1
|
Ebata S, Yoshizaki-Ogawa A, Sato S, Yoshizaki A. New Era in Systemic Sclerosis Treatment: Recently Approved Therapeutics. J Clin Med 2022; 11:jcm11154631. [PMID: 35956246 PMCID: PMC9369903 DOI: 10.3390/jcm11154631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic autoimmune disease with a poor prognosis. Among the various complications of SSc, treatment options for the fibrotic lesions, skin sclerosis, and SSc-associated interstitial lung disease (SSc-ILD) have been limited. However, since 2019, the efficacy and safety of nintedanib, tocilizumab, and rituximab for SSc or SSc-ILD have been demonstrated in double-blind, randomized, placebo-controlled trials, respectively. The antifibrotic agent nintedanib was approved for SSc-ILD in all regions of the United States, Europe, and Japan after the SENSCIS study confirmed that it suppressed the reduction in forced vital capacity (FVC), a measure of SSc-ILD. Tocilizumab, an anti-interleukin-6 receptor antibody, was approved for the treatment of SSc-ILD in the United States after the FocuSSced study showed that it inhibited the decrease in FVC. Rituximab, an anti-CD20 antibody, showed improvement in both modified Rodnan skin score, a measure of skin sclerosis, and FVC in the DESIRES study, and was approved in Japan for the treatment of SSc itself. With the development of these three drugs, SSc treatment is entering a new era. This paper outlines the latest advances in SSc therapeutics, focusing on nintedanib, tocilizumab, and rituximab.
Collapse
|
2
|
Rhodes CJ, Sweatt AJ, Maron BA. Harnessing Big Data to Advance Treatment and Understanding of Pulmonary Hypertension. Circ Res 2022; 130:1423-1444. [PMID: 35482840 PMCID: PMC9070103 DOI: 10.1161/circresaha.121.319969] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension is a complex disease with multiple causes, corresponding to phenotypic heterogeneity and variable therapeutic responses. Advancing understanding of pulmonary hypertension pathogenesis is likely to hinge on integrated methods that leverage data from health records, imaging, novel molecular -omics profiling, and other modalities. In this review, we summarize key data sets generated thus far in the field and describe analytical methods that hold promise for deciphering the molecular mechanisms that underpin pulmonary vascular remodeling, including machine learning, network medicine, and functional genetics. We also detail how genetic and subphenotyping approaches enable earlier diagnosis, refined prognostication, and optimized treatment prediction. We propose strategies that identify functionally important molecular pathways, bolstered by findings across multi-omics platforms, which are well-positioned to individualize drug therapy selection and advance precision medicine in this highly morbid disease.
Collapse
Affiliation(s)
- Christopher J Rhodes
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Andrew J Sweatt
- Department of Medicine, National Heart and Lung Institute, Imperial College London, United Kingdom (C.J.R.)
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.M.).,Division of Cardiology, VA Boston Healthcare System, West Roxbury, MA (B.A.M.)
| |
Collapse
|
3
|
Hughes M, Zanatta E, Sandler RD, Avouac J, Allanore Y. Improvement with time of vascular outcomes in systemic sclerosis: a systematic review and meta-analysis study. Rheumatology (Oxford) 2021; 61:2755-2769. [PMID: 34791057 DOI: 10.1093/rheumatology/keab850] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/15/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Vascular disease in systemic sclerosis (SSc) is associated with significant morbidity and mortality. Preliminary data may lead to the suggestion of a modifiable unified-vascular endophenotype. Our aim was to determine whether the prevalence, mortality, and severity of SSc-vascular disease have changed over time. METHODS We performed a systematic review and meta-analysis of the literature in PubMed 1950-2019 related to SSc-digital ulcers (DUs), pulmonary artery hypertension (PAH) and scleroderma renal crisis (SRC). We included full-text articles and extracted study characteristics and assessed risk of bias/quality. We examined the prevalence, mortality, and surrogate measures of SSc-associated vascular disease severity. RESULTS We included 55 studies in our meta-analysis. The pooled prevalence of DUs (41.0%), PAH (9.5%) and SRC (4.9%) remained largely stable over time. There was significant improvement in PAH 1-year (p= 0.001) and SRC mortality (P = <0.001), but not PAH 3-year (p= 0.312) or 5-year (p= 0.686) mortality. The prevalence of DU healing did not significantly change (p= 0.265). There was a trend (all P=∼0.1) towards improvement in PAH surrogates: mean pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure. For SRC, there was evidence that the overall frequency of dialysis (66.7%, p= 0.297) and permanent dialysis (34.5%, p= 0.036) increased over time. CONCLUSION Despite the heterogeneity and scarcity of the disease, there have been major improvements obtained in the various vascular complications in SSc leading to benefit in survival. This is supported by a trend towards improvement in several surrogate markers and demonstrates that progresses in vascular management translate into major patient benefit.
