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Budhram B, Weatherald J, Humbert M. Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:419-434. [PMID: 38499196 DOI: 10.1055/s-0044-1782217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.
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Affiliation(s)
- Brandon Budhram
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, European Reference Network for Rare Respiratory Diseases (ERN-LUNG), Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Le Kremlin-Bicêtre, France
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Liu Y, Cheng Z, Zha B, Chen X, Gong Z, Ji L, Wei L. Risk factors of pulmonary arterial hypertension in patients with systemic lupus erythematosus: A meta-analysis. Lupus 2023; 32:1310-1319. [PMID: 37699157 DOI: 10.1177/09612033231202398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
OBJECTIVE To determine the risk factors of pulmonary arterial hypertension (PAH) related to systemic lupus erythematosus (SLE) through systematic reviews and meta-analyses. METHODS We undertook electronic search strategies using Medline via PubMed, Embase, Web of Science, and Cochrane Library up to April 11, 2023. Study selection and data extraction were performed by 2 authors independently. We made risk of bias judgments based on the Newcastle-Ottawa Scale (NOS). Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to estimate the overall effect sizes of potential risk factors for PAH in SLE patients. Univariate and multivariate meta-regression models were used to assess the independent effects of each risk factor on PAH. Sensitivity analyses were also conducted to explore potential sources of heterogeneity. RESULTS A total of 19 articles were included in this meta-analysis, and the results showed that gender (female) [RR = 1.04, 95% CI (1.02, 1.06), p = .0001], interstitial lung disease [RR = 4.36, 95% CI (2.42, 7.85), p = .0001], alopecia [RR = 1.39, 95% CI (1.06, 1.83), p = .017], Raynaud's phenomenon [RR = 1.83, 95% CI (1.41, 2.37), p = .0001], systemic hypertension [RR = 1.30, 95% CI (1.07, 1.58), p = .007], serositis [RR = 2.29, 95% CI (1.89, 2.77), p = .0001], pericardial effusion [RR = 3.33, 95% CI (2.20, 5.05), p = .0001], anti-RNP [RR = 1.86, 95% CI (1.19, 2.91), p = .006], anti-SSA [RR = 1.28, 95% CI (1.01, 1.62), p = .041], anti-SSB [RR = 1.38, 95% CI (1.19, 1.60), p = .0001], anti-U1RNP [RR = 1.58, 95% CI (1.07, 2.34), p = .023], thrombocytopenia [RR = 1.38, 95% CI (1.14, 1.68), p = .001], and current smokers [RR = 2.20, 95% CI (1.19, 4.06), p = .012] were all risk factors for PAH related to SLE. CONCLUSION PAH is a serious complication of SLE. Since prognosis of SLE patients after the occurrence of PAH is poor, routine examination should be conducted for SLE patients with PAH risk factors.
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Affiliation(s)
- Yuqi Liu
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhen Cheng
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bowen Zha
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Chen
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhiyu Gong
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Lang Ji
- Central Laboratory, Beijing Luhe Clinical Institute, Capital Medical University, Beijing, China
| | - Lingling Wei
- Beijing Key Laboratory of Diabetic Prevention and Research, Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Ulutas Z, Tasolar H, Bayramoglu A, Yigit Y, Kuloglu HE, Karaca Y, Yolbas S, Hidayet S, Akaycan J. The importance of pulmonary pulse transit time in indicating right ventricular dysfunction and pulmonary arterial stiffness in rheumatoid arthritis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1321-1328. [PMID: 37530482 DOI: 10.1002/jcu.23531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
SUBJECT Rheumatoid arthritis patients are at risk of developing cardiovascular disease such as right heart failure and pulmonary hypertension (PH). Arterial stiffness can be used to assess pulmonary hemodynamics. Noninvasive approaches can also be used to assess pulmonary hemodynamics. Recently, there have been reports that pulmonary pulse transit time (PPTT) may also be a useful measure. This study aims to examine the effects of pulmonary hemodynamic alterations on PPTT in RA patients. METHODS Forty RA patients and 40 healthy controls were included in the study. Sociodemographic characteristics, laboratory data, and echocardiographic examinations were performed in both groups. Conventional echocardiographic examination included left and right ventricular systolic and diastolic diameters, right ventricular myocardial performance index (RVMPI), right ventricular diastolic function, estimated pulmonary artery systolic pressure (sPAP), tricuspid annular plane systolic excursion (TAPSE), pulmonary artery stiffness (PAS), and PPTT. Right ventricular diastolic and systolic volumes, right ventricular ejection fraction (RVEF), and right ventricular fractional area change (RVFAC) were determined by four-dimensional echocardiography (4DE). RESULTS There was no difference between the sPAP values of the patients. RVMPI and PAS were increased in RA patients compared with controls. The PPTT was shortened in RA patients and correlated with RVEF, RVFAC, RVMPI, TAPSE/sPAP, disease duration, and C-reactive protein (CRP). In univariate linear regression analysis, PPTT (p < .001) was thought to be an independent predictor of PAS. RVFAC, disease duration, and PAS were also independent predictors of PPTT. CONCLUSION In RA patients, PPTT may be the first evidence of early abnormalities in pulmonary vascular hemodynamics. PPTT and PAS are the values that may predict each other in RA patients. Due to its more practical application, PPTT can be used instead of PAS to assess pulmonary hemodynamics.
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Affiliation(s)
- Zeynep Ulutas
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Hakan Tasolar
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Adil Bayramoglu
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Yakup Yigit
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | | | - Yucel Karaca
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Servet Yolbas
- Department of Rheumatology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Siho Hidayet
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Julide Akaycan
- Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey
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Malhotra A, Pathak MA, Dalia T, Vidic A. Endomyocardial biopsy-proven hydroxychloroquine-induced cardiomyopathy in a patient with rheumatoid arthritis. BMJ Case Rep 2023; 16:16/4/e252327. [PMID: 37055077 PMCID: PMC10105987 DOI: 10.1136/bcr-2022-252327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Hydroxychloroquine is a disease-modifying antirheumatic drug used for various rheumatological conditions. Its long-term use is well-known to have toxic effects on cardiac muscle cells. We present a biopsy-proven case of hydroxychloroquine-induced cardiotoxicity with detailed histopathological and imaging findings. The patient was referred to our heart failure clinic for concerns of reduction in left ventricular ejection fraction despite being on guideline-directed medical therapy. She had been diagnosed with rheumatoid arthritis, pulmonary hypertension and then subsequently heart failure with reduced ejection fraction 5 years ago. The evaluation included right heart catheterisation, cardiac MRI and endomyocardial biopsy. Light and electron microscopy showed myocyte hypertrophy and vacuolar change, abnormal mitochondria, myeloid bodies and curvilinear bodies. These findings were specific for hydroxychloroquine-induced cardiomyopathy. This case highlights the importance of clinical monitoring, early suspicion and consideration of drug-induced toxicities as a culprit for heart failure.
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Affiliation(s)
- Anureet Malhotra
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mihir Abhijit Pathak
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Tarun Dalia
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrija Vidic
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Abstract
Rationale: Pulmonary hypertension (PH) has been described in patients treated with leflunomide. Objectives: To assess the association between leflunomide and PH. Methods: We identified incident cases of PH in patients treated with leflunomide from the French PH Registry and through the pharmacoVIGIlAnce in Pulmonary ArTerial Hypertension (VIGIAPATH) program between September 1999 to December 2019. PH etiology, clinical, functional, radiologic, and hemodynamic characteristics were reviewed at baseline and follow-up. A pharmacovigilance disproportionality analysis using the World Health Organization's global database was conducted. We then investigated the effect of leflunomide on human pulmonary endothelial cells. Data are expressed as median (min-max). Results: Twenty-eight patients treated with leflunomide before PH diagnosis was identified. A total of 21 (75%) had another risk factor for PH and 2 had two risk factors. The median time between leflunomide initiation and PH diagnosis was 32 months (1-120). Right heart catheterization confirmed precapillary PH with a cardiac index of 2.37 L⋅min-1 ⋅m-2 (1.19-3.1) and elevated pulmonary vascular resistance at 9.63 Wood Units (3.6-22.1) without nitric oxide reversibility. Five patients (17.9%) had no other risk factor for PH besides exposure to leflunomide. No significant hemodynamic improvement was observed after leflunomide withdrawal. The pharmacovigilance disproportionality analysis using the World Health Organization's database revealed a significant overrepresentation of leflunomide among reported pulmonary arterial hypertension-adverse drug reactions. In vitro studies showed the dose-dependent toxicity of leflunomide on human pulmonary endothelial cells. Conclusions: PH associated with leflunomide is rare and usually associated with other risk factors. The pharmacovigilance analysis suggests an association reinforced by experimental data.
