Cardiac Magnetic Resonance Imaging T1 and T2 Mapping in Systemic Lupus Erythematosus in Relation to Antimalarial Treatment

Differences in myocardial involvement between new onset and longstanding systemic lupus erythematosus patients assessed by cardiovascular magnetic resonance

Objectives

Subclinical myocardial involvement is common in systemic lupus erythematosus (SLE), but differences between new onset and longstanding SLE are not fully elucidated. This study compared myocardial involvement in new onset versus longstanding SLE using cardiovascular magnetic resonance (CMR).

Materials and methods

We prospectively enrolled 24 drug-naïve new onset SLE patients, 27 longstanding SLE patients, and 20 healthy controls. All participants underwent clinical evaluation and CMR examination. We analyzed left ventricular (LV) morphological, functional parameters, and tissue characterization parameters: native T1, T2, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE).

Results

Both new onset and longstanding SLE groups showed elevated native T1, T2, and ECV values compared to the control group (all P < 0.05). Additionally, the new onset SLE group exhibited higher T2 values compared to the longstanding SLE group [55.3 vs. 52.8 ms, P < 0.05]. The new onset group also demonstrated higher left ventricular (LV) end-diastolic volume index (LVEDVi), LV end-systolic volume index (LVSVi), and LV mass index (LVMi) than controls (all P < 0.05), with LVEDVi significantly higher than in the longstanding group (P < 0.05).

Conclusion

CMR tissue characterization imaging can detect early myocardial involvement in patients with new onset and longstanding SLE. Patients with new onset SLE exhibit more pronounced myocardial edema than those with longstanding SLE. This suggests that SLE patients are at risk of myocardial damage at various stages of the disease, underscoring the need for early monitoring and long-term management to prevent the progression of myocardial remodeling.

Diagnostic and prognostic value of quantitative cardiac magnetic resonance imaging biomarkers in systemic lupus erythematosus: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to compare CMR imaging biomarkers between SLE patients and matched controls.

MATERIALS AND METHODS

Electronic databases were systematically searched from inception until November 2023. All studies reporting CMR imaging data in SLE patients were included. PRISMA guidelines were followed, and risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. CMR findings of SLE patients were compared to that of matched controls. Clinical features associated with CMR biomarkers were collected in a qualitative analysis.

RESULTS

A total of 64 studies were included in the systematic review pooling 3304 individuals including 1870 SLE patients. Of these, 19 case-control studies were included in the comparative meta-analysis (1576 individuals, including 884 SLE patients). Compared to controls, left ventricular (LV) ejection fraction (62% vs. 64%, p = 0.001) and indexed end-diastolic volume (77 vs. 72 mL/m2, p = 0.006) were significantly altered in SLE patients. Late gadolinium enhancement (LGE) extent was higher in SLE patients (LGE mass/total LV mass: 3.5% vs. 1.1%, p = 0.009). Native T1 and T2 relaxation times were significantly higher in SLE patients (native T1 [1.5 T]: 1005 vs. 982 ms, p = 0.02; native T1 [3 T]: 1267 vs. 1140 ms, p < 0.001; T2 [all fields]: 58 vs. 51 ms, p < 0.001). Three studies found an association between disease activity and increased T2 relaxation times. Two studies identified an association between clinical outcomes and CMR parameters.

CONCLUSIONS

While CMR-assessed ventricular function and volumes only slightly differed in SLE patients when compared to controls, myocardial tissue characterization parameters were significantly modified and associated with disease activity.

KEY POINTS

Question What are the diagnostic and prognostic values of cardiac magnetic resonance (CMR) quantitative parameters in systemic lupus erythematosus (SLE) patients? Findings Myocardial tissue characterization parameters are significantly altered in SLE patients and associated with disease activity. Clinical relevance CMR imaging demonstrates subclinical cardiac alterations in systemic lupus erythematosus patients. Additional studies are required to further demonstrate the prognostic value of CMR in SLE.

Coexistent pleural effusion is found to be associated with aggravated subclinical myocardial injury in systemic lupus erythematous using cardiovascular magnetic resonance imaging

Objective

Pleural effusion (PE) is a common pulmonary manifestation in patients with systemic lupus erythematosus (SLE), and is associated with disease activity. However, little is known regarding the additive effects of PE on cardiac function. Therefore, this study aimed to investigate multi-parameter cardiovascular magnetic resonance imaging (CMR) findings in SLE patients with PE and to explore whether cardiac involvement is associated with PE.

Methods

Patients with SLE and age-matched/sex-matched healthy controls were included in this study. Patients with SLE were diagnosed according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria. Moreover, the PE diagnosis was based on computed tomography, and the height of the effusion was > 5 mm. All enrolled individuals underwent CMR imaging, including cine and late gadolinium enhancement (LGE), T1, and T2 mapping imaging. The left and right ventricular function, LGE, T1, extracellular volume (ECV), and T2 values were evaluated.

Results

A total of 111 patients with SLE were enrolled, of whom 26 (23.42%) had PE. White cell count, hemoglobin, CRP, ESR, and lactate dehydrogenase levels were higher in SLE patients with PE than in SLE patients without PE (P<0.05). LGE was more prevalent in SLE patients with PE compared with those without PE (P<0.001). In addition, Native T1 (1348 ± 65 ms vs. 1284 ± 67 ms vs. 1261 ± 41 ms; P<0.001), ECV (31.92 ± 4.16% vs. 28.61 ± 3.60% vs. 26.54 ± 2.94%; P<0.001), and T2 (44.76 ± 3.68 ms vs. 41.96 ± 3.62 ms vs. 39.21 ± 2.85 ms; P<0.001) values were high in SLE patients with PE, intermediate in SLE patients without PE, and the lowest in the control group. Linear regression analysis demonstrated that PE was independently associated with LGE (β=0.329; P<0.05), T1 (β=0.346; P<0.05), ECV (β=0.353; P<0.05), and T2 (β=0.201; P<0.05).

