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Lui JK, Sangani RA, Gillmeyer KR, Vakhshoorzadeh J, Trojanowski MA, Bujor AM, Gopal DM, Wiener RS, LaValley MP, Klings ES. Hemodynamic Response to Oral Vasodilator Therapy in Systemic Sclerosis-Related Pulmonary Hypertension. Cardiovasc Drugs Ther 2024; 38:651-656. [PMID: 36607535 PMCID: PMC10666735 DOI: 10.1007/s10557-022-07420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Although classified as group 1 pulmonary arterial hypertension (PAH), patients with systemic sclerosis-related pulmonary hypertension (SSc-PH) experience poorer clinical response to PAH therapy and increased mortality compared to those with idiopathic PAH. Due to heterogeneity in phenotypes, identifying patients likely to respond to therapy is challenging. The goal of this study was to determine clinical factors associated with hemodynamic response, defined by a > 20% reduction in pulmonary vascular resistance on repeat right heart catheterization. METHODS We applied a time-to-event model using a retrospective cohort of 39 patients with precapillary SSc-PH, defined by a mean pulmonary artery pressure of ≥ 25 mmHg and pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg on right heart catheterization. RESULTS Patients with PAWP ≤ 8 mmHg were nearly fourfold more likely to achieve a hemodynamic response compared to those with PAWP > 8 mmHg (HR 3.88; 95% CI: 1.20, 12.57); each 1 mmHg increase in PAWP was associated with a decreased hazard for hemodynamic response (HR 0.84; 95% CI: 0.70, 1.00). CONCLUSION In patients with precapillary SSc-PH, PAWP was associated with time to hemodynamic response, suggesting the importance of subclinical cardiac disease in determining hemodynamic response to oral vasodilator therapy.
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Affiliation(s)
- Justin K Lui
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Ruchika A Sangani
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Kari R Gillmeyer
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jasmine Vakhshoorzadeh
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Marcin A Trojanowski
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andreea M Bujor
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Deepa M Gopal
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Michael P LaValley
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Elizabeth S Klings
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Lui JK, Cozzolino M, Winburn M, Trojanowski MA, Wiener RS, LaValley MP, Bujor AM, Gopal DM, Klings ES. Role of Left Ventricular Dysfunction in Systemic Sclerosis-Related Pulmonary Hypertension. Chest 2023:S0012-3692(23)05932-9. [PMID: 38128607 DOI: 10.1016/j.chest.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND In systemic sclerosis (SSc), pulmonary hypertension remains a significant cause of morbidity and mortality. Although conventionally classified as group 1 pulmonary arterial hypertension, systemic sclerosis-related pulmonary hypertension (SSc-PH) is a heterogeneous disease. The contribution of left-sided cardiac disease in SSc-PH remains poorly understood. RESEARCH QUESTION How often does left ventricular (LV) dysfunction occur in SSc among patients undergoing right heart catheterization and how does coexistent LV dysfunction with SSc-PH affect all-cause mortality in this patient population? STUDY DESIGN AND METHODS We conducted a retrospective, observational study of 165 patients with SSc who underwent both echocardiography and right heart catheterization. LV dysfunction was identified using LV global longitudinal strain (GLS) on speckle-tracking echocardiography based on a defined threshold of > -18%. SSc-PH was defined by a mean pulmonary artery pressure > 20 mmHg. RESULTS Among patients with SSc who have undergone right heart catheterization, LV dysfunction occurred in 74.2% with SSc-PH and 51.2% without SSc-PH. The median survival of patients with SSc-PH and LV dysfunction was 67.9 (95% CI, 38.3-102.0) months, with a hazard ratio of 12.64 (95% CI, 1.73-92.60) for all-cause mortality when adjusted for age, sex, SSc disease duration, and FVC compared with patients with SSc without pulmonary hypertension with normal LV function. INTERPRETATION LV dysfunction is common in SSc-PH. Patients with SSc-PH and LV dysfunction by LV GLS have increased all-cause mortality. This suggests that LV GLS may be helpful in identifying underlying LV dysfunction and in risk assessment of patients with SSc-PH.