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Shioleno AM, Ruopp NF. Group 3 Pulmonary Hypertension: A Review of Diagnostics and Clinical Trials. Clin Chest Med 2021; 42:59-70. [PMID: 33541617 DOI: 10.1016/j.ccm.2020.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Group 3 pulmonary hypertension (PH) is a known sequelae of chronic lung disease. Diagnosis and classification can be challenging in the background of chronic lung disease and often requires expert interpretation of numerous diagnostic studies to ascertain the true nature of the PH. Stabilization of the underlying lung disease and adjunctive therapies such as oxygen remain the mainstays of therapy, as there are no Food and Drug Administration-approved therapies for group 3 PH. Referral to PH centers for individualized management and clinical trial enrollment is paramount.
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Affiliation(s)
- Andrea M Shioleno
- Division of Pulmonary and Critical Care Medicine, University of Miami, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
| | - Nicole F Ruopp
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 800 Washington Street, #257 (Tupper 3), Boston, MA 02111, USA.
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Echocardiographic evaluation of pulmonary hypertension, right ventricular function, and right ventricular-pulmonary arterial coupling in patients with rheumatoid arthritis. Clin Rheumatol 2021; 40:2651-2656. [PMID: 33443606 DOI: 10.1007/s10067-020-05544-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) patients are at increased risk for developing cardiovascular disease, including right heart failure. The evaluation of right ventricle (RV) using the relationship between tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic pressure (RVSP) is of clinical prognostic relevance. Mild echocardiographic pulmonary hypertension (ePH) has been associated with worse RV function. The aim of this study was to evaluate RV function as measured by TAPSE to RVSP ratio in rheumatoid arthritis patients compared to matched healthy controls. METHOD A case-control study with 67 RA patients aged 40 to 75 years that fulfilled the 2010 ACR/EULAR criteria and 45 matching controls was included. A transthoracic echocardiogram was performed to all patients. TAPSE was measured as the distance traveled from end-diastole to end-systole. RVSP was calculated using the modified Bernoulli equation. Comparisons were done using Chi-square and Mann-Whitney's U test or Student's t test. RESULTS Patients with RA had significantly reduced ventricular function (TAPSE 23 [21-25] vs 25 [23-26], p = 0.033) and TAPSE/RVSP ratio was significantly lower in RA-patients than controls (TAPSE to RVSP ratio 0.809 [0.67-1.01] vs 0.933 [0.79-1.11], p = 0.009). RA-patients with mild ePH had similar RV function, evaluated by TAPSE, in comparison to RA-patients with normal RVSP. CONCLUSION RA-patients had worse RV function measured by TAPSE and worse TAPSE/RVSP ratio than controls. Also, RA-patients with mild ePH had reduced right ventricular-pulmonary arterial coupling in comparison with patients with RA and normal RVSP. These echocardiographic findings could justify aggressive treatment for these patients and assess their evolution. Key Points • Right ventricular (RV) function and RV coupling with the pulmonary artery (RV-PA coupling) were worse in patients with RA in comparison to healthy controls. • Values of right ventricular systolic pressure (RVSP) were similar between RA-patients and non-RA controls. • Prevalence of normal RVSP, mild echocardiographic pulmonary hypertension (ePH), and pulmonary hypertension was similar between RA-patients and non-RA matched controls •Patients with RA and mild ePH had reduced RV-PA coupling in comparison with RA-patients with normal RVSP.
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8
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Wang D, Zhang J, Lau J, Wang S, Taneja V, Matteson EL, Vassallo R. Mechanisms of lung disease development in rheumatoid arthritis. Nat Rev Rheumatol 2019; 15:581-596. [PMID: 31455869 DOI: 10.1038/s41584-019-0275-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes joint inflammation and damage. Extra-articular manifestations occur in many patients and can include lung involvement in the form of airway or parenchymal inflammation and fibrosis. Although the pathophysiology of articular RA has been extensively investigated, the mechanisms causing airway and parenchymal lung disease are not well defined. Infections, cigarette-smoking, mucosal dysbiosis, host genetics and premature senescence are all potentially important contributors to the development of lung disease in patients with RA. RA-associated lung disease (which can predate the onset of articular disease by many years) probably originates from chronic airway and alveolar epithelial injury that occurs in an individual with a genetic background that permits the development of autoimmunity, leading to chronic inflammation and subsequent airway and lung parenchymal remodelling and fibrosis. Further investigations into the specific mechanisms by which lung disease develops in RA will be crucial for the development of effective therapies. Identifying mechanisms by which environmental and host factors cooperate in the induction of autoimmunity in the lung might also help to establish the order of early events in RA.
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Affiliation(s)
- Dan Wang
- Department of Rheumatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Zhang
- Division of Pulmonary Medicine, Department of Medicine, Chongqing General Hospital, Chongqing, China
| | - Jessica Lau
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Shaohua Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Veena Taneja
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. .,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
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Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med 2019; 40:545-560. [PMID: 31376890 DOI: 10.1016/j.ccm.2019.05.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.
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Affiliation(s)
- Anthony J Esposito
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sarah G Chu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Rachna Madan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Tracy J Doyle
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Paul F Dellaripa
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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Spagnolo P, Lee JS, Sverzellati N, Rossi G, Cottin V. The Lung in Rheumatoid Arthritis. Arthritis Rheumatol 2018; 70:1544-1554. [DOI: 10.1002/art.40574] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 05/22/2018] [Indexed: 12/21/2022]
Affiliation(s)
| | | | | | - Giulio Rossi
- Azienda USL Valle d'Aosta, Regional Hospital; Aosta Italy
| | - Vincent Cottin
- Hospices Civils de Lyon; Louis Pradel Hospital; National Reference Center for Rare Pulmonary Diseases; Lyon France
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11
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Kyranis SJ, Latona J, Platts D, Kelly N, Savage M, Brown M, Hamilton-Craig C, Scalia GM, Burstow D. Improving the echocardiographic assessment of pulmonary pressure using the tricuspid regurgitant signal-The “chin” vs the “beard”. Echocardiography 2018; 35:1085-1096. [DOI: 10.1111/echo.13893] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Stephen J. Kyranis
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Jilani Latona
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - David Platts
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Queensland Advanced Heart Failure and Cardiac Transplant Unit; The Prince Charles Hospital; Heart and Lung Institute; Brisbane QLD Australia
| | - Natalie Kelly
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Michael Savage
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Martin Brown
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Queensland Advanced Heart Failure and Cardiac Transplant Unit; The Prince Charles Hospital; Heart and Lung Institute; Brisbane QLD Australia
| | - Christian Hamilton-Craig
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Centre for Advanced Imaging; University of Queensland; Brisbane QLD Australia
- University of Washington; Seattle WA USA
| | - Gregory M. Scalia
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Darryl Burstow
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
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Montani D, Henry J, O’Connell C, Jaïs X, Cottin V, Launay D, Habib G, Bourdin A, Jevnikar M, Savale L, Rottat L, Simonneau G, Sitbon O, Humbert M, Allanore Y. Association between Rheumatoid Arthritis and Pulmonary Hypertension: Data from the French Pulmonary Hypertension Registry. Respiration 2018; 95:244-250. [DOI: 10.1159/000485631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 11/22/2017] [Indexed: 11/19/2022] Open
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Jawad H, McWilliams SR, Bhalla S. Cardiopulmonary Manifestations of Collagen Vascular Diseases. Curr Rheumatol Rep 2017; 19:71. [PMID: 28994016 DOI: 10.1007/s11926-017-0697-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The study aimed to illustrate the cardiopulmonary findings of the following collagen vascular diseases on cross-sectional imaging: rheumatoid arthritis, scleroderma (progressive systemic sclerosis), systemic lupus erythematosus, the inflammatory myopathies (polymyositis/dermatomyositis), and Sjögren's syndrome. RECENT FINDINGS Although collagen vascular diseases can affect any part of the body, interstitial lung disease and pulmonary hypertension are the two most important cardiopulmonary complications and are responsible for the majority of morbidity and mortality in this patient population. Interstitial pneumonia with autoimmune features (IPAF) is a newly described entity that encompasses interstitial lung disease in patients with clinical, serologic, or morphologic features suggestive of but not diagnostic of collagen vascular disease; these patients are thought to have better outcomes than idiopathic interstitial pneumonias. Interstitial lung disease and pulmonary hypertension determine the prognosis in collagen vascular disease patients. IPAF is a new term to label patients with possible collagen vascular disease-related interstitial lung disease. Collagen vascular disease patients are at increased risk for various malignancies.
