Cardiac remodeling in patients with systemic sclerosis with no signs or symptoms of heart failure: an endomyocardial biopsy study

The Fra-2 transgenic mouse model of systemic sclerosis

In systemic sclerosis, microvascular injury often precedes the development of fibrosis. Whereas the development of digital ulcers and skin fibrosis causes high morbidity, the affection of internal organs, in particular complications such as interstitial lung disease and pulmonary (arterial) hypertension, account for the high disease-associated mortality of these patients. Vascular animal models of systemic sclerosis are of utmost importance to study pathophysiological aspects, to identify molecular key players, and to perform interventional proof of concept-studies. So far, animal models of systemic sclerosis have mainly reflected the pro-fibrotic features of the human disease. The Fra-2 (Fos-related antigen-2) transgenic mouse model simultaneously displays both pro-fibrotic and vascular characteristics of human systemic sclerosis.

Which factors impact myocardial function in systemic sclerosis?

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).

Cardiac complications of systemic sclerosis: recent progress in diagnosis

PURPOSE OF REVIEW

Systemic sclerosis (SSc), a collagen vascular disease characterized by diverse organ system involvement, is associated with serious cardiac complications. Cardiac symptoms are much less frequent than autopsy-demonstrated cardiac involvement. Although frequent calls for early diagnosis have been made, validated strategies for assessment of scleroderma cardiac disease are not yet well established, mainly because the right ventricle, a common target of the disease, presents considerable obstacles to simple and reliable appraisal of its structure and function. This article reviews the current information about cardiac dysfunction in scleroderma, with special emphasis on its detection and prognostic implications.

RECENT FINDINGS

Cardiac involvement is a harbinger of poor prognosis in patients with SSc. Recent progress in its diagnosis has been made with the availability of more sophisticated diagnostic tools.

SUMMARY

Early detection of scleroderma heart disease will allow exploration of novel therapies with potential positive impact on the quality of life and life expectancy of this patient population.

Review series: Aspects of interstitial lung disease: connective tissue disease-associated interstitial lung disease: how does it differ from IPF? How should the clinical approach differ?

The lung is frequently involved in connective tissue diseases (CTDs), although the frequency of lung manifestations varies according to the type of CTD. Interstitial lung diseases (ILD) are frequently seen in CTDs, particularly systemic sclerosis (SSc), polymyositis/dermatomyositis (PM/DM) and rheumatoid arthritis (RA), accounting for a significant proportion of deaths. A large percentage of patients with CTD-associated ILD has limited and stable disease, not requiring treatment. However, a significant minority has severe and/or progressive disease, necessitating prompt initiation of treatment. CTD-ILD histological patterns include non-specific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP). NSIP is the most common pattern in all CTDs, except for RA, characterized by a higher frequency of UIP. ILD can present acutely or chronically, with acute presentations being more common in systemic lupus erythematosus and PM/DM. Idiopathic pulmonary fibrosis (IPF) is a progressively worsening ILD characterized by inflammation and fibrosis. The characteristic histological pattern of IPF is UIP. Interestingly, a UIP pattern is associated with a significantly better survival in CTD-related disease compared to the idiopathic variety. Prognosis in IPF is dismal, with a median survival since diagnosis of 2-3 years. No treatment regimen has been shown to improve survival in IPF. By contrast, although there have been only two randomized placebo-controlled trials investigating the effect of immunosuppressive treatment in SSc-associated ILD, clinical experience suggests that immunosuppressive drugs in CTD-related ILDs are capable of benefiting a significant proportion of patients, particularly those with certain histological patterns of disease. This review will essentially focus on CTD-associated ILD and will compare aspects of clinical presentation and management to those of IPF.

Pulmonary hypertension in systemic sclerosis

OBJECTIVES

To discuss the clinical subtypes, pathogenesis, pathology, diagnostic evaluation, treatment options, and prognosis of pulmonary hypertension in systemic sclerosis (SSc-PH) and highlight its fundamental differences from idiopathic pulmonary arterial hypertension (IPAH).

