-to-date diagnosis criteria and classification standards. Treatment is based on correct diagnosis of these conditions.

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Challenges of diagnosis and management influences the clinical research and practice of Polymyositis and dermatomyositis.

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Diagnostic criteria have been updated and novel therapies have been developed in PM/DM.

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Pathogenesis investigation and diagnosis precision improvement may help to guide future treatment strategies.

Classification and management of adult inflammatory myopathies

Inflammatory myopathies, collectively known as myositis, are heterogeneous disorders characterised by muscle inflammation, and frequently accompanied by extramuscular manifestations that affect the skin, lung, and joints. Patients with inflammatory myopathies were previously classified as having dermatomyositis if characteristic rashes accompanied the muscle involvement, and as having polymyositis if no rashes were present. Five main types of inflammatory myopathies are now widely recognised: dermatomyositis, immune-mediated necrotising myopathy, sporadic inclusion-body myositis, overlap myositis (including antisynthetase syndrome), and polymyositis. The discovery of autoantibodies that are specifically associated with characteristic clinical phenotypes has been instrumental to the understanding of inflammatory myopathies. Treatment is still largely based on expert opinion, but several studies have shown effectiveness of different therapies in various subsets of inflammatory myopathies. These advances will undoubtedly improve the outcomes of patients with inflammatory myopathies.

Immune-mediated necrotising myopathy: A critical review of current concepts

Immune-mediated necrotising myopathy (IMNM) is a relatively recently described form of idiopathic inflammatory myopathy (IIM) that is characterised by progressive proximal weakness and few extra-muscular manifestations. Prominent myonecrosis, muscle fibre regeneration and a relative paucity of intramuscular lymphocytes are seen histologically. Immunological mechanisms are believed to underpin the pathogenesis, and intense immunotherapy is frequently required. Disease is often severe and neuromuscular recovery may be poor. Recently there has been an impressive international research effort to understand and characterise this emerging condition, although much remains unknown. Significant advances in the field include the discovery of specific autoantibodies, increased understanding of the risk factors, clinical characteristics and treatment options owing to a wealth of observational studies, and the development of novel classification criteria. Herein we review the current evidence regarding the pathophysiology, clinical presentation, histological features and serological profiles associated with this condition. Diagnostic approaches are discussed, including the role of muscle MRI and antibodies targeting 3‑hydroxy-3-methylglutaryl-CoA reductase (HMGCR) and signal-recognition peptide (SRP), and a review of current treatment recommendations is provided.