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Affiliation(s)
- Hamza Jawad
- Division of Diagnostic Radiology, Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University in St. Louis, Campus Box 8131, 510 S Kingshighway Blvd, St. Louis, MO, USA.
| | - Sebastian R McWilliams
- Division of Diagnostic Radiology, Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University in St. Louis, Campus Box 8131, 510 S Kingshighway Blvd, St. Louis, MO, USA
| | - Sanjeev Bhalla
- Division of Diagnostic Radiology, Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University in St. Louis, Campus Box 8131, 510 S Kingshighway Blvd, St. Louis, MO, USA
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14
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Relationship between matrix metalloproteinase-3 serum level and pulmonary artery systolic pressure in patients with rheumatoid arthritis. Heart Vessels 2017; 33:191-197. [DOI: 10.1007/s00380-017-1045-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
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15
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Rheumatoid arthritis associated pulmonary hypertension: Clinical challenges reflecting the diversity of pathophysiology. Respir Med Case Rep 2017; 20:164-167. [PMID: 28275536 PMCID: PMC5328703 DOI: 10.1016/j.rmcr.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 12/21/2022] Open
Abstract
The present article reports three clinical cases in order to elucidate the diversity of the pathophysiological mechanisms that underlie rheumatoid arthritis associated pulmonary hypertension. The condition's three major causes are: interstitial lung disease, vasculitis, and chronic thromboembolic disease, but it should be noted that the multiple pulmonary manifestations of rheumatoid arthritis, can all contribute to chronic lung disease or hypoxia. The first patient in this report suffered from moderate restriction due to fibrosis and was diagnosed with pulmonary hypertension during an episode of life threatening hypoxia. Early upfront combination therapy prevented intubation and reversed hypoxia to adequate levels. The second presented patient was a case of isolated pulmonary hypertension attributable to vasculopathy. The patient maintained normal lung volumes but low diffusion capacity and echocardiography dictated the need for right heart catheterization. Finally, the third patient presented severe functional limitation due to several manifestations of rheumatoid arthritis, but a past episode of acute pulmonary embolism was also reported although it had never been evaluated. Chronic thromboembolic disease was eventually proved to be one major cause of the patient's pulmonary hypertension. The importance of early identification of pulmonary hypertension in patients with rheumatoid arthritis is therefore emphasized, especially since multiple treatment options are available, symptoms can be treated, and right heart failure can be avoided.
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Abstract
Involvement of the respiratory system is common in connective tissue diseases (CTDs), and the resultant lung injury can affect every part of the lung: the pleura, alveoli, interstitium, vasculature, lymphatic tissue, and large and/or small airways. Most of the parenchymal manifestations of CTD are similar to those found in interstitial lung diseases (ILDs), especially idiopathic interstitial pneumonias, and can be classified using the same system. Although there is some overlap, each CTD is associated with a characteristic pattern of pulmonary involvement. For this reason, thin-section CT as well as pulmonary function tests and serum markers are utilized for diagnosis, disease severity assessment, and therapeutic efficacy evaluation of ILD associated with CTD. In addition, newly developed pulmonary magnetic resonance imaging (MRI) procedures have been recommended as useful alternative imaging options for patients with CTD. This review article will (1) address radiological findings for chest radiography and conventional or thin-section CT currently used for six major types of CTD, rheumatoid arthritis, scleroderma (progressive systemic sclerosis), polymyositis/dermatomyositis, systemic lupus erythematosus, Sjögren syndrome and mixed connective tissue disease; (2) briefly deal with radiation dose reduction for thin-section CT examination; and (3) discuss clinically applicable or state-of-the-art MR imaging for CTD patients.
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Reeves GEM, Collins N, Hayes P, Knapp J, Squance M, Tran H, Bastian B. SAPHIRE: Stress and Pulmonary Hypertension in Rheumatoid Evaluation-A Prevalence Study. Int J Rheumatol 2016; 2016:4564531. [PMID: 27200094 PMCID: PMC4854985 DOI: 10.1155/2016/4564531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/02/2016] [Accepted: 03/16/2016] [Indexed: 11/18/2022] Open
Abstract
Pulmonary artery hypertension (PAH) is a disorder of elevated resistance in the pulmonary arterial vessels, reflected by elevation of measured pulmonary artery pressure (PAP), and presenting with breathlessness and, if untreated, progressing to right heart failure and death. The heightened prevalence of PAH in populations with underlying systemic autoimmune conditions, particularly scleroderma and its variants, is well recognised, consistent with the proposed autoimmune contribution to PAH pathogenesis, along with disordered thrombotic, inflammatory, and mitogenic factors. Rheumatoid arthritis (RA) is one of a group of systemic autoimmune conditions featuring inflammatory symmetrical erosive polyarthropathy as its hallmark. This study explored the prevalence of PAH in a population of unselected individuals with RA, using exercise echocardiography (EchoCG). The high prevalence of EchoCG-derived elevation of PAP (EDEPP) in this population (14%) suggests that, like other autoimmune conditions, RA may be a risk factor for PAH. Patients with RA may therefore represent another population for whom PAH screening with noninvasive tools such as EchoCG may be justified.
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Affiliation(s)
- G. E. M. Reeves
- John Hunter Hospital, University of Newcastle, Callaghan, NSW 2308, Australia
| | - N. Collins
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - P. Hayes
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - J. Knapp
- Autoimmune Resource and Research Centre, New Lambton Heights, NSW 2305, Australia
| | - M. Squance
- Autoimmune Resource and Research Centre, New Lambton Heights, NSW 2305, Australia
| | - H. Tran
- Pathology North, New Lambton Heights, NSW 2305, Australia
| | - B. Bastian
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
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Dodo-Siddo MN, Diao M, Ndiaye MB, Ndongo S, Kane A, Mbaye A, Bodian M, Sarr SA, Sarr M, Ba S, Diop TM. [Study of echocardiographic parameters of rheumatoid arthritis black African without clinically evident cardiovascular manifestations: A cross-sectional study of 73 cases in Senegal]. Ann Cardiol Angeiol (Paris) 2016; 65:71-76. [PMID: 25702242 DOI: 10.1016/j.ancard.2015.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 01/20/2015] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Research of cardiac involvement in patients with rheumatoid arthritis can prevent complications and place in a logical secondary prevention. The objective of this study was to investigate the echocardiographic parameters in a population of Senegalese patients with rheumatoid arthritis without clinically evident cardiovascular manifestations. PATIENTS AND METHOD We conducted a descriptive cross-sectional study, which included prospectively from outpatients in the internal medicine department of university hospital center Aristide Le Dantec in Dakar, Senegal, with a diagnosis of rheumatoid arthritis without clinically evident cardiovascular disease. It focused on a sample of 73 patients of both sexes aged at least 18 years. Following clinical examination, we conducted laboratory tests (CRP, fibrinogen, ESR, rheumatoid factors: Latex and Waaler-Rose, anti-CCP, antinuclear factors and anti-ENA antibodies), ECG, echocardiography standard. Data were analyzed using a descriptive study of the different variables with the calculation of proportions for categorical variables, and the positional parameters and dispersion for quantitative variables. RESULTS A total of 73 patients with rheumatoid arthritis without obvious cardiac events and meeting the criteria of definition of the ACR 1987 were included in the study. The mean age was 44.17±14.43 years with extremes of 18 and 75 years. The mean duration of RA was 5.93±4.78 years. The concept of family inflammatory arthritis was reported in 35.60% of cases and almost one in six patients had at least a factor of cardiovascular risk (16.96%). The abnormalities found in Doppler echocardiography were dominated by diastolic LV dysfunction (42.46%), increased left ventricular mass in 35.61%. Valvular leaks of variable grades were highlighted regarding all orifices but were rarely significant. CONCLUSION The realization of echocardiography in patients with rheumatoid arthritis without clinically evident cardiovascular manifestations helps to highlight cardiovascular abnormalities related to the natural course of the disease.