Conclusions

SLE patients with PE have a higher prevalence of LGE and more diffuse myocardial fibrosis and edema than SLE patients without PE. Moreover, PE is associated with increased diffuse interstitial fibrosis and edema.

Cardiovascular magnetic resonance imaging and clinical follow-up in patients with clinically suspected myocarditis after COVID-19 vaccination

BACKGROUND

The purpose of this study was to evaluate cardiovascular magnetic resonance (CMR) findings and their relationship to longer-term clinical outcomes in patients with suspected myocarditis following coronavirus disease 2019 (COVID-19) vaccination.

METHODS

Consecutive adult patients who underwent clinically indicated CMR for evaluation of suspected myocarditis following messenger ribonucleic acid (mRNA)-based COVID-19 vaccination at a single center between 2021 and 2022 were retrospectively evaluated. Patients were classified based on the revised Lake Louise criteria for T1-based abnormalities (late gadolinium enhancement [LGE] or high T1 values) and T2-based abnormalities (regional T2-hyperintensity or high T2 values).

RESULTS

Eighty-nine patients were included (64% [57/89] male, mean age 34 ± 13 years, 38% [32/89] mRNA-1273, and 62% [52/89] BNT162b2). On baseline CMR, 42 (47%) had at least one abnormality; 25 (28%) met both T1- and T2-criteria; 17 (19%) met T1-criteria but not T2-criteria; and 47 (53%) did not meet either. The interval between vaccination and CMR was shorter in those who met T1- and T2-criteria (28 days, IQR 8-69) compared to those who met T1-criteria only (110 days, IQR 66-255, p < 0.001) and those who did not meet either (120 days, interquartile range (IQR) 80-252, p < 0.001). In the subset of 21 patients who met both T1- and T2-criteria at baseline and had follow-up CMR, myocardial edema had resolved and left ventricular ejection fraction had normalized in all at median imaging follow-up of 214 days (IQR 132-304). However, minimal LGE persisted in 10 (48%). At median clinical follow-up of 232 days (IQR 156-405, n = 60), there were no adverse cardiac events. However, mild cardiac symptoms persisted in 7 (12%).

CONCLUSION

In a cohort of patients who underwent clinically indicated CMR for suspected myocarditis following COVID-19 vaccination, 47% had at least one abnormality at baseline CMR. Detection of myocardial edema was associated with the timing of CMR after vaccination. There were no adverse cardiac events. However, minimal LGE persisted in 48% at follow-up.

Myocardial fibrosis associates with lupus anticoagulant in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that carries increased risk of cardiovascular disease; however, the underlying pathophysiological mechanisms remain poorly understood. We aimed to investigate the prevalence and degree of myocardial fibrosis in SLE patients and associated disease characteristics. Forty-nine SLE patients (89% female, mean age 52 ± 13 years, median disease duration 19 (11-25) years) and 79 sex-and age-matched healthy controls were included. CMR with T1 mapping was performed on SLE patients and healthy controls. Fifty-one SLE patients received gadolinium contrast for the evaluation of late gadolinium enhancement (LGE) and extra cellular volume (ECV). Multiple linear regression analyses were performed to investigate the association between markers of myocardial fibrosis on CMR (LGE, T1, ECV) and SLE-related variables [clinical disease activity, lupus nephritis, chronic kidney disease, anti-cardiolipin and/or anti-beta-2 glycoprotein I antibodies, and lupus anticoagulant (LAC)] with adjustment for traditional risk factors. T1 values were elevated in SLE patients compared to healthy controls (1031 ± 36 ms vs. 1019 ± 25 ms, p = 0.01). LGE was present in 20% of SLE patients who received gadolinium contrast. On multivariable analysis, LAC was associated with LGE in SLE patients (β = 3.87, p = 0.02). Neither T1 nor ECV associated with SLE disease characteristics; however, there was a trend towards an association between LAC and T1 (β = 16.9, p = 0.08). SLE patients displayed signs of myocardial fibrosis on CMR that were associated with the presence of LAC. These findings support the pathophysiological understanding of LAC as a mediator of microvascular and subsequent myocardial dysfunction.

The Presence, Location, and Degree of Late Gadolinium Enhancement in Relation to Myocardial Dysfunction and Poor Prognosis in Patients with Systemic Lupus Erythematosus

Patients with systemic lupus erythematosus (SLE) typically develop myocardial fibrosis. No studies have investigated the clinical significance of the presence, location, and degree of fibrosis in SLE patients. Seventy-four SLE patients were included. Thirty-seven non-autoimmune disease patients and thirty-seven healthy individuals were included as controls. Myocardial fibrosis was evaluated at cardiac magnetic resonance via a qualitative and quantitative assessment of late gadolinium enhancement (LGE). Myocardial function was measured via speckle-tracking echocardiography. All patients were followed up for the occurrence of major adverse cardiac events (MACE). The presence, locations, and degrees of LGE disturbed regional and global myocardial function. The presence of LGE, left ventricular free-wall LGE (LVFW LGE), and severe LGE were all independent predictors of MACE in SLE patients [LGE presence HR: 3.746 (1.434-9.79), p = 0.007; LVFW LGE HR: 2.395 (1.023-5.606), p = 0.044; severe LGE HR: 3.739 (1.241-11.266), p = 0.019]. LGE combined with SLE-related organ damage identified patients at high risk of MACE (p < 0.001). In conclusion, the presence, degree, and location of LGE were associated with myocardial dysfunction. The presence, location, and degree of LGE had the potential to independently predict poor prognosis and improve risk stratification in SLE patients.