Collapse
Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine-DIMED, Padova University Hospital, Padova, Italy
| | - Robert D Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Jérôme Avouac
- Rhumatologie, Hôpital Cochin, APHP, Université de Paris, Paris, France
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, AP-HP, Paris Descartes University, Paris, France
| |
Collapse
|
4
|
Yen EY, Singh DR, Singh RR. Trends in Systemic Sclerosis Mortality Over Forty-Eight Years, 1968-2015: A US Population-Based Study. Arthritis Care Res (Hoboken) 2021; 73:1502-1510. [PMID: 32770721 PMCID: PMC7868470 DOI: 10.1002/acr.24411] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 08/04/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To identify secular trends associated with systemic sclerosis (SSc) mortality over a 48-year period. METHODS Using national mortality data compiled by the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research, and population data from the US Census Bureau, we calculated an age-standardized mortality rate (ASMR) for SSc and non-SSc (all other causes), and we also calculated the ratio of the SSc ASMR to the non-SSc ASMR for each year from 1968 to 2015. We then used a joinpoint regression model to evaluate mortality trends overall and by sex and race. RESULTS From 1968 to 2015, there were 46,798 deaths with SSc recorded as the "underlying" cause of death and 106,058,839 non-SSc deaths. There were an additional 9,063 deaths with SSc recorded as a "contributing" cause of death from 1999 to 2015. Whereas the non-SSc ASMR decreased throughout the 48-year time period, the SSc ASMR increased from 1968 to 2000, followed by decreases each year from 2001 to 2015. The SSc ASMR also decreased for deaths where SSc was a contributing cause from 1999 to 2015. Women and Black persons had higher SSc ASMRs and SSc ASMR to non-SSc ASMR ratios than men and White persons, respectively. Additionally, SSc ASMRs and SSc ASMR to non-SSc ASMR ratios increased at higher rates in women and White persons than in men and Black persons, respectively, during the initial three decades. CONCLUSION Mortality attributable to SSc increased from 1968 to 2000, followed by a steady decline from 2001 to 2015. However, SSc mortality relative to non-SSc mortality remains high. SSc mortality has disproportionately changed by sex and race over the 48-year period assessed in the present study.
Collapse
Affiliation(s)
- Eric Y Yen
- University of California David Geffen School of Medicine, Los Angeles
| | - Devanshu R Singh
- University of California David Geffen School of Medicine, Los Angeles, and Whiting School of Engineering and Zanvyl Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Ram R Singh
- University of California David Geffen School of Medicine, and Jonsson Comprehensive Cancer Center, Los Angeles
| |
Collapse
|
5
|
Denton CP, Spierings J. Combining Data Sets as Well as Therapies Shows Improved Outcome in Connective Tissue Disease-Associated Pulmonary Hypertension. Arthritis Rheumatol 2021; 73:725-727. [PMID: 33533554 DOI: 10.1002/art.41670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/26/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Julia Spierings
- University College London and Royal Free Hospital, London, UK
| |
Collapse
|
6
|
Lei Y, Zhang X, Lin H, Feng Y, Wang J, Luo R. The effects of oral treatment for systemic sclerosis related pulmonary arterial hypertension: A systematic review and meta-analysis. Mod Rheumatol 2020; 31:151-161. [PMID: 31829087 DOI: 10.1080/14397595.2019.1704125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The usage of oral therapies, endothelin receptor antagonists (ERAs), phosphodiesterase type-5 (PDE-5) inhibitors and prostaglandin analogs has resulted in improved outcomes in patients with pulmonary arterial hypertension related to systemic sclerosis (SSc-PAH). However, the optimal therapeutics have not been determined. METHODS A systematic searching in the databases of Medline (PubMed), Embase, the Cochrane Library (Central) and unpublished clinical trials (clinicaltrials.gov) was conducted to identify the clinical studies with oral treatment for SSc-PAH patients published before 1 June 2019. The data were extracted and the quality was assessed. The main outcomes are exercise capacity and hemodynamic parameters, which were synthesized and analyzed. RESULTS In total, 27 clinical trials were enrolled for further analysis. It was demonstrated that bosentan treatment, the widely used drug for PAH, might improve the exercise capacity and pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) in this clinical setting, although without significant difference. Meanwhile, the usage of prostaglandin analogs could improve the parameters mentioned above. Furthermore, combined therapy with ambrisentan and tadalafil significantly increased the treatment efficacy of key parameters in SSc-PAH patients compared with basic treatment. CONCLUSION This meta-analysis reveals that combination therapy might provide more benefits to exercise capacity and hemodynamic parameters in SSc-PAH patients. Still more RCTs are needed to provide more solid evidence.