METHODS

A Medline search for articles published between January 1969 and June 2010 was conducted using the following keywords: scleroderma, systemic sclerosis, pulmonary hypertension, pulmonary arterial hypertension, pulmonary veno-occlusive disease, pathogenesis, pathology, investigation, treatment, and prognosis. The essential differences from IPAH in pathogenesis and histopathologic findings were highlighted and the limitations of some of the investigations used were emphasized. The differences in response to currently accepted therapy and prognosis were also reviewed.

RESULTS

In scleroderma, pulmonary hypertension can be present in isolation or along with interstitial lung disease and left heart disease. In SSc-PH, the unique histopathologic findings in the lungs include intimal fibrosis, absence of plexiform lesions, and a high prevalence of pulmonary veno-occlusive disease-like lesions. Both "6-minute walk test" and NT-proBNP have their limitations in the evaluation of SSc-PH. For treatment, calcium channel blockers are ineffective and anticoagulation should be used with caution. Currently approved therapies are not as effective and prognosis is much worse in SSc-PH compared with IPAH.

CONCLUSIONS

SSc-PH is a complex condition with poorer response to therapy and worse outcome compared with that of IPAH. Recent findings have shed some light about the pathophysiology and pathogenesis of SSc-PH. Further research in this area is warranted to better understand the complex pathogenesis and devise better therapeutic strategies.

Characteristics of interstitial fibrosis and inflammatory cell infiltration in right ventricles of systemic sclerosis-associated pulmonary arterial hypertension

Objective. Systemic sclerosis-associated pulmonary arterial hypertension (SScPAH) has a disturbed function of the right ventricle (RV) when compared to idiopathic PAH (IPAH). Systemic sclerosis may also affect the heart. We hypothesize that RV differences may occur at the level of interstitial inflammation and-fibrosis and compared inflammatory cell infiltrate and fibrosis between the RV of SScPAH, IPAH, and healthy controls. Methods. Paraffin-embedded tissue samples of RV and left ventricle (LV) from SScPAH (n = 5) and IPAH (n = 9) patients and controls (n = 4) were picrosirius red stained for detection of interstitial fibrosis, which was quantified semiautomatically. Neutrophilic granulocytes (MPO), macrophages (CD68), and lymphocytes (CD45) were immunohistochemically stained and only interstitial leukocytes were counted. Presence of epi- or endocardial inflammation, and of perivascular or intimal fibrosis of coronary arteries was assessed semiquantitatively (0-3: absent to extensive). Results. RV's of SScPAH showed significantly more inflammatory cells than of IPAH (cells/mm(2), mean ± sd MPO 11 ± 3 versus 6 ± 1; CD68 11 ± 3 versus 6 ± 1; CD45 11 ± 1 versus 5 ± 1 , P < .05) and than of controls. RV interstitial fibrosis was similar in SScPAH and IPAH (4 ± 1 versus 5 ± 1%, P = .9), and did not differ from controls (5 ± 1%, P = .8). In 4 SScPAH and 5 IPAH RV's foci of replacement fibrosis were found. No differences were found on epi- or endocardial inflammation or on perivascular or intimal fibrosis of coronary arteries. Conclusion. SScPAH RVs display denser inflammatory infiltrates than IPAH, while they do not differ with respect to interstitial fibrosis. Whether increased inflammatory status is a contributor to altered RV function in SScPAH warrants further research.

Care of patients with scleroderma in the intensive care setting

Scleroderma or systemic sclerosis (SSc) is a connective tissue disease (CTD) associated with fibrosing and vascular complications involving multiple organs. The care of these patients in the critical care setting is frequently challenging due to multiple complications and refractory organ involvement. However, awareness of specific organ involvement associated with scleroderma can allow many complications to be anticipated and effectively treated. Cardiac involvement can lead to arrhythmias and heart failure, whereas pulmonary involvement can be associated with pulmonary arterial hypertension, fibrosis, or both. Renal vascular disease and scleroderma renal crisis (SRC), once a uniformly fatal complication, is particularly important to recognize early, as it can be treated successfully. Gastrointestinal involvement can lead to bleeding, aspiration, obstruction, and malabsorption. Severe Raynaud may lead to digital ischemia and gangrene. Therapies must target involved organ system or organ systems. Corticosteroids, a mainstay for related CTDs, do not typically provide any benefit and may cause harm. Vasodilators can effectively treat vascular complications but must target the appropriate vascular bed. Proactive utilization of proton pump inhibitors, recognition of bleeding from gastrointestinal vascular ectasia, and nutritional support can considerably ameliorate gastrointestinal morbidities. Effective treatment of fibrotic complications remains elusive and is the current frontier for scleroderma therapeutics.