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Affiliation(s)
- M N Dodo-Siddo
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal.
| | - M Diao
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - M B Ndiaye
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - S Ndongo
- Service de médecine interne, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - A Kane
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - A Mbaye
- Service de cardiologie, hôpital général de Grand-Yoff, Dakar, Sénégal
| | - M Bodian
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - S A Sarr
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - M Sarr
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - S Ba
- Service de cardiologie, hôpital Aristide Le Dantec, Dakar, Sénégal
| | - T M Diop
- Service de médecine interne, hôpital Aristide Le Dantec, Dakar, Sénégal
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Abstract
Comprehensive, up-to-date review of RA-associated lung diseases including pathogenesis and managementhttp://ow.ly/FBaNZ
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Affiliation(s)
- Megan Shaw
- Division of Rheumatology, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Bridget F Collins
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Lawrence A Ho
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
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20
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Schau T, Gottwald M, Arbach O, Seifert M, Schöpp M, Neuß M, Butter C, Zänker M. Increased Prevalence of Diastolic Heart Failure in Patients with Rheumatoid Arthritis Correlates with Active Disease, but Not with Treatment Type. J Rheumatol 2015; 42:2029-37. [PMID: 26373561 DOI: 10.3899/jrheum.141647] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Although heart failure (HF) is a major cause of premature mortality, there is little information regarding its prevalence and associated risk factors in patients with rheumatoid arthritis (RA). In this study, we evaluated the prevalence of HF in a community-based RA cohort. Further, we investigated the effect of RA activity and present treatment on HF rate and cardiac structure. METHODS A diagnostic workup for HF according to the European Society of Cardiology recommendations was performed in 157 patients with RA fulfilling the American College of Rheumatology/European League Against Rheumatism criteria (68% women, age 61 ± 13 yrs) from our outpatient clinic and in 77 age- and sex-matched controls. RESULTS The prevalence of HF in patients with RA (24%) was unexpectedly high and differed significantly from the control sample (6%, p = 0.001). Diastolic HF was the dominant type (23% vs 6%), and clinical symptoms alone were of low diagnostic value. Active RA (28-joint Disease Activity Score ≥ 2.6: OR 3.4, 95% CI 1.3-9.8) was an independent risk factor of HF, as well as systemic inflammation (erythrocyte sedimentation rate > 16 mm/h: OR 5.4, 95% CI 2.1-16; C-reactive protein > 10 mg/l: OR 2.6, 95% CI 0.8-8.0) and RA duration > 10 years (OR 2.6, 95% CI 1.2-5.8). HF in RA was associated with concentric hypertrophy (48% vs 17%, p < 0.001) and reduced longitudinal strain (-17.2% vs -19.7%, p < 0.001). However, the prevalence of HF was equivalent between the treatment groups [conventional synthetic disease-modifying antirheumatic drugs (DMARD) 25%, tumor necrosis factor inhibitors 22%, other biological DMARD 27%]. CONCLUSION Recognition of all diastolic HF in RA requires a complex diagnostic approach. Active rather than inactive RA places patients at a higher risk for HF, whereas influence of RA treatment on HF risk needs to be elucidated in further studies.
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Affiliation(s)
- Thomas Schau
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Michael Gottwald
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Olga Arbach
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Martin Seifert
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Maren Schöpp
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Michael Neuß
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Christian Butter
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg
| | - Michael Zänker
- From the Department of Cardiology, and Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; Rheumatic Disease Center Northern Brandenburg, Bernau; Stem Cell Facility, Charité Universitätsmedizin Berlin, Berlin, Germany.T. Schau, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Gottwald, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, Brandenburg Medical School; O. Arbach, MD, Stem Cell Facility, Charité Universitätsmedizin Berlin; M. Seifert, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Schöpp, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Neuß, MD, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; C. Butter, MD, Professor, Department of Cardiology, Heart Center Brandenburg, Brandenburg Medical School; M. Zänker, MD, Department of Internal Medicine, Nephrology and Rheumatology, Heart Center Brandenburg, and Rheumatic Disease Center Northern Brandenburg.
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Tsuchiya Y, Fischer A, Solomon JJ, Lynch DA. Connective Tissue Disease-related Thoracic Disease. Clin Chest Med 2015; 36:283-97, ix. [PMID: 26024605 DOI: 10.1016/j.ccm.2015.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary involvement is a frequent manifestation of connective tissue disease (CTD)-related thoracic disease. It is important to characterize the underlying pattern when pulmonary involvement occurs in a patient with CTD, and to exclude other causes. A systematic approach, evaluating each compartment of the lung (airway, interstitium, pleura, pulmonary vasculature) may be helpful. In complex cases, a multidisciplinary approach should be considered, potentially including the pulmonologist, rheumatologist, radiologist, pathologist, and sometimes the infectious disease specialist or oncologist. New techniques, such as quantitative computed tomography and MRI, are expected to be helpful for evaluation and management of CTD-associated thoracic disease.
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Affiliation(s)
- Yutaka Tsuchiya
- Department of Radiology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Department of Respiratory Medicine, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Yokohama 227-8501, Japan.
| | - Aryeh Fischer
- Department of Rheumatology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Joshua J Solomon
- Department of Respiratory and Critical Care Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - David A Lynch
- Department of Radiology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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22
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Sung YK, Chung L. Connective tissue disease-associated pulmonary arterial hypertension. Rheum Dis Clin North Am 2015; 41:295-313. [PMID: 25836644 DOI: 10.1016/j.rdc.2015.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by vascular remodeling of pulmonary arterioles that leads to increased pulmonary vascular resistance, right heart failure, and death. It is associated with connective tissue diseases, including systemic sclerosis, systemic lupus erythematosus, and mixed connective tissue disease. PAH is characterized by dyspnea on exertion and fatigue. Syncopal events suggest severe disease. Patients may present with signs of right heart failure. One- and 3-year survival rates are approximately 81% and 52%, respectively. Given the high prevalence and mortality, algorithms for screening are currently under investigation and will hopefully lead to earlier diagnosis and improved survival.
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Affiliation(s)
- Yon K Sung
- Division of Pulmonary and Critical Care Medicine, Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Lorinda Chung
- Division of Rheumatology and Immunology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Division of Rheumatology, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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Sadeghi S, Granton JT, Akhavan P, Pasarikovski CR, Roos AM, Thenganatt J, Moric J, Johnson SR. Survival in rheumatoid arthritis-associated pulmonary arterial hypertension compared with idiopathic pulmonary arterial hypertension. Respirology 2015; 20:481-7. [PMID: 25583377 DOI: 10.1111/resp.12464] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 09/24/2014] [Accepted: 10/21/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVE In this study, we evaluated survival in rheumatoid arthritis-associated pulmonary arterial hypertension (RA-PAH) compared with idiopathic pulmonary arterial hypertension (IPAH) patients, and evaluate differences in disease severity and treatment. METHODS We conducted a retrospective cohort study of RA-PAH and IPAH at the University Health Network Pulmonary Hypertension Programme, Toronto, Canada. The primary outcome was time to all-cause mortality. We evaluated survival using Kaplan-Meier curves. Using a propensity score-matched cohort, we used Cox proportional hazards models to estimate survival. RESULTS Screening 1385 patients identified 18 RA-PAH and 155 IPAH patients. RA-PAH patients had an older median age of onset (64.0 vs 53.7 years) and lower baseline mean pulmonary arterial pressure (mPAP) (41 vs 50 mm Hg, P = 0.02). RA-PAH patients tended to have a higher proportion of females (83% vs 70%, relative risk 0.55, 95% confidence interval (CI): 0.19-1.57), lower proportion with baseline World Health Organization functional class III/IV (39% vs 52%), lower median baseline brain natriuretic peptide (58.4 vs 95.0 pg/mL) and longer baseline 6-min walk distance (440 vs 397 m). There were 35 deaths, 2/18 (11%) RA-PAH patients and 33/155 (21%) IPAH patients. The unadjusted 1-year survival was 93% for RA-PAH and 94% for IPAH. In the matched cohort, there were seven deaths: 2/18 (11%) RA-PAH and 5/18 (28%) IPAH patients, hazard ratio 1.53 (95% CI: 0.15-2.84). Separation of survival curves did not achieve statistical significance, log-rank 0.56. CONCLUSIONS Compared with IPAH patients, RA-PAH patients have an older age of onset and lower baseline mPAP. RA-PAH patients have comparable survival to IPAH patients.
