Cardiac calcium score in systemic sclerosis

Increased risk of acute myocardial infarction in Swedish patients with systemic sclerosis: a population-based study

Objectives

To study the risk of acute myocardial infarction (AMI) in patients with SSc in a population-based cohort.

Methods

Using nationwide Swedish registers, we identified patients with incident SSc 2004-19 and age- and sex-matched comparators from the general population (1:10). Our primary outcome was incident AMI or death from incident AMI. We started follow-up from SSc diagnosis until the primary outcome, death from other cause than AMI, emigration or study end (31 December 2019). We estimated crude AMI incidence rate. We used flexible parametric models to explore the relative risk of AMI over time since diagnosis. We also used age as time scale to explore how AMI risk changes over increasing age. We also studied the outcomes of AMI in SSc compared with the matched comparators.

Results

We identified 1579 patients and 16 064 comparators. The incidence rate of AMI was 75.2 (95% CI 58.8-94.6) per 10 000 person-years in patients with SSc and 37.5 (95% CI 34.0-41.3) in the comparators, median follow-up was 5.2 and 6.3 years, respectively. The adjusted hazard ratio (HR) was highest during the first year after SSc diagnosis (HR 3.1, 95% CI 2.0-4.6). In patients with SSc, the risk of AMI increased more rapidly with increasing age compared with the comparators. AMI in SSc was associated with higher risk of mortality (HR 2.7, 95% CI 1.6-4.4) but not 30-day readmission (HR 1.3, 95% CI 0.7-2.0) compared with the comparators.

Conclusion

In line with previous studies, SSc is associated with a 2-fold increase in AMI incidence compared with the general population.

Subclinical coronary artery calcification in systemic sclerosis using high-resolution chest CT: Identification, extent, and disease-specific risk factors

OBJECTIVES

Early detection of subclinical atherosclerosis is pivotal for preventing symptomatic coronary artery disease. This study aimed to compare the proportion of patients with systemic sclerosis (SSc) having an Agatston coronary artery calcification (CAC) score ≥100 using high-resolution computed tomography (HRCT) chest scans to a background population using cardiac CT scans, and to identify disease-specific risk factors for subclinical CAC in patients with SSc.

METHODS

Logistic regression models, adjusted for cardiovascular risk factors, evaluated the odds ratio of patients having a CAC score ≥100. CAC scores for the background population were derived from two cardiac CT screening cohorts. CAC scores by HRCT chest scans were calibrated using a conversion factor to adjust for overestimation in comparison to CAC scores obtained from dedicated cardiac CT scans.

RESULTS

HRCT chest scans from 394 patients with SSc were evaluated. In total, 116 (29.4 %) had a CAC score of 0, while 162 (41.1 %) had a CAC score ≥100. Disease duration (OR=1.05, 95 % CI 1.01-1.09) and a history of digital ulcers (OR=2.25, 95 % CI 1.31; 3.86) were independently associated with a CAC score ≥100. Compared to the background population, a significantly higher proportion of SSc patients had a CAC score ≥100 (35.0 % vs. 23.2 %, p<0.001).

CONCLUSION

The identification of subclinical atherosclerosis using routine HRCT chest scans in patients with SSc offers the potential to detect individuals at increased risk of developing CAD and guide preventive treatment strategies. Additionally, digital ulcers appear to be a novel risk factor for subclinical CAD in these patients.

Quantification of coronary artery calcification in systemic sclerosis using visual ordinal and deep learning scoring: Association with systemic sclerosis clinical features

OBJECTIVE

To investigate the association between systemic sclerosis (SSc) clinical features and the extent and progression of coronary artery calcifications.

METHODS

We conducted a single-center retrospective cohort study of patients with SSc. In our primary aim, we investigated the association between SSc clinical features and the annual progression of coronary artery calcium (CAC) scores quantified using the visual ordinal scoring method. In our secondary aim, we utilized DeepCAC, a deep learning-based method, to quantify coronary artery calcifications ("deep learning CAC score"), and explored its association with SSc clinical features.

RESULTS

Eighty-six SSc patients were included in the primary aim and 171 in the secondary aim. SSc disease duration was inversely associated with annual ordinal CAC score progression in the demographics-adjusted model (coefficient = -0.004, 95 % CI -0.006 to -0.001, p-value = 0.01) and the demographics- and cardiovascular (CV) risk factor-adjusted model (coefficient = -0.004, 95 % CI -0.008 to -0.0004, p-value = 0.03). The presence of "fingertip ischemic ulcers or digital pitting scars" (demographics-adjusted model: coefficient = 1.07, 95 % CI 0.29 to 1.85, p < 0.01; demographics- and CV risk factor-adjusted model: coefficient = 1.39, 95 % CI 0.43 to 2.34, p < 0.01) and Group 1 pulmonary hypertension (demographics-adjusted model: coefficient = 1.34, 95 % CI 0.34 to 2.35, p < 0.01; demographics- and CV risk factor-adjusted model: coefficient = 1.52, 95 % CI 0.38 to 2.65, p < 0.01) were both associated with the deep learning CAC score.