Hemodynamic predictors of survival in scleroderma-related pulmonary arterial hypertension

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.

Systemic sclerosis-associated pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a devastating vascular complication of a number of connective tissue diseases, including systemic sclerosis (SSc), where it has a dramatic impact on the clinical course and overall survival and is the single most common cause of death in patients afflicted with this syndrome. Although remarkable advances have been achieved in elucidating the pathogenesis of PAH over the past 2 decades, leading to the development of disease-targeted therapies for the idiopathic form of this condition (IPAH), the response to therapy is suboptimal in SSc-related PAH (SSc-PAH), and survival remains very poor. Factors accounting for striking clinical and prognostic differences between these two syndromes are unclear but may include a more pronounced autoimmune, cellular, and inflammatory response, and a higher prevalence of comorbidities in SSc-PAH, including cardiac and pulmonary venous and parenchymal involvement. Furthermore, currently available markers of disease severity and clinical tools to assess response to therapy, which may be reliable in IPAH, are either limited or lacking in SSc-PAH. Thus, a more focused approach, including a better understanding of the pathogenesis and genetic factors underlying the development of SSc-PAH, a search for more specific and reliable tools to adequately assess functional impairment and monitor therapy, as well as the design of novel targeted therapies, are all urgently required to alter the dismal course of this syndrome.

Function of the left ventricular myocardium in patients with systemic sclerosis

Deposits of myocardial fibrosis are the principal cause of myocardial dysfunction and poor prognosis in the patients with systemic sclerosis. Our aim was to assess whether there are changes in regional function of the left ventricular myocardium in female patients with systemic sclerosis without clinical signs and symptoms of cardiovascular disease. The study included 23 female patients with systemic sclerosis (without cardiovascular disease and with normal global systolic and diastolic function of the left ventricle) and 21 healthy female controls. In both groups, pulsed wave tissue Doppler imaging was done at rest and during exercise stress test echocardiography. The myocardial function was assessed from the basal segments in systola and diastola. The level achieved and duration of exercise tests were significantly reduced in the patients with systemic sclerosis compared to the controls (P < 0.001 for both). The patients had significantly lower baseline regional systolic (P < 0.02) and diastolic (P < 0.001) myocardial functions, which became even more evident after the exercise test. During the test, those with systemic sclerosis demonstrated a smaller increase of systolic (20.6%) and diastolic (6.5%) function compared to the controls (systolic by 32.3% and diastolic by 25.0%). Quantification of regional function of the left ventricular myocardium using pulsed wave tissue Doppler imaging demonstrated an impaired systolic and diastolic myocardial function in the female patients with systemic sclerosis who had no clinical signs and symptoms of a cardiovascular disease.

Right ventricular function in scleroderma-related pulmonary hypertension

SSc-associated pulmonary arterial hypertension (PAH) has a poorer prognosis than that of other types of pulmonary hypertension. Recent echocardiographic and haemodynamic studies suggest that right ventriculer (RV) pump function and filling characteristics are altered in SSc-PAH as compared with idiopathic PAH. This could be explained by intrinsic myocardial involvement of the disease, related to abnormal collagen deposition, also observed in the left ventricle, or an increased vulnerability to ischaemia due to coronary vasculopathy, abnormal collagen cross-linking and altered myocyte function. It is also possible that a relatively more important decrease in pulmonary arterial compliance as evidenced by recently reported increased characteristic impedance measurements, would contribute to RV-arterial decoupling. More pathological, imaging and haemodynamic studies are needed for a better understanding for relatively more important vulnerability of the RV in SSc-PAH.

How much myocardial damage is necessary to enable detection of focal late gadolinium enhancement at cardiac MR imaging?

PURPOSE

To assess the visibility of small myocardial lesions at magnetic resonance (MR) imaging and to estimate how much myocardial damage is necessary to enable detection of late gadolinium enhancement (LGE) in vivo.

