Subclinical Myocardial Dysfunction Assessment Using Speckle Tracking Echocardiography in Patients With Psoriasis: A Pilot Meta-Analysis

INTRODUCTION

Psoriasis is a systemic inflammatory disease associated with elevated cardiovascular risk due to inflammatory and oxidative stress. Two-dimensional speckle-tracking echocardiography (2D-STE) can detect both regional and global myocardial strain. Impairment of ventricular strain can assist in the early detection of myocardial dysfunction. Subclinical myocardial dysfunction in psoriasis has not yet been elucidated with inconsistent results.

METHODS

A systematic literature search of various databases was conducted to identify studies comparing global longitudinal strain (GLS) and global circumferential strain (GCS) between patients with psoriasis and healthy controls. Standardized mean differences (SMD) with 95% confidence intervals (CI) were pooled using the inverse-variance random-effects model in Review Manager Software Version 5.4.1.

RESULTS

Eleven studies with 879 participants (501 patients with psoriasis and 378 healthy controls) were included. Psoriasis was associated with a statistically significant reduction in GLS [SMD: -1.04; 95% CI: -1.45, -0.62; p < 0.00001] and GCS [SMD: -0.66; 95% CI: -1.27, -0.05; p = 0.03] compared to healthy controls.

CONCLUSION

This study demonstrated that patients with psoriasis are at an elevated risk of subclinical myocardial dysfunction, as shown by the reduced GLS and GCS. Early assessment of subclinical impairment in psoriasis will allow targeted intervention and may mitigate future adverse cardiovascular events. Prospective studies with larger sample sizes are warranted to validate these results.

Endothelial glycocalyx and microvascular perfusion are associated with carotid intima-media thickness and impaired myocardial deformation in psoriatic disease

Psoriatic disease is associated with vascular and myocardial dysfunction. We aimed to evaluate endothelial glycocalyx barrier properties and microvascular perfusion in psoriatic patients, as well as their correlation with carotid intima-media thickness (cIMT) and markers of left ventricular (LV) myocardial deformation. We examined 297 psoriatic patients and 150 controls, adjusted for age, sex, and atherosclerotic risk factors. The severity of psoriatic disease was estimated using the psoriasis area and severity index (PASI). Perfused boundary region (PBR), a marker of glycocalyx barrier function, was measured non-invasively in sublingual microvessels with a diameter 5-25 μm using Sidestream Dark Field camera (Microscan, GlycoCheck). Increased PBR indicates reduced glycocalyx thickness. Indexes of microvascular perfusion, including red blood cells filling (RBCF) and functional microvascular density, were also calculated. We measured cIMT, coronary flow reserve (CFR) and markers of myocardial deformation by speckle-tracking imaging, namely global longitudinal strain (GLS) and percentage changes between peak twisting and untwisting at mitral valve opening (%dpTw-Utw_MVO). Compared to controls, psoriatic patients had higher PBR_5-25μm (2.13 ± 0.29μm versus 1.78 ± 0.25μm, p < 0.001) and lower RBCF and functional microvascular density (p < 0.001). Increased PASI was associated with elevated PBR and more impaired cIMT and GLS (p < 0.05). There was an inverse association of PBR with RBCF and functional microvascular density (p < 0.001). In psoriatic population, increased PBR was related to increased cIMT, reduced CFR, impaired GLS and decreased %dpTw-Utw_MVO (p < 0.001). Glycocalyx thickness is reduced in psoriatic patients, which in turn impairs microvascular perfusion, and is associated with carotid IMT and impaired coronary and myocardial function.Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT02144857.

Incidence of and Risk Factors for Heart Failure in Patients with Psoriatic Disease - A Cohort Study

OBJECTIVES

To assess the incidence and risk factors for heart failure (HF) in patients with psoriatic disease (PsD) and describe their electrocardiographic and echocardiographic findings.