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Affiliation(s)
- Justin K Lui
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
| | - Matthew Cozzolino
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Morgan Winburn
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Marcin A Trojanowski
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Michael P LaValley
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Andreea M Bujor
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Deepa M Gopal
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Elizabeth S Klings
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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Lui JK, Gillmeyer KR, Sangani RA, Smyth RJ, Gopal DM, Trojanowski MA, Bujor AM, Wiener RS, LaValley MP, Klings ES. A Multimodal Prediction Model for Diagnosing Pulmonary Hypertension in Systemic Sclerosis. Arthritis Care Res (Hoboken) 2023; 75:1462-1468. [PMID: 35678779 PMCID: PMC9732142 DOI: 10.1002/acr.24969] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 05/26/2022] [Accepted: 06/07/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Diagnosis of pulmonary hypertension (PH) in systemic sclerosis (SSc) requires an invasive right heart catheterization (RHC), often based on an elevated estimated pulmonary artery systolic pressure on screening echocardiography. However, because of the poor specificity of echocardiography, a greater number of patients undergo RHC than necessary, exposing patients to potentially avoidable complication risks. The development of improved prediction models for PH in SSc may inform decision-making for RHC in these patients. METHODS We conducted a retrospective study of 130 patients with SSc; 66 (50.8%) were diagnosed with PH by RHC. We used data from pulmonary function testing, electrocardiography, echocardiography, and computed tomography to identify and compare the performance characteristics of 3 models predicting the presence of PH: 1) random forest, 2) classification and regression tree, and 3) logistic regression. For each model, we generated receiver operating curves and calculated sensitivity and specificity. We internally validated models using a train-test split of the data. RESULTS The random forest model performed best with an area under the curve of 0.92 (95% confidence interval [95% CI] 0.83-1.00), sensitivity of 0.95 (95% CI 0.75-1.00), and specificity of 0.80 (95% CI 0.56-0.94). The 2 most important variables in our random forest model were pulmonary artery diameter on chest computed tomography and diffusing capacity for carbon monoxide on pulmonary function testing. CONCLUSIONS In patients with SSc, a random forest model can aid in the detection of PH with high sensitivity and specificity and may allow for better patient selection for RHC, thereby minimizing patient risk.
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Affiliation(s)
- Justin K. Lui
- The Pulmonary Center, Boston University School of Medicine,
Boston, MA
- Department of Biostatistics, Boston University School of
Public Health, Boston, MA
| | - Kari R. Gillmeyer
- The Pulmonary Center, Boston University School of Medicine,
Boston, MA
| | | | - Robert J. Smyth
- The Pulmonary Center, Boston University School of Medicine,
Boston, MA
| | - Deepa M. Gopal
- Section of Cardiovascular Medicine, Boston University
School of Medicine, Boston, MA
| | - Marcin A. Trojanowski
- The Arthritis & Autoimmune Diseases Research Center,
Boston University School of Medicine, Boston, MA
| | - Andreea M. Bujor
- The Arthritis & Autoimmune Diseases Research Center,
Boston University School of Medicine, Boston, MA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Boston University School of Medicine,
Boston, MA
- Center for Healthcare Organization & Implementation
Research, VA Boston Healthcare System, Boston, MA, USA
| | - Michael P. LaValley
- Department of Biostatistics, Boston University School of
Public Health, Boston, MA
- The Arthritis & Autoimmune Diseases Research Center,
Boston University School of Medicine, Boston, MA
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Arrhythmias and Conduction Disturbances in Patients with Systemic Sclerosis—A Systematic Literature Review. Int J Mol Sci 2022; 23:ijms232112963. [PMID: 36361752 PMCID: PMC9658897 DOI: 10.3390/ijms232112963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/29/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by skin and internal organ fibrosis and microvascular impairment, which can affect major organs, including the heart. Arrhythmias are responsible for approximately 6% of deaths in patients with SSc, and mainly occur due to myocardial fibrosis, which causes electrical inhomogeneity. The aim of this study was to determine the frequency of arrhythmias and conduction disturbances in SSc cohorts, and to identify the characteristics and risk factors associated with the occurrence of dysrhythmias in patients with SSc. A systematic literature review using PubMed, Embase, Web of Science and Scopus databases was performed. Full-text articles in English with arrhythmias as the main topic published until 21 April 2022 were included. Most prevalent arrhythmias were premature supraventricular and ventricular contractions, while the most frequent conduction disturbance was represented by right bundle branch block (RBBB). Elevated concentrations of N-terminal prohormones of brain natriuretic peptides (NT-pro BNP) were associated with numerous types of atrial and ventricular arrhythmias, and with the occurrence of RBBB. A lower value of the turbulence slope (TS) emerged as an independent predictor for ventricular arrhythmias. In conclusion, dysrhythmias are frequent in SSc cohorts. Paraclinical and laboratory parameters are useful instruments that could lead to early diagnosis in the course of the disease.
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