MATERIALS AND METHODS

The study was approved by the local bioethics committee. Coronary microembolization was performed by injecting 300,000 microspheres into the distal portion of the left anterior descending artery in 18 anesthetized minipigs to create multifocal areas of myocardial damage. In vivo MR imaging was performed a mean of 6 hours after microembolization by using an inversion-recovery spoiled gradient-echo sequence (repetition time msec/echo time msec, 8/4; inversion time, 240-320 msec; flip angle, 20 degrees; spatial resolution, 1.3 x 1.7 x 5.0 mm(3)) after injection of 0.2 mmol gadopentetate dimeglumine per kilogram of body weight. High-spatial-resolution imaging of the explanted heart was performed by using the same sequence with a higher spatial resolution (0.5 x 0.5 x 2.0 mm(3)). Imaging results were verified with histologic examination. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of in vivo and ex vivo images were calculated, and a t test was used to analyze observed differences.

RESULTS

Multifocal myocardial damage was successfully induced in all animals. Areas of LGE with low SNR (mean, 36.3 +/- 29.4 [standard deviation]) and CNR (23.7 +/- 19.8) were observed in vivo in 12 (67%) of 18 animals, whereas ex vivo imaging revealed spotted to streaky areas of LGE with higher SNR (91.4 +/- 27.8, P < .0001) and CNR (72.1 +/- 25.4, P < .0001) among normal-appearing myocardium in all cases (100%). Focal myocardial lesions exceeding 5% of myocardium per slice at histologic examination were detected in vivo with a sensitivity of 83%.

CONCLUSION

Focal myocardial damage exceeding 5% of myocardium within the region of interest seems to be necessary for detection of LGE in vivo in an experimental model of coronary microembolization.

Cardiac involvement in systemic sclerosis assessed by tissue-doppler echocardiography during routine care: A controlled study of 100 consecutive patients

OBJECTIVE

To assess the prevalence of primary cardiac complications in a large population of patients with systemic sclerosis (SSc), using recently developed echocardiographic techniques.

METHODS

We prospectively studied 100 consecutive patients (mean +/- SD age 54 +/- 14 years; 86 women) presenting with SSc without pulmonary arterial hypertension or clinical manifestations of heart failure. All patients underwent standard echocardiography, along with measurements of longitudinal velocities by tissue Doppler imaging (TDI) to assess left ventricular (LV) and right ventricular (RV) contractility and LV diastolic function. Results were compared with those in 26 age- and sex-matched healthy controls.

RESULTS

Patients with SSc had a wider mean left atrial diameter and impaired relaxation compared with the controls. A trend was observed toward a smaller LV ejection fraction (EF) in the patients (mean +/- SD 64.9 +/- 0.6%) than in the controls (67.2 +/- 0.7%), as well as higher pulmonary artery pressure (mean +/- SD 33.3 +/- 0.6 mm Hg versus 30.8 +/- 1.0 mm Hg). LVEF was <55% in 7 patients versus none of the controls. Peak systolic mitral annular velocity as measured by TDI was <7.5 cm/second in 14 patients versus none of the controls (P = 0.040). Mitral annulus early diastolic velocity was <10 cm/second in 30 patients versus 2 of the controls (P = 0.022). Fifteen patients and none of the controls had reduced peak systolic tricuspid annular velocity (P = 0.039). The TDI results correlated with each other, but not with lung abnormalities or other disease characteristics.

CONCLUSION

Depression of LV and RV systolic and LV diastolic function is common in patients with SSc and is due to primary myocardial involvement. Considering the major contributions of TDI, the addition of this simple technique to standard measurements may improve the detection of heart involvement in patients with SSc.

Fibrosis in systemic sclerosis

This article reviews current understanding of the pathophysiology of fibrosis in systemic sclerosis. It highlights recent discoveries, insights, and emerging research, and potential opportunities for the development of targeted antifibrotic therapies.

Evaluation of cardiac abnormalities by Doppler echocardiography in a large nationwide multicentric cohort of patients with systemic sclerosis

OBJECTIVES

There is increasing concern about heart and pulmonary vascular involvement in systemic sclerosis (SSc). One of the most severe complications of SSc is pulmonary arterial hypertension (PAH). There has been an increased awareness of left ventricular (LV) diastolic abnormalities in SSc patients. However, previous studies have generally been conducted in small populations. The aims of this study were to prospectively screen for PAH and to describe echocardiographic parameters in a large group of SSc patients.