METHODS

A cohort analysis was conducted involving patients with PsD followed prospectively from 1978 to 2018. Participants were assessed according to a standard protocol every 6 to 12-months. The primary outcome was the time to first event of HF, further classified into ischemic and non-ischemic HF (secondary outcomes). The association between cardiovascular risk factors, measures of disease activity and HF events was assessed using Cox proportional hazards regression. Electrocardiographic and echocardiographic findings associated with HF events were described.

RESULTS

A total of 1994 patients with PsD were analyzed with 64 incident HF events (38 ischemic, 26 non-ischemic). The incidence rate of first HF event was 2.85 per 1000 patient years. In all events, most common electrocardiographic findings were atrial fibrillation (22%) and bundle branch blocks (29%). Echocardiogram revealed 37% reduced ejection fraction and 63% preserved ejection fraction. In multivariable analysis, independent risk factors for all HF events were ischemic heart disease, adjusted mean (AM)-tender joint count, AM-swollen joint count, AM-erythrocyte sedimentation rate, AM-C-reactive protein, and physical function (by health assessment questionnaire) (all p<0.05). Minimal disease activity state was protective for all HF (p<0.05).

CONCLUSIONS

Increased risk of HF is associated with a combination of known cardiovascular risk factors and measures of disease activity, particularly in non-ischemic HF. The effect of inflammation on HF may be partially independent of atherosclerotic disease.

Right ventricular dysfunction and remodeling in diabetic cardiomyopathy

The increasing prevalence of diabetic cardiomyopathy (DCM) is an important threat to health worldwide. While left ventricular (LV) dysfunction in DCM is well recognized, the accurate detection, diagnosis, and treatment of changes in right ventricular (RV) structure and function have not been well characterized. The pathophysiology of RV dysfunction in DCM may share features with LV diastolic and systolic dysfunction, including pathways related to insulin resistance and oxidant injury, although the RV has a unique cellular origin and composition and unique biomechanical properties and is coupled to the lower-impedance pulmonary vascular bed. In this review, we discuss potential mechanisms responsible for RV dysfunction in DCM and review the imaging approaches useful for early detection, protection, and intervention strategies. Additional data are required from animal models and clinical trials to better identify the onset and features of altered RV and pulmonary vascular structure and function during the onset and progression of DCM and to determine the efficacy of early detection and treatment of RV dysfunction on clinical symptoms and outcomes.

The conundrum of patients with obesity, exercise intolerance, elevated ventricular filling pressures and a measured ejection fraction in the normal range

Patients with obesity, a reduced exercise capacity, increased cardiac filling pressures and a measured left ventricular ejection fraction in the normal range do not have a homogeneous disorder, but instead, exhibit one of three phenotypes. First, many obese people exhibit sodium retention, plasma volume expansion and cardiac enlargement, and some are likely to have heart failure that is related to hypervolaemia, even though cardiac index and circulating levels of natriuretic peptides are not meaningfully increased. Second, in some middle-aged men and women (particularly those with minimal co-morbidities), levels of natriuretic peptides increase markedly and can lower systemic vascular resistance, thus leading to high-output heart failure (HOHF) and glomerular hyperfiltration. Third, older obese people, particularly women with multiple co-morbidities, exhibit the syndrome of heart failure with a preserved ejection fraction (HFpEF). Despite degrees of plasma volume expansion similar to HOHF, these patients exhibit only modestly increased ventricular dimensions and circulating levels of natriuretic peptides (despite a high prevalence of atrial fibrillation), and glomerular function is characteristically impaired. A conceptual framework is proposed to distinguish among the three phenotypes seen in obese patients with exercise intolerance, increased ventricular filling pressures and a measured left ventricular ejection fraction in the normal range, since they may respond differently to therapeutic interventions. Efforts are needed to enhance the recognition of heart failure in obese people and to ensure that clinical trials that are designed to study patients with HFpEF actually enrol those who have the disease.