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Affiliation(s)
- Saghar Sadeghi
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada
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Risk factors for asymptomatic ventricular dysfunction in rheumatoid arthritis patients. ISRN CARDIOLOGY 2013; 2013:635439. [PMID: 24368945 PMCID: PMC3866864 DOI: 10.1155/2013/635439] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/08/2013] [Indexed: 11/29/2022]
Abstract
Objective. The aim of the study was to describe echocardiographic abnormalities in patients with rheumatoid arthritis, concurrent systemic comorbidities, rheumatologic clinical activity, serologic markers of rheumatoid arthritis, and inflammatory activity. Methods. In an observational, cross-sectional study, rheumatoid arthritis outpatients were included (n = 105). Conventional transthoracic echocardiographic variables were compared between patients with arthritis and non-RA controls (n = 41). For rheumatoid arthritis patients, articular activity and rheumatologic and inflammatory markers were obtained. Results. Ventricular dysfunction was found in 54.3% of the population: systolic (18.1%), diastolic (32.4%), and/or right (24.8%), with lower ejection fraction (P < 0.0001). Pulmonary hypertension was found in 46.9%. Other echocardiographic findings included increased left atrial diameter (P = 0.01), aortic diameter (P = 0.01), ventricular septum (P = 0.01), left ventricular posterior wall (P = 0.013), and right ventricular (P = 0.01) and atrial diameters compared to control subjects. Rheumatoid factor and anti-CCP antibodies levels were significantly elevated in cases with ventricular dysfunction. Angina and myocardial infarction, diabetes, and dyslipidemia were the main risk factors for ventricular dysfunction. Conclusions. Ventricular dysfunction is common in rheumatoid arthritis and associated with longer disease duration and increased serologic markers of rheumatoid arthritis. Screening for cardiac abnormalities should be considered in this kind of patients.
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Yang X, Mardekian J, Sanders KN, Mychaskiw MA, Thomas J. Prevalence of pulmonary arterial hypertension in patients with connective tissue diseases: a systematic review of the literature. Clin Rheumatol 2013; 32:1519-31. [PMID: 23780636 PMCID: PMC3778216 DOI: 10.1007/s10067-013-2307-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/26/2013] [Accepted: 05/23/2013] [Indexed: 11/29/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and life-threatening disease. Understanding of PAH prevalence remains limited, but PAH has been reported as a frequent complication in connective tissue diseases. This study estimated prevalence of PAH in patients with connective tissue diseases and prevalence of idiopathic PAH using a systematic review of the literature. We searched PubMed through May 19, 2012 for all studies on prevalence of PAH in patients with connective tissue diseases or prevalence of idiopathic PAH. To be included, studies had to be in English, have humans as subjects, and determine prevalence within a time interval of up to 2 years. Studies only investigating pediatric patients were excluded. Pooled prevalence estimates were calculated. Twenty studies were identified in the review. Seventeen of the 20 studies reported prevalence of PAH in connective tissue diseases and three reported prevalence of idiopathic PAH. The pooled prevalence estimate of idiopathic PAH was 12 cases per million population (95 % CI 5 cases per million to 22 cases per million) with estimates ranging from 5.9 cases per million population to 25 cases per million population. The pooled prevalence estimate of PAH in patients with connective tissue diseases was 13 % (95 % CI, 9.18 % to 18.16 %) with reported estimates ranging from 2.8 % to 32 %. Prevalence of PAH in patients with connective tissue diseases was substantially higher than that of idiopathic PAH based on pooled prevalence estimates. Comparisons of PAH prevalence in persons with connective tissue disease and idiopathic PAH using a large observational study would be helpful in better assessing relative prevalence.
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Affiliation(s)
- Xiaoqin Yang
- College of Pharmacy, Purdue University, Heine Pharmacy Building, Room 502A, 575 Stadium Mall Drive, West Lafayette, IN, 47907-2091, USA,
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Marigliano B, Soriano A, Margiotta D, Vadacca M, Afeltra A. Lung involvement in connective tissue diseases: a comprehensive review and a focus on rheumatoid arthritis. Autoimmun Rev 2013; 12:1076-84. [PMID: 23684699 DOI: 10.1016/j.autrev.2013.05.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 12/20/2022]
Abstract
The lungs are frequently involved in Connective Tissue Diseases (CTDs). Interstitial lung disease (ILD) is one of the most common pleuropulmonary manifestations that affects prognosis significantly. In practice, rheumatologists and other physicians tend to underestimate the impact of CTD-ILDs and diagnose respiratory impairment when it has reached an irreversible fibrotic stage. Early investigation, through clinical evidence, imaging and - in certain cases - lung biopsy, is therefore warranted in order to detect a possible ILD at a reversible initial inflammatory stage. In this review, we focus on lung injury during CTDs, with particular attention to ILDs, and examine their prevalence, clinical manifestations and histological patterns, as well as therapeutic approaches and known complications till date. Although several therapeutic agents have been approved, the best treatment is still not certain and additional trials are required, which demand more knowledge of pulmonary involvement in CTDs. Our central aim is therefore to document the impact that lung damage has on CTDs. We will mainly focus on Rheumatoid Arthritis (RA), which - unlike other rheumatic disorders - resembles Idiopathic Pulmonary Fibrosis (IPF) in numerous aspects.
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Affiliation(s)
- Benedetta Marigliano
- Department of Clinical Medicine and Rheumatology, University Campus Bio-Medico of Rome, Italy
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Abstract
Pulmonary hypertension (PH) can develop in association with many different diseases and risk factors, and its presence is nearly always associated with reduced survival. The prognosis and management of PH is largely dependent upon its underlying etiology and severity of disease. The combination of clinical and hemodynamic classifications of PH provides a framework for the diagnostic evaluation of PH to establish a final clinical diagnosis that guides therapy. As our understanding of the different pathologic mechanisms that underlie the syndrome of PH evolves, so too will the classification and treatment of PH.
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Affiliation(s)
- Dana McGlothlin
- Division of Cardiology, UCSF Medical Center, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0124, USA.
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Pulmonary hypertension in parenchymal lung disease. Pulm Med 2012; 2012:684781. [PMID: 23094153 PMCID: PMC3474989 DOI: 10.1155/2012/684781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/07/2012] [Indexed: 01/23/2023] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) has been extensively investigated, although it represents a less common form of the pulmonary hypertension (PH) family, as shown by international registries. Interestingly, in types of PH that are encountered in parenchymal lung diseases such as interstitial lung diseases (ILDs), chronic obstructive pulmonary disease (COPD), and many other diffuse parenchymal lung diseases, some of which are very common, the available data is limited. In this paper, we try to browse in the latest available data regarding the occurrence, pathogenesis, and treatment of PH in chronic parenchymal lung diseases.
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Massey H, Darby M, Edey A. Thoracic complications of rheumatoid disease. Clin Radiol 2012; 68:293-301. [PMID: 22998801 DOI: 10.1016/j.crad.2012.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/11/2012] [Accepted: 07/09/2012] [Indexed: 01/15/2023]
Abstract
Rheumatoid arthritis is a relatively common multisystem disease associated with significant mortality and morbidity. Thoracic disease, both pleural and pulmonary, is a frequent extra-articular manifestation of rheumatoid arthritis and responsible for approximately 20% of rheumatoid-associated mortality. Rheumatoid disease and its associated therapies can affect all compartments of the lung inciting a range of stereotyped pathological responses and it is not infrequent for multiple disease entities to co-exist. In some instances, development of pulmonary complications may precede typical rheumatological presentation of the disease and be the first indication of an underlying connective tissue disease. The spectrum of thoracic disease related to rheumatoid arthritis is reviewed.