Collapse
Affiliation(s)
- Yunxia Lei
- Southern Medical University, Guangzhou, China.,Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiao Zhang
- Southern Medical University, Guangzhou, China.,Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haobo Lin
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuan Feng
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jieying Wang
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Riqiang Luo
- Department of Rheumatology and Clinical Immunology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
7
|
Nazemiyeh M, Hajalilou M, Rajabnia M, Sharifi A, Hasani S. Diagnostic value of Endothelin 1 as a marker for diagnosis of pulmonary parenchyma involvement in patients with systemic sclerosis. AIMS MEDICAL SCIENCE 2020. [DOI: 10.3934/medsci.2020014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
8
|
Saygin D, Domsic RT. Pulmonary Arterial Hypertension In Systemic Sclerosis: Challenges In Diagnosis, Screening And Treatment. Open Access Rheumatol 2019; 11:323-333. [PMID: 31920409 PMCID: PMC6939800 DOI: 10.2147/oarrr.s228234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/15/2019] [Indexed: 12/31/2022] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem autoimmune disease characterized by vasculopathy, fibrosis and immune system activation. Pulmonary hypertension and interstitial lung disease account for majority of SSc-related deaths. Diagnosis of SSc-PAH can be challenging due to nonspecific clinical presentation which can lead to delayed diagnosis. Many screening algorithms have been developed to detect SSc-associated pulmonary arterial hypertension (SSc-PAH) in early stages. Currently used PAH-specific medications are largely extrapolated from IPAH studies due to smaller number of patients with SSc-PAH. In this review, we discuss the current state of knowledge in epidemiology and risk factors for development of SSc-PAH, and challenges and potential solutions in the diagnosis, screening and management of SSc-PAH.
Collapse
Affiliation(s)
- Didem Saygin
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
9
|
|
10
|
Pestaña-Fernández M, Rubio-Rivas M, Tolosa-Vilella C, Guillén-Del-Castillo A, Freire M, Vargas-Hitos JA, Todolí-Parra JA, Rodríguez-Carballeira M, Marín-Ballvé A, Espinosa G, Colunga-Argüelles D, Ortego-Centeno N, Trapiella-Martínez L, Carbonell-Muñoz C, Pla-Salas X, Perales-Fraile I, Corbella X, Fonollosa-Pla V, Simeón-Aznar CP. Longterm Efficacy and Safety of Monotherapy versus Combination Therapy in Systemic Sclerosis–associated Pulmonary Arterial Hypertension: A Retrospective RESCLE Registry Study. J Rheumatol 2019; 47:89-98. [DOI: 10.3899/jrheum.180595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2019] [Indexed: 11/22/2022]
Abstract
Objective.Monotherapy is an option as first-line therapy for pulmonary arterial hypertension (PAH). However, combination therapy is a beneficial alternative. Our objective was to evaluate the efficacy of monotherapy versus combination therapy in patients with systemic sclerosis (SSc)–associated PAH.Methods.All patients with SSc-associated PAH from the Spanish Scleroderma Registry (RESCLE) were reviewed. Patients were split into 3 groups: monotherapy versus sequential combination versus upfront combination therapy. The primary endpoint was death from any cause at 1, 3, and 5 years from PAH diagnosis.Results.Seventy-six patients (4.2%) out of 1817 had SSc-related PAH. Thirty-four patients (45%) were receiving monotherapy [endothelin receptor antagonist (n = 22; 29%) or phosphodiesterase-5 inhibitors (n = 12; 16%)], 25 (33%) sequential combination, and 17 (22%) upfront combination therapy. A lower forced vital capacity/DLCO in the sequential combination group was reported (2.9 ± 1.1 vs 1.8 ± 0.4 vs 2.3 ± 0.8; p = 0.085) and also a higher mean pulmonary arterial pressure in combination groups (37.2 ± 8.7 mmHg vs 40.8 ± 8.8 vs 46 ± 15.9; p = 0.026) at baseline. Treatment regimen (p = 0.017) and functional class (p = 0.007) were found to be independent predictors of mortality. Sequential combination therapy was found to be an independent protective factor (HR 0.11, 95% CI 0.03–0.51; p = 0.004), while upfront combination therapy showed a trend (HR 0.68, 95% CI 0.23–1.97; p = 0.476). Survival from PAH diagnosis among monotherapy, sequential, and upfront combination groups was 78% versus 95.8% versus 94.1% at 1 year, 40.7% versus 81.5% versus 51.8% at 3 years, and 31.6% versus 56.5% versus 34.5% at 5 years (p = 0.007), respectively. Side effects were not significantly different among groups.Conclusion.Combination sequential therapy improved survival in our cohort.