METHODS

This prospective study was conducted in 21 centres for SSc in France. Patients without severe pulmonary function abnormalities, severe cardiac disease and known PAH underwent Doppler echocardiography performed by a reference cardiologist.

RESULTS

Of the 570 patients evaluated, PAH was suspected in 33 patients and was confirmed in 18 by right heart catheterisation. LV systolic dysfunction was rare (1.4%). LV hypertrophy was found in 22.6%, with LV diastolic dysfunction in 17.7%. These LV abnormalities were influenced by age, gender and blood pressure. We identified a small group of 21 patients with a restrictive mitral flow pattern in the absence of any other cardiopulmonary diseases, suggesting a specific cardiac involvement in SSc.

CONCLUSIONS

Left and right heart diseases, including PAH, LV hypertrophy and diastolic dysfunction, are common in SSc. However, a small subset of patients without any cardiac or pulmonary diseases have a restrictive mitral flow pattern that could be due to primary cardiac involvement of SSc. The prognostic implications of the LV abnormalities will be evaluated in the 3-year follow-up of this cohort.

Pattern and distribution of myocardial fibrosis in systemic sclerosis: a delayed enhanced magnetic resonance imaging study

OBJECTIVE

To assess the prevalence and pattern of myocardial fibrosis as detected by delayed enhanced magnetic resonance imaging (DE-MRI) in patients with systemic sclerosis (SSc), and to evaluate a possible association between myocardial fibrosis and cardiac arrhythmias.

METHODS

Forty-one patients with SSc underwent 24-hour Holter monitoring, Doppler echocardiography, and DE-MRI following gadolinium administration.

RESULTS

Technically acceptable DE-MRIs were obtained in 36 patients with SSc. Enhancement on DE-MRI, consistent with myocardial fibrosis, was observed in 24 of these patients (66%), and it was invariably midwall with a linear pattern, mostly involving basal and midcavity segments of the left ventricle. The volume of enhancement (total volume percentage index [TVPI]) did not differ between patients with diffuse SSc and those with limited SSc (mean +/- SD 1.46 +/- 1.73% versus 1.44 +/- 1.77%; P = 0.98). Patients with a long duration (> or = 15 years) of Raynaud's phenomenon had a greater number of enhancing segments (mean +/- SD 6.55 +/- 4.93 versus 2.96 +/- 3.46; P = 0.017) and a greater TVPI (mean +/- SD 2.44 +/- 1.97% versus 1.02 +/- 1.43%; P = 0.02) than those with a duration of Raynaud's phenomenon <15 years. Nineteen patients with SSc (53%) had abnormal Holter study results. Compared with patients with normal Holter study results, those with abnormal results had a greater number of enhancing segments (mean +/- SD 5.4 +/- 4.8 versus 2.5 +/- 2.9; P < 0.05) and a greater TVPI (mean +/- SD 2.1 +/- 1.9% versus 0.8 +/- 1.2%; P < 0.05).

CONCLUSION

DE-MRI can identify myocardial fibrosis in a significant percentage of patients with SSc and may be a useful noninvasive tool for determining cardiac involvement.

Associations between left ventricular myocardial involvement and endothelial dysfunction in systemic sclerosis: noninvasive assessment in asymptomatic patients

OBJECTIVES

Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult.

AIM OF THE STUDY

To analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc.

METHODS

30 healthy patients and 33 age- and sex-comparable asymptomatic patients classified as having either diffuse (18 patients) or limited form (15 patients) of SSc underwent standard Doppler Echo, Doppler myocardial imaging, Strain rate imaging of interventricular septum and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel (after dipyridamole infusion), and brachial artery vasodilatation measurement (Vivid 7, GE Medical Systems Inc).

RESULTS

LV diameters and ejection fraction were comparable between the two groups, while systolic pulmonary pressure (P < 0.001) was increased in SSc. By chest-CT, 15 SSc patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 14 SSc patients, and anti Scl-70 in 19 patients. In SSc, LV myocardial early diastolic peak velocity, peak systolic strain rate and strain were both reduced in basal and middle interventricular septum, and in basal and middle LV lateral wall. Both CFR (P < 0.0001) and endothelial flow-mediated dilatation (P < 0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (P < 0.001) and endothelial function (P < 0.001) were powerful independent determinants of middle LV strain.