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Affiliation(s)
- H Massey
- Department of Radiology, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
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The estimated pulmonary artery pressure can be elevated in Behçet’s syndrome. Respir Med 2011; 105:1739-47. [DOI: 10.1016/j.rmed.2011.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 07/26/2011] [Accepted: 07/27/2011] [Indexed: 11/22/2022]
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Miyamichi-Yamamoto S, Fukumoto Y, Sugimura K, Ishii T, Satoh K, Miura Y, Tatebe S, Nochioka K, Aoki T, Do E Z, Shimokawa H. Intensive immunosuppressive therapy improves pulmonary hemodynamics and long-term prognosis in patients with pulmonary arterial hypertension associated with connective tissue disease. Circ J 2011; 75:2668-74. [PMID: 21873802 DOI: 10.1253/circj.cj-11-0473] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) remains a serious disease characterized by elevated pulmonary artery pressure (PAP) and increased pulmonary vascular resistance (PVR). Among its subtypes, PAH associated with connective tissue disease (CPAH) has the worse prognosis, because of resistance to conventional vasodilator therapy. We hypothesized that intensive immunosuppressive therapy (IIT) could improve the pulmonary hemodynamics in CPAH. METHODS AND RESULTS In our pulmonary hypertension (PH) cohort of 182 patients, we evaluated 13 consecutive patients with CPAH who received IIT combined with cyclophosphamide and glucocorticosteroids (IIT group, mean age 45 ± 8 years, 12 females and 1 male). We compared them with 8 historical controls (control group: mean age 52 ± 18 years, 8 females) for pulmonary hemodynamics and prognosis. Both groups were treated with conventional vasodilator therapy. Although the mean PAP (mPAP) remained unchanged in the control group, IIT significantly decreased mPAP (40 ± 9 to 29 ± 11 mmHg, P < 0.01) and tended to decrease PVR (700 ± 434 to 481 ± 418 dyne·s·cm⁻⁵, P=0.07). Importantly, in 6 of the 13 patients in the IIT group, mPAP was almost normalized (< 25 mmHg) and remained stabilized for more than 1 year. Furthermore, the IIT group showed significantly better prognosis compared with the control group (P<0.01). CONCLUSIONS These results suggest that IIT as well as conventional vasodilator therapy improves the pulmonary hemodynamics and long-term prognosis of patients with CPAH.
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Amital A, Shitrit D, Adir Y. The lung in rheumatoid arthritis. Presse Med 2010; 40:e31-48. [PMID: 21196098 DOI: 10.1016/j.lpm.2010.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/05/2010] [Accepted: 11/08/2010] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.
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Affiliation(s)
- Anat Amital
- Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
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Pulmonary arterial hypertension in systemic sclerosis. Autoimmun Rev 2010; 9:761-70. [PMID: 20601197 DOI: 10.1016/j.autrev.2010.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 06/13/2010] [Indexed: 12/16/2022]
Abstract
Pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) is a complex clinical situation resulting from restricted flow through the pulmonary arterial circulation ending in increased pulmonary vascular resistance and right heart failure. PAH is a common and life-threatening complication in connective tissue diseases, specifically in SSc if not treated rapidly and adequately. Based on the emerging knowledge in SSc epidemiology by large scale patient cohorts such as EUSTAR, of PAH pathophysiology and advances in cardiopulmonary diagnostic techniques, several novel treatment approaches have been examined and have proceeded to licensing and daily use in the clinical practice. Amongst them are different endothelin receptor antagonists and PDE-5 inhibitors, but several other ideas are being currently pursued to improve the long-term outcome of the affected patients.
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Liang KP, Myasoedova E, Crowson CS, Davis JM, Roger VL, Karon BL, Borgeson DD, Therneau TM, Rodeheffer RJ, Gabriel SE. Increased prevalence of diastolic dysfunction in rheumatoid arthritis. Ann Rheum Dis 2010; 69:1665-70. [PMID: 20498217 DOI: 10.1136/ard.2009.124362] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the prevalence of left ventricular (LV) diastolic dysfunction in subjects with and without rheumatoid arthritis (RA), among those with no history of heart failure (HF), and to determine risk factors for diastolic dysfunction in RA. METHODS A cross-sectional, community-based study comparing cohorts of adults with and without RA and without a history of HF was carried out. Standard two-dimensional/Doppler echocardiography was performed in all participants. Diastolic dysfunction was defined as impaired relaxation (with or without increased filling pressures) or advanced reduction in compliance or reversible or fixed restrictive filling. RESULTS The study included 244 subjects with RA and 1448 non-RA subjects. Mean age was 60.5 years in the RA cohort (71% female) and 64.9 years (50% female) in the non-RA cohort. The vast majority (>98%) of both cohorts had preserved ejection fraction (EF> or =50%). Diastolic dysfunction was more common in subjects with RA at 31% compared with 26% (age and sex adjusted) in non-RA subjects (OR=1.6; 95% CI 1.2 to 2.4). Patients with RA had significantly lower LV mass, higher pulmonary arterial pressure and higher left atrial volume index than non-RA subjects. RA duration and interleukin 6 (IL-6) level were independently associated with diastolic dysfunction in RA even after adjustment for cardiovascular risk factors. CONCLUSION Subjects with RA have a higher prevalence of diastolic dysfunction than those without RA. RA duration and IL-6 are independently associated with diastolic dysfunction, suggesting the impact of chronic autoimmune inflammation on myocardial function in RA. Clinical implications of these findings require further investigation.
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Affiliation(s)
- Kimberly P Liang
- Department of Health Sciences Research, Mayo Clinic, Mayo Clinic College of Medicine, 200 First Street SW, Rochester MN 55905, USA
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Chatterjee S, Farver C. Severe pulmonary hypertension in Anti-Jo-1 syndrome. Arthritis Care Res (Hoboken) 2010; 62:425-9. [PMID: 20391490 DOI: 10.1002/acr.20109] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Soumya Chatterjee
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of Rheumatic and Immunologic Diseases, Orthopedics and Rheumatology Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A50, Cleveland, OH 44195, USA.
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Davis JM, Roger VL, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. The presentation and outcome of heart failure in patients with rheumatoid arthritis differs from that in the general population. ACTA ACUST UNITED AC 2010; 58:2603-11. [PMID: 18759286 DOI: 10.1002/art.23798] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the clinical presentation, management, and outcome of heart failure in patients with rheumatoid arthritis (RA) compared with non-RA patients. METHODS We conducted a community-based cohort study in the setting of Olmsted County, Minnesota, from 1979 to 2000. One hundred three patients with RA and 852 non-RA patients with incident heart failure (physician diagnosed and Framingham criteria validated) were compared. Age- and sex-adjusted rates/frequencies and multivariable logistic regression models were used to compare the clinical features and mortality of heart failure following its onset in the 2 groups of patients. RESULTS The patients with RA were more often female and less frequently were obese, were hypertensive, or had ischemic heart disease. Patients with RA and heart failure had fewer typical symptoms and signs and were less likely to undergo echocardiography compared with non-RA patients. After adjusting for differences, the patients with RA and heart failure were more likely to have preserved ejection fraction (>or=50%). Mortality at 1 year following heart failure was higher in patients with RA compared with non-RA patients (35% versus 19%; multivariable hazard ratio 1.89, 95% confidence interval 1.26-2.84). CONCLUSION Both the clinical presentation and the outcome of heart failure differ significantly between patients with and those without RA from the same population. Among patients with RA, the presentation of heart failure is more subtle, myocardial function is more likely preserved, while mortality from heart failure is significantly higher. These findings emphasize the importance of more vigilant screening of patients with RA for early signs of heart failure and may represent important insights into the biologic mechanisms underlying heart failure in RA.
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Abstract
Collagen vascular disease is one of the most common causes of chronic infiltrative lung disease. Patterns of lung injury from collagen vascular disease include nonspecific interstitial pneumonia (NSIP), usual interstitial pneumonia, organizing pneumonia, bronchiectasis, obliterative bronchiolitis, and pulmonary arterial hypertension. The prevalence of each entity varies according to the specific disease entity. NSIP and pulmonary hypertension are common in scleroderma, whereas usual interstitial pneumonia, bronchiectasis, and obliterative bronchiolitis are commonly found in rheumatoid arthritis. In systemic lupus erythematosus, pleural effusions and pulmonary hemorrhage are the salient features. In polymyositis, a combination of organizing pneumonia and NSIP is characteristic. Sjögren syndrome is characterized by bronchiectasis and lymphoid interstitial pneumonia, often associated with thin-walled cysts. Ankylosing spondylitis is associated with upper lobe fibrosis, and may be complicated by mycetoma.