Collapse
|
11
|
Streicher K, Sridhar S, Kuziora M, Morehouse CA, Higgs BW, Sebastian Y, Groves CJ, Pilataxi F, Brohawn PZ, Herbst R, Ranade K. Baseline Plasma Cell Gene Signature Predicts Improvement in Systemic Sclerosis Skin Scores Following Treatment With Inebilizumab (MEDI-551) and Correlates With Disease Activity in Systemic Lupus Erythematosus and Chronic Obstructive Pulmonary Disease. Arthritis Rheumatol 2018; 70:2087-2095. [PMID: 29956883 DOI: 10.1002/art.40656] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/26/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE B cells impact the progression of systemic sclerosis (SSc; scleroderma) through multiple pathogenic mechanisms. CD19 inhibition in mice reduced skin thickness, collagen production, and autoantibody levels, consistent with CD19 expression on plasma cells (PCs), the source of antibody production. PC depletion could effectively reduce collagen deposition and inflammation in SSc; therefore, we investigated the effects of PC depletion on SSc disease activity. METHODS A PC gene signature was evaluated in SSc skin biopsy samples in 2 phase I clinical trials. We assessed microarray data from tissue from public studies of chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), dermatomyositis (DM), systemic lupus erythematosus (SLE), and atopic dermatitis, as well as blood from a phase IIb clinical trial in SLE. RESULTS The PC signature was elevated in SSc skin specimens compared to healthy donor skin (P = 2.28 × 10-6 ) and correlated with the baseline modified Rodnan skin thickness score (MRSS) (r = 0.64, P = 0.0004). Patients with a high PC signature at baseline showed greater improvement in the MRSS (mean ± SD change 35 ± 16%; P = 6.30 × 10-4 ) following anti-CD19 treatment with inebilizumab (MEDI-551) than did patients with a low PC signature at baseline (mean ± SD change 8 ± 12%; P = 0.104). The PC signature was overexpressed in tissue from patients with SLE, DM, COPD, interstitial lung disease, and IPF relative to controls (all fold change >2; P < 0.001). The PC signature also differed significantly between SLE patients with mild-to-moderate disease and those with severe disease (SLE Disease Activity Index cutoff at 10) (fold change 1.44; P = 3.90 × 10-3 ) and correlated significantly with the degree of emphysema in COPD (r = 0.53, P = 7.55 × 10-8 ). CONCLUSION Our results support the notion that PCs have a role in the pathogenesis of SSc and other autoimmune or pulmonary indications. An elevated pretreatment PC signature was associated with increased benefit from MEDI-551 in SSc.
Collapse
|
12
|
Weatherald J, Boucly A, Launay D, Cottin V, Prévot G, Bourlier D, Dauphin C, Chaouat A, Savale L, Jaïs X, Jevnikar M, Traclet J, De Groote P, Simonneau G, Hachulla E, Mouthon L, Montani D, Humbert M, Sitbon O. Haemodynamics and serial risk assessment in systemic sclerosis associated pulmonary arterial hypertension. Eur Respir J 2018; 52:13993003.00678-2018. [PMID: 30209196 DOI: 10.1183/13993003.00678-2018] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/12/2018] [Indexed: 11/05/2022]
Abstract
The prognostic importance of follow-up haemodynamics and the validity of multidimensional risk assessment are not well established for systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH).We assessed incident SSc-PAH patients to determine the association between clinical and haemodynamic variables at baseline and first follow-up right heart catheterisation (RHC) with transplant-free survival. RHC variables included cardiac index, stroke volume index (SVI), pulmonary arterial compliance and pulmonary vascular resistance. Risk assessment was performed according to the number of low-risk criteria: functional class I or II, 6-min walking distance (6MWD) >440 m, right atrial pressure <8 mmHg and cardiac index ≥2.5 L·min-1·m-2Transplant-free survival from diagnosis (n=513) was 87%, 55% and 35% at 1, 3 and 5 years, respectively. At baseline, 6MWD was the only independent predictor. A follow-up RHC was available for 353 patients (median interval 4.6 months, interquartile range 3.9-6.4 months). The 6MWD, functional class, cardiac index, SVI, pulmonary arterial compliance and pulmonary vascular resistance were independently associated with transplant-free survival at follow-up, with SVI performing better than other haemodynamic variables. 1-year outcomes were better with increasing number of low-risk criteria at baseline (area under the curve (AUC) 0.63, 95% CI 0.56-0.69) and at first follow-up (AUC 0.71, 95% CI 0.64-0.78).Follow-up haemodynamics and multidimensional risk assessment had greater prognostic significance than at baseline in SSc-PAH.