CONCLUSIONS

Strain rate imaging, transthoracic CFR, and brachial artery flow-mediated dilatation are valuable noninvasive and easily repeatable tools for detecting LV myocardial and vascular involvement caused by SSc. Their combined use may be therefore useful for early identifying patients with more diffused and severe form of SSc, ideally in asymptomatic cases prior to the development of severe vasculopathy, when it may be most feasible to modify the disease process by new potential therapies.

Myocardial and vascular dysfunction in systemic sclerosis: The potential role of noninvasive assessment in asymptomatic patients

Systemic sclerosis (SSc) is a multi-system disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. The aim of the present study was to analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc. Thirty healthy subjects and 33 age- and sex-comparable asymptomatic SSc patients underwent standard Doppler Myocardial Imaging, Strain Rate (SR) Imaging of interventricular septum (IVS) and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel, and brachial artery vasodilatation measurement. In SSc patients, LV myocardial early diastolic peak velocity, peak systolic SR and strain were both reduced in basal and middle IVS, and in basal and middle LV lateral wall (p<0.001). In addition, both CFR (p<0.0001) and endothelial flow-mediated dilatation (p<0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (p<0.001) and endothelial function (p<0.001) were powerful independent determinants of middle LV strain of SSc patients. In conclusion, SR Imaging, transthoracic CFR and brachial artery flow-mediated dilatation are valuable non-invasive and easy-repeatable tools for detecting early LV myocardial and vascular involvement caused by SSc.

Pathophysiological basis of right ventricular remodeling

The pathophysiology of right ventricular (RV) remodeling is a complex process and may include unique elements not observed in left ventricular (LV) remodeling. The RV also has a relatively irregular geometry not accounted for in LV analyses. RV remodeling includes basic changes in geometry, wall thickness, and ventricular pressure-volume relationships. Also, myocyte dimensions and number increase, and myocardial extracellular matrix and biochemical milieu are modified. Remodeling has been associated with such diseases as pulmonary hypertension, lung transplant, LV pathology, Chagas' disease, and arrhythmogenic right ventricular cardiomyopathy. Disease progression may lead to further RV changes, including hypertrophy, dilatation, and subsequently to variable alterations in RV hemodynamic status. The multiple methods to assess RV hypertrophy include cine magnetic resonance imaging and 3-D echocardiography. Each technique offers different precision in evaluating RV dimensions and functional performance characteristics. Strategies to prevent RV remodeling include pharmacological agents, such as vasodilators and angiotensin-converting enzyme inhibitors, as well as more invasive interventions, such as ventricular assist devices.

Assessment of Atrial Conduction in Patients with Scleroderma by Tissue Doppler Echocardiography and P Wave Dispersion

BACKGROUND

Atrial conduction abnormalities in patients with scleroderma have not been evaluated in terms of P wave duration, P wave dispersion (P(d)) and electromechanical coupling measured by tissue Doppler echocardiography.

METHODS

Twenty-four patients with scleroderma and 24 control subjects underwent resting electrocardiogram (ECG), M mode and tissue Doppler echocardiography. The P wave duration was calculated in all leads of the surface ECG. The difference between the maximum (P(max)) and minimum P wave duration was calculated and defined as P(d). Interatrial and intraatrial electromechanical delays were measured with tissue Doppler tissue echocardiography.

RESULTS

The left ventricular dimensions, fractional shortening, and left atrial diameter did not differ between the patients and the controls. P(d) and P(max) were significantly higher in patients with scleroderma compared with controls: 51 +/- 17 versus 28 +/- 7 ms (p < 0.01) and 109 +/- 10 versus 93 +/- 6 ms (p < 0.01), respectively. There was a delay between the onset of the P wave on surface ECG and the onset of the late diastolic wave (A wave; PA) obtained by tissue Doppler echocardiography in patients with scleroderma compared with controls measured at lateral septal annulus (lateral PA; 122 +/- 8 vs. 105 +/- 7 ms, p = 0.001), septal mitral annulus (104 +/- 11 vs. 93 +/- 10 ms, p = 0.01) and tricuspid annulus (right ventricular PA; 71 +/- 9 vs. 64 +/- 7 ms, p = 0.05). Interatrial conduction time (lateral PA - right ventricular PA) was delayed in patients with scleroderma compared with controls (88 +/- 13 vs. 76 +/- 11 ms, p = 0.01). A positive correlation was detected between interatrial electromechanical delay (lateral PA - right ventricular PA) and P(d) (r = 0.5, p = 0.03).