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Affiliation(s)
- David A Lynch
- Division of Radiology, National Jewish Health, Denver, CO 80206, USA.
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Simonneau G, Robbins IM, Beghetti M, Channick RN, Delcroix M, Denton CP, Elliott CG, Gaine SP, Gladwin MT, Jing ZC, Krowka MJ, Langleben D, Nakanishi N, Souza R. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2009; 54:S43-S54. [PMID: 19555858 DOI: 10.1016/j.jacc.2009.04.012] [Citation(s) in RCA: 1430] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 04/15/2009] [Indexed: 01/15/2023]
Abstract
The aim of a clinical classification of pulmonary hypertension (PH) is to group together different manifestations of disease sharing similarities in pathophysiologic mechanisms, clinical presentation, and therapeutic approaches. In 2003, during the 3rd World Symposium on Pulmonary Hypertension, the clinical classification of PH initially adopted in 1998 during the 2nd World Symposium was slightly modified. During the 4th World Symposium held in 2008, it was decided to maintain the general architecture and philosophy of the previous clinical classifications. The modifications adopted during this meeting principally concern Group 1, pulmonary arterial hypertension (PAH). This subgroup includes patients with PAH with a family history or patients with idiopathic PAH with germline mutations (e.g., bone morphogenetic protein receptor-2, activin receptor-like kinase type 1, and endoglin). In the new classification, schistosomiasis and chronic hemolytic anemia appear as separate entities in the subgroup of PAH associated with identified diseases. Finally, it was decided to place pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis in a separate group, distinct from but very close to Group 1 (now called Group 1'). Thus, Group 1 of PAH is now more homogeneous.
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Affiliation(s)
- Gérald Simonneau
- Centre National de Référence des Maladies Vasculaires Pulmonaires, Université Paris-Sud Hôpital Antoine Béclère, Clamart, France.
| | - Ivan M Robbins
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Hôpital des Enfants, University Hospital of Geneva, Geneva, Switzerland
| | - Richard N Channick
- Division of Pulmonary and Critical Care Medicine, UCSD Medical Center, La Jolla, California
| | - Marion Delcroix
- Center for Pulmonary Vascular Disease, Department of Pneumology, Gasthuisberg University Hospital, Leuven, Belgium
| | | | - C Gregory Elliott
- Department of Medicine, Intermountain Medical Center, University of Utah, Salt Lake City, Utah
| | - Sean P Gaine
- Department of Respiratory Medicine, Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland
| | - Mark T Gladwin
- Pulmonary, Allergy, and Critical Care Medicine, Hemostasis and Vascular Biology Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zhi-Cheng Jing
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Michael J Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David Langleben
- Center for Pulmonary Vascular Disease, Sir Mortimer B. Davis Jewish General Hospital, Montréal, Québec, Canada
| | - Norifumi Nakanishi
- Division of Cardiology and Pulmonary Circulation, Department of Internal Medicine National Cardiovascular Center, Osaka, Japan
| | - Rogério Souza
- Pulmonary Department, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
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Tanasescu C, Jurcut C, Jurcut R, Ginghina C. Vascular disease in rheumatoid arthritis: from subclinical lesions to cardiovascular risk. Eur J Intern Med 2009; 20:348-54. [PMID: 19524171 DOI: 10.1016/j.ejim.2008.09.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 07/31/2008] [Accepted: 09/04/2008] [Indexed: 12/13/2022]
Abstract
Rheumatoid arthritis (RA) is one of the most prevalent and complex inflammatory diseases affecting primarily the joints, but also associating several extra-articular features. The vascular disease in RA encompasses a large spectrum of lesions, from rheumatoid vasculitis to atherosclerotic lesions. During the last years the importance of the vascular disease related to atherosclerosis in terms of cardiovascular morbidity and global mortality became evident in RA. The inflammatory hypothesis of atherosclerosis in RA implies that mediators originating from the inflamed synovial tissue or from the liver may have systemic vascular consequences, leading to endothelial dysfunction and structural abnormalities of the vessels. Hence, the global management of patients with RA must include the improvement of cardiovascular risk in parallel with the management of joint disease.
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Affiliation(s)
- Coman Tanasescu
- Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania.
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Abstract
INTRODUCTION Lung disease is the most frequent and among the most severe extra-articular manifestation of rheumatoid arthritis (RA). Several interesting advances have been made in recent years in our understanding of this respiratory disease. STATE OF ART 1. The induction of BALT responsible for follicular lymphoid infiltrates has been demonstrated in the wall of respiratory bronchioles. These lymphoid infiltrates are similar to synovial and skin cellular infiltrates and secrete specific markers of RA (citrullinated proteins). These data strongly suggest a common pathogenic mechanism for RA in the joints and in other sites, such as the lung. 2. Improvements in high resolution computed tomography (HR- CT) increased the sensitivity of diagnosis. CT evidence of pulmonary disease is present in 50% of RA patients, but only 10% of these patients have clinical symptoms. The different lung manifestations, frequently combined, have been clearly described: pulmonary nodules (20%); small airways disease (30%): bronchiolitis, bronchiolectasis, and bronchiectasis; diffuse interstitial pneumonia of various types (20%). 3. Predictors of progression and therapeutic response remain unknown. Therefore treatment is empirical and based on usual indications and on drugs used in idiopathic fibrosis and other connective tissue pulmonary pathologies. CONCLUSIONS New biological drugs such as TNF blocking agents or anti CD20 antibody could be beneficial. Infections and drug-induced pneumonitis are not described in this review but must be considered systematically when an RA patient presents with lung involvement.
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Abstract
PURPOSE OF REVIEW To examine the role of lung disease in rheumatoid arthritis from a clinical, epidemiologic, pathophysiologic, and therapeutic perspective. RECENT FINDINGS Lung disease in rheumatoid arthritis is pleomorphic and has a marked adverse impact on the morbidity and premature mortality of patients with this disease. Recent advances in the understanding of the pathophysiology of lung disease associated with rheumatoid arthritis reveal it to be characterized by more active cellular infiltrates of both T cells and B cells, as well as other immunologically active cells, including mast cells, than many of the other forms of interstitial lung disease. Satisfactory treatment is lacking; available biologic response modifiers have been reported to have both beneficial and adverse effects on the lung. Newer approaches targeting cellular immunologic dysfunction including T-cell-directed and B-cell-directed therapies hold the promise of reducing lung damage related to the underlying disease. SUMMARY Lung disease in rheumatoid arthritis is a heterogeneous and oftentimes serious condition, with a profound impact on patient wellbeing and survival. Advances in the understanding of its etiology and targeted application of available, as well as development of new, more specific therapeutics will be of benefit to patients with rheumatoid arthritis who are suffering from lung disease.
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Increased frequency of pulmonary hypertension in psoriasis patients. Arch Dermatol Res 2008; 300:435-40. [DOI: 10.1007/s00403-008-0859-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 04/04/2008] [Accepted: 04/17/2008] [Indexed: 10/22/2022]
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Udayakumar N, Venkatesan S, Rajendiran C. Pulmonary hypertension in rheumatoid arthritis--relation with the duration of the disease. Int J Cardiol 2007; 127:410-2. [PMID: 17689710 DOI: 10.1016/j.ijcard.2007.04.084] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Accepted: 04/12/2007] [Indexed: 10/23/2022]
Abstract
Isolated pulmonary hypertension with clinical implication is rare in rheumatoid arthritis. We sought to study the prevalence of pulmonary arterial hypertension in an unselected population of 45 patients with rheumatoid arthritis (classified according to the ARA criteria) without cardiac disease and corresponding age and sex matched controls by Doppler echocardiography. The pulmonary artery systolic pressure was higher in patients with Rheumatoid Arthritis (27.49+/-12.66 mm Hg) than in controls (20.40+/-8.88) (p=0.003). Incidence of pulmonary artery systolic pressure>30 mm Hg suggesting pulmonary hypertension was significantly higher in patients with RA (26.7% versus 4.5% in controls; p=0.03) and 20% of patients had pulmonary hypertension without lung disease or cardiac disease evident on pulmonary function testing, and echocardiogram respectively. There was also a strong correlation between the pulmonary artery pressure and the disease duration (r=0.68, p<0.0001) suggesting a subclinical involvement of the pulmonary vasculature with disease progression and may be relevant to the high incidence of cardiovascular deaths observed in patients with Rheumatoid Arthritis.