Collapse
Affiliation(s)
- Jason Weatherald
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Dept of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.,Both authors contributed equally
| | - Athénaïs Boucly
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Both authors contributed equally
| | - David Launay
- Université Lille, U995 - LIRIC - Lille Inflammation Research International Center, Lille, France.,INSERM, U995, Lille, France.,CHU Lille, Département de Médecine Interne et Immunologie Clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Dept of Respiratory Medicine, Louis Pradel Hospital, Lyon, France.,University Claude Bernard Lyon 1, University of Lyon, UMR 754, Lyon, France
| | - Grégoire Prévot
- CHU de Toulouse, Hôpital Larrey, Service de Pneumologie, Toulouse, France
| | - Delphine Bourlier
- Université de Bordeaux, CHU de Bordeaux, Hôpital du Haut Lévêque, Service de Maladies Respiratoires, Pessac, France
| | - Claire Dauphin
- University of Auvergne, CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France
| | - Ari Chaouat
- CHU Nancy, Pôle des Spécialités Médicales, Département de Pneumologie, Vandoeuvre-lès-Nancy, France.,Université de Lorraine, INGRES, EA 7298, Vandoeuvre-lès-Nancy, France.,CHU de Lille, Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Xavier Jaïs
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Julie Traclet
- Hospices Civils de Lyon, Dept of Respiratory Medicine, Louis Pradel Hospital, Lyon, France.,University Claude Bernard Lyon 1, University of Lyon, UMR 754, Lyon, France
| | - Pascal De Groote
- CHU de Lille, Hôpital Cardiologique de Lille, Centre de Compétences de l'Hypertension Pulmonaire, Lille, France
| | - Gérald Simonneau
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Eric Hachulla
- Université Lille, U995 - LIRIC - Lille Inflammation Research International Center, Lille, France.,INSERM, U995, Lille, France.,CHU Lille, Département de Médecine Interne et Immunologie Clinique, Lille, France.,Centre de Référence des Maladies Autoimmunes et Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
| | - Luc Mouthon
- APHP, Hôpital Cochin, Service de Médecine Interne, Centre de Référence des Maladies Auto-immunes Systémiques Rares Ile de France, Paris, France.,Université Paris Descartes, Paris, France
| | - David Montani
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Both authors contributed equally
| | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France .,APHP, Hôpital Bicêtre, Service de Pneumologie, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Both authors contributed equally
| |
Collapse
|
13
|
Rice LM, Mantero JC, Stratton EA, Warburton R, Roberts K, Hill N, Simms RW, Domsic R, Farber HW, Layfatis R. Serum biomarker for diagnostic evaluation of pulmonary arterial hypertension in systemic sclerosis. Arthritis Res Ther 2018; 20:185. [PMID: 30115106 PMCID: PMC6097341 DOI: 10.1186/s13075-018-1679-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023] Open
Abstract
Background Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is one of the leading causes of death in SSc. Identification of a serum-based proteomic diagnostic biomarker for SSc-PAH would allow for rapid non-invasive screening and could positively impact patient survival. Identification and validation of novel proteins could potentially facilitate the identification of SSc-PAH, and might also point to important protein mediators in pathogenesis. Methods Thirteen treatment-naïve SSc-PAH patients had serum collected at time of diagnosis and were used as the discovery cohort for the protein-expression biomarker. Two proteins, Midkine and Follistatin-like 3 (FSTL3) were then validated by enzyme-linked immunosorbent assays. Midkine and FSTL3 were tested in combination to identify SSc-PAH and were validated in two independent cohorts of SSc-PAH (n = 23, n = 11). Results Eighty-two proteins were found to be differentially regulated in SSc-PAH sera. Two proteins (Midkine and FSTL3) were also shown to be elevated in publicly available data and their expression was evaluated in independent cohorts. In the validation cohorts, the combination of Midkine and FSTL3 had an area under the receiver operating characteristic curve (AUC) of 0.85 and 0.92 with respective corresponding measures of sensitivity of 76% and 91%, and specificity measures of 76% and 80%. Conclusions These findings indicate that there is a clear delineation between overall protein expression in sera from SSc patients and those with SSc-PAH. The combination of Midkine and FSTL3 can serve as an SSc-PAH biomarker and are potential drug targets for this rare disease population. Electronic supplementary material The online version of this article (10.1186/s13075-018-1679-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lisa M Rice
- Boston University School of Medicine, E5 Arthritis Center, 72 E Concord Street, Boston, MA, 0211, USA.