CONCLUSION

Atrial conduction abnormalities as estimated with P(d) and P(max) are significantly higher in patients with scleroderma compared with controls. There is a delay in both intraatrial and interatrial electromechanical coupling intervals in patients with scleroderma.

Clinical differences between idiopathic and scleroderma-related pulmonary hypertension

OBJECTIVE

Pulmonary arterial hypertension related to scleroderma (PAH-Scl) is associated with high morbidity and mortality as well as poorer response to therapy and worse outcomes compared with the idiopathic form of PAH (IPAH). Scleroderma is an autoimmune disease that can affect left and right heart function directly through inflammation and fibrosis and indirectly through systemic and pulmonary hypertension. This study tested the hypothesis that an increased prevalence of left heart disease might explain the higher mortality in patients with PAH-Scl compared with patients with IPAH.

METHODS

The study was designed as a retrospective cohort study comparing the baseline clinical data from 91 consecutive patients (41 with IPAH and 50 with PAH-Scl). Cox proportional hazards models were used to predict the effect of clinical covariates on patient survival.

RESULTS

Patients with PAH-Scl had a lower mean pulmonary artery pressure (46.6 mm Hg versus 54.4 mm Hg in patients with IPAH; P = 0.002) despite similar levels of cardiac dysfunction (cardiac index 2.2 and 2.1 liters/minute/m(2), respectively; P = 0.19). Echocardiography revealed similar degrees of right ventricular dysfunction in the 2 groups, whereas a predominance of left heart dysfunction was observed in patients with PAH-Scl. One- and three-year survival estimates were 87.8% and 48.9%, respectively, in patients with PAH-Scl and 95.1% and 83.6%, respectively, in those with IPAH. Patients with PAH-Scl were 3.06 times more likely to die than were patients with IPAH, after controlling for the presence of pericardial effusion; there was no significant change in increased risk of death in PAH-Scl after controlling for left heart disease.

CONCLUSION

The results confirm that there are significant clinical and survival differences between IPAH and PAH-Scl. The presence of left heart disease, although more common in PAH-Scl, was not predictive of the higher mortality in these patients.

Damage of cutaneous peripheral nervous system evolves differently according to the disease phase and subset of systemic sclerosis

OBJECTIVE

Evidence shows that peripheral nervous system (PNS) is involved in systemic sclerosis (SSc), but few morphological studies have assessed the ultrastructural pathological modifications. The aim was to study ultrastructural modifications of skin PNS fibres in SSc according to subsets [limited SSc (lSSc) and diffuse SSc (dSSc)] and phases (early and advanced) of the disease.

METHODS

Skin biopsies were taken from the forearms of 23 SSc patients (11 lSSc and 12 dSSc) and 10 controls. Each biopsy was processed for transmission electron microscopy (TEM).

RESULTS

At TEM, observation in skin from early lSSc, signs of inflammation were evident, while PNS fibres were not damaged. The microvascular wall showed hypertrophic endothelial cells bulging into the lumen. In advanced lSSc, fibrosis prevailed on inflammation and slight ultrastructural alterations of PNS fibres were evident in the papillary derma. In early dSSc, ultrastructural alterations of PNS fibres, similar to those observed in the advanced phase of lSSc, were found together with signs of inflammation and fibrosis. In advanced dSSc, in the papillary and reticular dermis PNS fibres were reduced and showed relevant ultrastructural alterations.

CONCLUSIONS

In SSc, PNS ultrastructure damage is linked to the progression and severity of skin involvement. The alterations evolve from the early to the advanced phase mainly in the diffuse subset. In particular, the severe PNS lesions found in advanced lSSc are already present and widely diffuse in early dSSc and the microvascular involvement in early lSSc seems to precede the modification of the PNS in the skin. Thus, an early therapeutic approach can be useful to reduce the progression of PNS and skin damage in SSc patients.