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Shariff N, Kumar A, Narang R, Malhotra A, Mukhopadhyaya S, Sharma SK. A study of pulmonary arterial hypertension in patients with rheumatoid arthritis. Int J Cardiol 2007; 115:75-6. [PMID: 16737753 DOI: 10.1016/j.ijcard.2006.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Accepted: 01/08/2006] [Indexed: 11/19/2022]
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Abstract
The number of publications in the field of pulmonary hypertension has increased exponentially over the past 10 years. As a consequence our understanding of the condition has advanced enormously. Pulmonary hypertension is now recognised as an uncommon and treatable disease, rather than a rare lethal disease. Progress in the field of connective tissue disease associated pulmonary hypertension has been less consistent. This paper covers the most influential published data on connective tissue associated pulmonary hypertension, and adds some insights from data available on file with pharmaceutical companies and from our database at the Royal Free Hospital. The following conclusions may be drawn. First, the prevalence of pulmonary hypertension associated with connective tissue diseases is lower than generally accepted. Second, the natural history and prognosis, at least in the setting of systemic sclerosis, is worse than seen in patients with idiopathic pulmonary hypertension. Finally, widespread and timely availability of disease modifying therapies substantially improves the prognosis for patients with systemic sclerosis associated pulmonary hypertension, in the treatment population and consequentially in the population as a whole. Identifying patients with very early disease and analysing the drivers for disease progression, is the key to further progress. Early diagnosis is most readily achieved in patients with connective tissue disease associated pulmonary hypertension. This represents an opportunity for those with an interest in academic rheumatology.
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Affiliation(s)
- J G Coghlan
- Department of Cardiology, Royal Free Hospital, London, UK.
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Lettieri CJ, Nathan SD, Barnett SD, Ahmad S, Shorr AF. Prevalence and outcomes of pulmonary arterial hypertension in advanced idiopathic pulmonary fibrosis. Chest 2006; 129:746-52. [PMID: 16537877 DOI: 10.1378/chest.129.3.746] [Citation(s) in RCA: 528] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The development of pulmonary arterial hypertension (PAH) can complicate many interstitial lung diseases, including idiopathic pulmonary fibrosis (IPF). We sought to characterize the prevalence of PAH and its impact on survival in patients with advanced IPF. DESIGN Retrospective analysis of consecutive IPF patients undergoing pretransplantation right heart catheterization. SETTING Lung transplant and IPF referral center. METHODS PAH was defined as a mean pulmonary artery pressure (mPAP) of > 25 mm Hg. We compared demographic, spirometric, 6-min walk test (6MWT) results, and survival outcomes between those with PAH and those without PAH. MEASUREMENTS AND RESULTS Seventy-nine patients were included in the study. PAH was present in 31.6% of patients (mean [+/- SD] mPAP, 29.5 +/- 3.3 vs 19.1 +/- 3.7 mm Hg, respectively). Those patients with PAH had a lower mean diffusing capacity of the lung for carbon monoxide (Dlco) (37.6 +/- 11.3% vs 31.1 +/- 10.1%, respectively; p = 0.04) and were more likely to require supplemental oxygen (66.7% vs 17.6%, respectively; p < 0.0001). Mean distance walked (143.5 +/- 65.5 vs 365.9 +/- 81.8 m, respectively; p < 0.001) and mean pulse oximetric saturation nadir (80.1 +/- 3.7% vs 88.0 +/- 3.5%, respectively; p < 0.001) during the 6MWT were also lower among those with PAH. PAH was associated with a greater risk of death during the study period (mortality rate, 60.0% vs 29.9%, respectively; odds ratio, 2.6; 95% confidence interval [CI], 2.3 to 3.1; p = 0.001). One-year mortality rates were higher in those with PAH (28.0% vs 5.5%, respectively; p = 0.002). As a predictor of mortality, PAH had a sensitivity, specificity, and accuracy of 57.1%, 79.3%, and 73.4%, respectively. There was a linear correlation between mPAP and outcomes with higher pressures associated with a greater risk of mortality (hazard ratio, 1.09; 95% CI, 1.02 to 1.16). FVC and Dlco did not predict outcomes. CONCLUSIONS PAH is common in advanced cases of IPF and significantly impacts survival. A reduced Dlco, supplemental oxygen requirement, or poor 6-min walk performance should raise suspicion of the presence of underlying PAH. Identifying PAH might be an important adjunct in monitoring disease progression, triaging for transplantation, and guiding therapy.
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Affiliation(s)
- Christopher J Lettieri
- Walter Reed Army Medical Center, Department of Pulmonary & Critical Care, 6900 Georgia Avenue NW, Washington, DC 20307, USA.
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Castro GWR, Appenzeller S, Bertolo MB, Costallat LTL. Isolated pulmonary hypertension secondary to rheumatoid arthritis. Clin Rheumatol 2005; 25:901-3. [PMID: 16308666 DOI: 10.1007/s10067-005-0089-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2005] [Accepted: 06/01/2005] [Indexed: 10/25/2022]
Abstract
The authors report a case of a woman with pulmonary hypertension secondary to rheumatoid arthritis, whose treatment with azathioprine resulted in normalization of pulmonary artery pressure and resolution of clinical symptoms. Different etiologies for pulmonary hypertension are discussed and literature review is presented.
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Affiliation(s)
- Glaucio W R Castro
- Unit of Rheumatology, Department of Internal Medicine, State University of Campinas, Campinas, Brazil
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Rocks SA, Davies CA, Hicks SL, Webb AJ, Klocke R, Timmins GS, Johnston A, Jawad ASM, Blake DR, Benjamin N, Winyard PG. Measurement of S-nitrosothiols in extracellular fluids from healthy human volunteers and rheumatoid arthritis patients, using electron paramagnetic resonance spectrometry. Free Radic Biol Med 2005; 39:937-48. [PMID: 16140213 DOI: 10.1016/j.freeradbiomed.2005.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Revised: 04/19/2005] [Accepted: 05/09/2005] [Indexed: 01/14/2023]
Abstract
In human tissues, S-nitrosothiols (RSNOs) are generated by the nitric oxide (NO.)-dependent S-nitrosation of thiol-containing species. Here, a novel electron paramagnetic resonance spectrometry assay for RSNOs is described, together with its application to studies of human health and disease. The assay involves degrading RSNOs using N-methyl-d-glucamine dithiocarbamate (MGD) at high pH and spin trapping the NO. released using (MGD)2-Fe2+. Because dietary nitrate might contribute to tissue RSNOs, the assay was used to monitor the effect of Na15NO3 ingestion on plasma and gastric juice RSNOs in healthy human volunteers. Na15NO3 ingestion (2 mmol) increased gastric RS15NO concentrations (p<0.01), but there was no significant effect on plasma RS15NO concentrations. Having established that dietary nitrate was not a confounding factor, we applied the RSNO assay to matched plasma and knee-joint synovial fluid (SF) from rheumatoid arthritis (RA) patients, with healthy subjects as controls. Clinical markers of RA inflammatory disease activity were quantified, as were plasma and SF NO2- and NO3-. Median RSNO concentrations were 0 (interquartile range 68) nM, 109 (282) nM, and 309 (470) nM in normal plasma, RA plasma, and SF, respectively. The median RSNO concentration was significantly elevated in RA SF compared with RA plasma (p<0.05) and in RA plasma compared with normal plasma (p<0.05). SF RSNO concentrations correlated positively with SF neutrophil counts (rs=0.55, p<0.05) and inversely with blood hemoglobin concentrations (rs=-0.52, p<0.05), but not with NO2- or NO3-. Thus the raised levels of RSNOs in RA SF correlate with some established markers of inflammation, suggesting the described RSNO assay may have applications in rapid clinical monitoring of NO metabolism in human inflammatory conditions.
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Affiliation(s)
- Sophie A Rocks
- Bone and Joint Research Unit, William Harvey Research Institute, Barts and The London, Queen Mary's School of Medicine and Dentistry, London, UK
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