Role of galectin-3 in subclinical myocardial impairment in psoriasis

BACKGROUND

Psoriasis has been shown to increase cardiovascular risk, and a contributor to this might be enhanced myocardial fibrosis promoted by the disease-associated pro-inflammatory milieu.

OBJECTIVE

We sought to investigate the relationship of galectin-3 (Gal-3) - a recognized mediator of fibrosis with inflammatory activation and left ventricular (LV) systolic and diastolic function in patients with psoriasis.

METHODS

We enrolled 102 psoriatic patients (mean age: 52.5 ± 12.6 years). Sixty-five age- and sex-matched healthy subjects served as controls. Echocardiographic assessment of myocardial function included estimation of LV longitudinal systolic deformation (GLS) and diastolic indices: tissue e' velocity and E/e' ratio. Laboratory measurements encompassed blood Gal-3, creatinine, glucose, insulin, CRP and erythrocyte sedimentation rate (ESR).

RESULTS

Patients with psoriasis were characterized by elevated Gal-3 (12.3 [9.3-13.4] vs. 6.3 [5.5-9.4] ng/mL in healthy controls, P < 0.001), ESR (17.0 [11.0-29.0] vs. 8.5 [6.0-13.0] mm, respectively, P < 0.001) and CRP (3.1 [1.7-10.6] vs. 1.9 [1.5-4.0] mg/L, respectively, P < 0.001), and reduced GLS (19.9 ± 3.7 vs. 22.0 ± 3.0%, respectively, P < 0.001). Progressive deterioration of GLS was demonstrated across Gal-3 tertiles. Significant associations between GLS and age (beta = -0.21, P < 0.04), Gal-3 (beta = -0.27, P < 0.01), CRP (beta = -0.22, P < 0.03), ESR (beta = -0.25, P < 0.01), waist circumference (beta = -0.22, P < 0.03) and waist-to-hip ratio (beta = -0.20, P < 0.05) were found. Stepwise multiple regression analysis revealed that the independent determinants of GLS in psoriatic patients were Gal-3 (beta = -0.24, P < 0.01) and ESR (beta = -0.21, P < 0.03). Regression-based mediation analysis demonstrated that the relationship between ESR and GLS was partially mediated by Gal-3.

CONCLUSIONS

Subclinical left ventricular systolic dysfunction in psoriasis, as evidenced by reduced GLS, is linked with the inflammatory upregulation, and enhanced profibrotic activity (as reflected by elevated serum Gal-3) may be involved in this process. These putative mechanisms may be responsible for the observed higher incidence of heart failure in this disease condition and should be considered as a potential target for preventive and therapeutic measures.

Psoriasis and Cardiovascular Risk: Correlation Between Psoriasis and Cardiovascular Functional Indices

Evidence suggests that psoriasis together with other cardiovascular (CV) risk factors is associated with increased vascular morbidity, but it is not clear whether psoriasis is an independent risk factor. Consecutive patients (n = 33; 35.6 ± 5.7 years; 13 females) with mild psoriasis (Psoriasis Area and Severity Index <10) without comorbidities and 33 healthy participants (36.3 ± 5.9 years; 15 females) were enrolled. Both groups underwent echocardiography, speckle tracking (2-dimensional strain echocardiography [2D-SE]), and pulse wave velocity (PWV) testing. Clinical and conventional echocardiographic characteristics were comparable between both groups. Global longitudinal strain (GLS) was significantly lower ( P = .002) in the psoriasis group (22.39% ± 2.28%) than in controls (24.15% ± 2.17%). The PWV was significantly lower ( P = .004) in controls (8.06 ± 1.68 m/s) than in the psoriasis group (9.23 ± 1.53 m/s). Significant correlations between GLS and disease duration ( r = −.66, P < .0001) and between GLS and patient age at diagnosis ( r = .48, P = .0043) were found. Psoriasis may be an independent CV risk factor, causing cardiac and vascular impairment. Both 2D-SE and PWV may be useful tools for the screening of CV risk in these patients.