| | - Julio C Mantero
- Boston University School of Medicine, E5 Arthritis Center, 72 E Concord Street, Boston, MA, 0211, USA
| | - Eric A Stratton
- Boston University School of Medicine, E5 Arthritis Center, 72 E Concord Street, Boston, MA, 0211, USA
| | | | | | | | - Robert W Simms
- Boston University School of Medicine, E5 Arthritis Center, 72 E Concord Street, Boston, MA, 0211, USA
| | - Robyn Domsic
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Harrison W Farber
- Boston University School of Medicine, E5 Arthritis Center, 72 E Concord Street, Boston, MA, 0211, USA
| | - Robert Layfatis
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Pulmonale Hypertonie bei Kollagenosen. Z Rheumatol 2018; 77:219-230. [DOI: 10.1007/s00393-018-0443-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
15
|
Karampitsakos T, Tzouvelekis A, Chrysikos S, Bouros D, Tsangaris I, Fares WH. Pulmonary hypertension in patients with interstitial lung disease. Pulm Pharmacol Ther 2018; 50:38-46. [PMID: 29605286 DOI: 10.1016/j.pupt.2018.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/12/2018] [Accepted: 03/28/2018] [Indexed: 01/20/2023]
Abstract
Interstitial lung diseases (ILDs) comprise a broad and heterogeneous group of more than two hundred diseases with common functional characteristics. Their diagnosis and management require a multidisciplinary approach. This multidisciplinary approach involves the assessment of comorbid conditions including pulmonary hypertension (PH) that exerts a dramatic impact on survival. The current World Health Organization (WHO) classification of PH encompasses many of the interstitial lung diseases into WHO Group 3, while sarcoidosis, Pulmonary Langerhans Cell Histiocytosis and lymphangioleiomyomatosis are placed into WHO Group 5 as diseases with unclear or multifactorial mechanisms. Connective tissue diseases could span any of the 5 WHO groups based on the primary phenotype into which they manifest. Interestingly, several challenging phenotypes present with features that overlap between two or more WHO PH groups. Currently, PH-specific treatment is recommended only for patients classified into WHO Group 1 PH. The lack of specific treatment for other groups, including PH in the setting of ILD, reflects the poor outcomes of these patients. Thus, identification of the optimal strategy for ILD patients with PH remains an amenable need. This review article provides a brief overview of biomarkers indicative of vascular remodeling in interstitial lung disease, summarizes the current state of knowledge regarding patients with PH and ILD and highlights future perspectives that remain to be addressed.
Collapse
Affiliation(s)
| | - Argyrios Tzouvelekis
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece; Division of Immunology, Biomedical Sciences Research Center "Alexander Fleming", Athens, Greece
| | - Serafeim Chrysikos
- 5(th) Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Iraklis Tsangaris
- Second Critical Care Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Wassim H Fares
- Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
16
|
Russell FM, Kline JA, Lahm T. High rate of isolated right ventricular dysfunction in patients with non-significant CT pulmonary angiography. Am J Emerg Med 2017; 36:281-284. [PMID: 29050845 DOI: 10.1016/j.ajem.2017.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/22/2017] [Accepted: 10/08/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction and pulmonary hypertension (PH) are commonly unrecognized in the emergency department (ED), but are associated with poor outcomes. Prior research has found a 30% prevalence of isolated RV dysfunction in ED patients after non-significant computed tomographic pulmonary angiography (CTPA). We aimed to prospectively define the prevalence of RV dysfunction and/or PH in short of breath ED patients, and assess outcomes. METHODS Prospective observational study of patients with a non-significant CTPA. Isolated RV dysfunction and/or PH was defined as normal left ventricular function plus RV dilation, moderate to severe tricuspid regurgitation or RV systolic pressure>40mmHg on comprehensive echocardiography. RESULTS Of 83 patients, 20 (24%, 95% [confidence interval] CI: 16-34%) had isolated RV dysfunction and/or PH. These patients had 40% ED recidivism and 30% hospital readmission at 30-days. When compared to patients with normal echocardiographic function, they had significantly longer intensive care unit and hospital length of stays. CONCLUSIONS In a prospective cohort of ED patients, we found a high prevalence of isolated RV dysfunction and/or PH after a non-significant CTPA. These patients had high rates of recidivism and hospital readmission. This data supports a continued need for ED based screening and specialty referral.