CONCLUSION

Our results suggest that the progression of coronary artery calcification accelerates early during the SSc disease course and that severe microvasculopathy may be a risk factor for atherosclerotic CVD.

Coronary artery calcification is prevalent in systemic sclerosis and is associated with adverse prognosis

Objective

Coronary artery calcification assessed on thoracic computed tomography represents the calcific component of established coronary artery disease, is a biomarker of total atheromatous plaque burden and predicts mortality. Systemic sclerosis is a pro-inflammatory condition, and inflammation is also a driver of coronary artery disease. We assessed coronary artery calcification prevalence, mortality risk and potential clinical impact on primary prevention in a cohort of patients with systemic sclerosis, differentiated by clinical phenotype including the presence of interstitial lung disease and pulmonary arterial hypertension.

Methods

Retrospective analysis of 258 computed tomographies in systemic sclerosis patients from three prospectively maintained clinical and research databases at a single tertiary rheumatology/pulmonary hypertension (PH) service between March 2007 and September 2020 (mean age = 65 ± 12, 14% male). Co-morbidities, statin prescription and all-cause mortality were recorded. Patients were subtyped according to underlying systemic sclerosis complications. Computed tomographies were re-reviewed for coronary artery calcification; severity was graded using a 4-point scale per vessel and summed for total coronary artery calcification score. The impact of reporting coronary artery calcification was assessed against pre-existing statin prescriptions.

Results

Coronary artery calcification was present in 58% (149/258). Coronary artery calcification was more prevalent in systemic sclerosis-pulmonary arterial hypertension than in systemic sclerosis subgroups with interstitial lung disease or without pulmonary arterial hypertension, controlling for age, sex, co-morbidities and smoking status (71%; χ 2(13) = 81.4; p < 0.001). The presence and severity of coronary artery calcification were associated with increased risk of mortality independently of age and co-morbidities (hazard ratio = 2.8; 95% confidence interval = 1.2-6.6; p = 0.018). The 'number needed to report' coronary artery calcification presence to potentially impact management was 3.

Conclusions

Coronary artery calcification is common in systemic sclerosis. Coronary artery calcification predicts mortality independently of age and confounding co-morbidities which suggests this finding has clinical relevance and is a potential target for screening and therapeutic intervention.

Calcinosis in systemic sclerosis: An update on pathogenesis, related complications, and management: A heavy burden still waiting to be lifted off patients' hands

In SSc, dystrophic calcinosis is one of the major clinical manifestations, characterized by the deposition of insoluble calcific substances in tissues, predominantly in the chemical form of calcium hydroxyapatite. Furthermore, calcinosis might lead to compressive neuropathies and severe pain. Current evidence suggests that tissue ischemia and repeated trauma are implicated in the development of calcinosis; however, there are still too many unknown areas that need to be investigated. Detection of calcinosis is commonly performed using X-ray or ultrasound. Moreover, quantification of calcinosis with X-ray and dual-energy computed tomography might be useful for the assessment of disease burden and monitoring of the disease. Despite its prevalence and clinical outcomes, there are no approved disease-modifying treatments for calcinosis in SSc. Debulking or surgical intervention might be preferred for calcinosis complicated with infection, compressive symptoms, or relief of pain. Therefore, innovative investigations and tailored therapeutic approaches are urgently needed to lift the burden of calcinosis from the hands of SSc patients.

Biomarkers in the evaluation of cardiac involvement in systemic sclerosis

Systemic sclerosis is a multisystemic disease for which the heart can be affected leading to cardiac complications and mortality. Up to 80% of patients with systemic sclerosis have cardiac involvement with varying levels of severity. Several molecules have been identified that can be used as markers of cardiac involvement. These biomarkers can arise directly from the heart due to cardiac damage from the disease such as cardiac troponins or from the underlying dysregulated immune process itself such as the proinflammatory cytokines including interleukin (IL)-6. This review aims to summarize the evidence on currently known biomarkers that are can be diagnostic, prognostic or predictive of primary cardiac involvement in systemic sclerosis. We also highlight potential new biomarkers based on the current understanding of the disease process. Clinical use of these markers can benefit patients through earlier identification of those with cardiac involvement, many of whom can be asymptomatic in the early stage, with higher risk of complications, with the overall goal to improve outcomes of these affected patients.