Collapse
Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, United States.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, United States.
| | - Timothy Lahm
- Department of Internal Medicine, Division of Pulmonology, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, United States.
| |
Collapse
|
17
|
Hao Y, Hudson M, Baron M, Carreira P, Stevens W, Rabusa C, Tatibouet S, Carmona L, Joven BE, Huq M, Proudman S, Nikpour M. Early Mortality in a Multinational Systemic Sclerosis Inception Cohort. Arthritis Rheumatol 2017; 69:1067-1077. [PMID: 28029745 DOI: 10.1002/art.40027] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 12/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine mortality and causes of death in a multinational inception cohort of subjects with systemic sclerosis (SSc). METHODS We quantified mortality as standardized mortality ratio (SMR), years of life lost, and percentage mortality in the first decade of disease. The inception cohort comprised subjects recruited within 4 years of disease onset. For comparison, we used a prevalent cohort, which included all subjects irrespective of disease duration at recruitment. We determined a single primary cause of death (SSc related or non-SSc related) using a standardized case report form, and we evaluated predictors of mortality using multivariable Cox regression. RESULTS In the inception cohort of 1,070 subjects, there were 140 deaths (13%) over a median follow-up of 3.0 years (interquartile range 1.0-5.1 years), with a pooled SMR of 4.06 (95% confidence interval [95% CI] 3.39-4.85), up to 22.4 years of life lost in women and up to 26.0 years of life lost in men, and mortality in the diffuse disease subtype of 24.2% at 8 years. In the prevalent cohort of 3,218 subjects, the pooled SMR was lower at 3.39 (95% CI 3.06-3.71). In the inception cohort, 62.1% of the primary causes of death were SSc related. Malignancy, sepsis, cerebrovascular disease, and ischemic heart disease were the most common non-SSc-related causes of death. Predictors of early mortality included male sex, older age at disease onset, diffuse disease subtype, pulmonary arterial hypertension, and renal crisis. CONCLUSION Early mortality in SSc is substantial, and prevalent cohorts underestimate mortality in SSc by failing to capture early deaths, particularly in men and those with diffuse disease.
Collapse
Affiliation(s)
- Yanjie Hao
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia, and Peking University First Hospital, Beijing, China
| | - Marie Hudson
- Jewish General Hospital and Lady Davis Research Institute, Montreal, Quebec, Canada
| | - Murray Baron
- Jewish General Hospital and Lady Davis Research Institute, Montreal, Quebec, Canada
| | | | - Wendy Stevens
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Candice Rabusa
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Molla Huq
- St. Vincent's Hospital Melbourne and The University of Melbourne, Melbourne, Victoria, Australia
| | - Susanna Proudman
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Mandana Nikpour
- St. Vincent's Hospital Melbourne and The University of Melbourne, Melbourne, Victoria, Australia
| | | | | |
Collapse
|
18
|
Kim HL. The Importance of Echocardiographic Screening for Pulmonary Arterial Hypertension in Korean Patients with Systemic Sclerosis. J Cardiovasc Ultrasound 2017; 24:276-277. [PMID: 28090254 PMCID: PMC5234334 DOI: 10.4250/jcu.2016.24.4.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Yoo SJ, Park JH, Park Y, Lee JH, Sun BJ, Kim J, Yoo IS, Shim SC, Kang SW. Prevalence of Pulmonary Arterial Hypertension in Korean Adult Patients with Systemic Sclerosis: Result of a Pilot Echocardiographic Screening Study. J Cardiovasc Ultrasound 2016; 24:312-316. [PMID: 28090259 PMCID: PMC5234342 DOI: 10.4250/jcu.2016.24.4.312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a major cause of morbidity and mortality among patients with systemic sclerosis (SSc). Early detection and prompt treatment of PAH associated with SSc (SSc-PAH) result in better prognosis. We conducted echocardiographic study to presume the prevalence of PAH in Korean adult SSc patients and to diagnose SSc-PAH in their early stages with right heart catheterization (RHC). Methods We performed free of charge echocardiographic study including 37 adult SSc patients at the Chungnam National University Hospital. The possibility of PAH is determined by the estimation of pulmonary arterial pressure by peak tricuspid regurgitation velocity of > 3.0 m/s. Patients with possible PAH were recommended to undergo RHC to confirm the diagnosis. Results In 37 patients, 8 patients were suspected with PAH. Among them, 6 patients agreed to be examined with RHC, and 4 were confirmed with PAH. The prevalence of possible PAH was 21.6% (8 of 37 patients), and that of confirmed PAH was 10.8% (4 of 37 patients). Four patients who were confirmed with SSc-PAH through RHC have been treated with specific pulmonary vasodilators and maintained stable. Conclusion Eight patients (21.6%) were possible PAH and 4 (10.8%) were diagnosed as SSc-PAH by RHC after the echocardiographic screening study of 37 adult SSc patients.