Plasma Dephosphorylated-Uncarboxylated Matrix Gla-Protein in Systemic Sclerosis Patients: Biomarker Potential for Vascular Calcification and Inflammation

BACKGROUND

Systemic sclerosis (SSc) patients face an elevated risk of cardiovascular disease (CVD), even when classic cardiovascular risk factors are considered. Plasma dephosphorylated-uncarboxylated Matrix Gla-protein (dp-ucMGP), an inactive form of MGP, is associated with increased CVD risk. Smooth muscle cells, implicated in SSc's development, are the primary dp-ucMGP producers. This study assessed dp-ucMGP levels and initial CVD events in early-diagnosed SSc patients, investigating its potential as a CVD and all-cause mortality predictor over time.

METHODS

In a cohort of 87 SSc patients (excluding those with pre-existing CVD or on dialysis), baseline dp-ucMGP levels were measured, along with cardiovascular risk factors. Validation involved assessing dp-ucMGP in a subset of treatment-naive SSc patients.

RESULTS

A significantly elevated median dp-ucMGP level of 634 pmol/L (IQR 301) compared with healthy controls (dp-ucMGP < 393 pmol/L; p < 0.001) was observed. Validation in a treatment-naive SSc patient subset yielded similar results (median 589 pmol/L; IQR 370). During a median 10.5-year follow-up among 78 SSc patients, 33.3% experienced their first CVD event, independent of traditional risk factors. Elevated dp-ucMGP levels (>634 pmol/L) correlated with a higher risk of CVD and/or death (log-rank test: p < 0.01).

CONCLUSIONS

In summary, dp-ucMGP emerges as a novel biomarker in SSc patients, with elevated levels indicating an increased risk of CVD and/or mortality in this population.

Serum markers in systemic sclerosis with cardiac involvement

Cardiac involvement in systemic sclerosis is a common clinical entity that may range from subclinical to life-threatening complications. The classification of cardiac involvement may be expressed as either primary or secondary involvement. Primary systemic sclerosis heart involvement (SSc-pHI) refers to cardiac pathologies primarily ascribed to systemic sclerosis rather than concomitant conditions like ischemic heart disease and pulmonary hypertension. The timely recognition of cardiac involvement holds significant clinical relevance. Therefore, numerous screening or diagnostic tools have been evaluated to forecast the likelihood of cardiac involvement, particularly in the absence of clinically evident cardiac symptoms. Of these modalities, serum biomarkers are often preferred due to their expeditiousness and non-invasive nature. Hence, the crucial goal of this narrative review is to review serum biomarkers that can be a valuable or promising tool in diagnosing cardiac involvement, especially SSc-pHI, in the early stages or predicting disease prognosis.

CREST Syndrome in Systemic Sclerosis Patients - Is Dystrophic Calcinosis a Key Element to a Positive Diagnosis?

Introduction

CREST syndrome is a clinical entity associated with systemic sclerosis, which meets at least three of the five clinical features: calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Three of these clinical features (Raynaud’s phenomenon, sclerodactyly and esophageal dysmotility) are often present in classical subsets of SSc: limited and diffuse, and their presence in association does not define CREST syndrome. Calcinosis seems to be less common in SSc and its association with other clinical features is characteristic of CREST syndrome. Therefore, it can be appreciated that calcinosis is the key element of CREST syndrome.

Methods

This study included a number of 37 candidates with SSc, diagnosed with the help of the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2013 criteria.

Results and Discussions

These three elements (calcinosis, Raynaud’s phenomenon, esophageal dysmotility) were recorded both in the limited subset of SSc, but especially in the subset of diffuse SSc, contrary to the data in the literature.

Conclusion

We appreciate that CREST syndrome is a clinical entity that can overlap with both subsets of SSc. Given the divergent views of the authors on the classification of CREST syndrome, future studies may contribute to a reassessment of SSc classification.

Cellular and Molecular Diversity in Scleroderma

With the increasing armamentarium of high-throughput tools available at manageable cost, it is attractive and informative to determine the molecular underpinnings of patient heterogeneity in systemic sclerosis (SSc). Given the highly variable clinical outcomes of patients labelled with the same diagnosis, unravelling the cellular and molecular basis of disease heterogeneity will be crucial to predicting disease risk, stratifying management and ultimately informing a patient-centered precision medicine approach. Herein, we summarise the findings of the past several years in the fields of genomics, transcriptomics, and proteomics that contribute to unraveling the cellular and molecular heterogeneity of SSc. Expansion of these findings and their routine integration with quantitative analysis of histopathology and imaging studies into clinical care promise to inform a scientifically driven patient-centred personalized medicine approach to SSc in the near future.