Collapse
Affiliation(s)
- Su-Jin Yoo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Yunseon Park
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Byung-Joo Sun
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Jinhyun Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - In Seol Yoo
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Seung Cheol Shim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| | - Seong Wook Kang
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea
| |
Collapse
|
20
|
Calderone A, Stevens W, Prior D, Nandurkar H, Gabbay E, Proudman SM, Williams T, Celermajer D, Sahhar J, Wong PKK, Thakkar V, Dwyer N, Wrobel J, Chin W, Liew D, Staples M, Buchbinder R, Nikpour M. Multicentre randomised placebo-controlled trial of oral anticoagulation with apixaban in systemic sclerosis-related pulmonary arterial hypertension: the SPHInX study protocol. BMJ Open 2016; 6:e011028. [PMID: 27932335 PMCID: PMC5168661 DOI: 10.1136/bmjopen-2016-011028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a severe and costly multiorgan autoimmune connective tissue disease characterised by vasculopathy and fibrosis. One of the major causes of SSc-related death is pulmonary arterial hypertension (PAH), which develops in 12-15% of patients with SSc and accounts for 30-40% of deaths. In situ thrombosis in the small calibre peripheral pulmonary vessels resulting from endothelial dysfunction and an imbalance of anticoagulant and prothrombotic mediators has been implicated in the complex pathophysiology of SSc-related PAH (SSc-PAH), with international clinical guidelines recommending the use of anticoagulants for some types of PAH, such as idiopathic PAH. However, anticoagulation has not become part of standard clinical care for patients with SSc-PAH as only observational evidence exists to support its use. Therefore, we present the rationale and methodology of a phase III randomised controlled trial (RCT) to evaluate the efficacy, safety and cost-effectiveness of anticoagulation in SSc-PAH. METHODS AND ANALYSIS This Australian multicentre RCT will compare 2.5 mg apixaban with placebo, in parallel treatment groups randomised in a 1:1 ratio, both administered twice daily for 3 years as adjunct therapy to stable oral PAH therapy. The composite primary outcome measure will be the time to death or clinical worsening of PAH. Secondary outcomes will include functional capacity, health-related quality of life measures and adverse events. A cost-effectiveness analysis of anticoagulation versus placebo will also be undertaken. ETHICS AND DISSEMINATION Ethical approval for this RCT has been granted by the Human Research Ethics Committees of all participating centres. An independent data safety monitoring board will review safety and tolerability data for the duration of the trial. The findings of this RCT are to be published in open access journals. TRIAL REGISTRATION NUMBER ACTRN12614000418673, Pre-results.
Collapse
Affiliation(s)
- Alicia Calderone
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Harshal Nandurkar
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eli Gabbay
- The University of Notre Dame, Fremantle, Western Australia, Australia
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
- University of Adelaide Discipline of Medicine at Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
| | - Trevor Williams
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Monash University, Prahran, Victoria, Australia
| | - David Celermajer
- Department of Cardiology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health and Monash University, Clayton, Victoria, Australia
| | - Peter K K Wong
- Mid-North Coast Arthritis Clinic, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, Rural Clinical School, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Nathan Dwyer
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Weng Chin
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Margaret Staples
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
21
|
Is cystatin C an evaluative marker for right heart functions in systemic sclerosis? Int J Cardiol 2016; 221:478-83. [PMID: 27414726 DOI: 10.1016/j.ijcard.2016.07.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
|
22
|
Stamm A, Saxer S, Lichtblau M, Hasler ED, Jordan S, Huber LC, Bloch KE, Distler O, Ulrich S. Exercise pulmonary haemodynamics predict outcome in patients with systemic sclerosis. Eur Respir J 2016; 48:1658-1667. [DOI: 10.1183/13993003.00990-2016] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/03/2016] [Indexed: 12/26/2022]
Abstract
The aim of the present study was to investigate the prognostic value of exercise haemodynamics measured during right heart catheterisation (RHC) in patients with systemic sclerosis (SSc) referred for evaluation of pulmonary hypertension.SSc patients undergoing RHC at rest and during maximal supine incremental cycle exercise were grouped into resting precapillary pulmonary hypertension (PHrest) (mean pulmonary artery pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure <15 mmHg), exercise-induced pulmonary hypertension (PHex) (mPAP ≥30 mmHg and mPAP/cardiac output >3 mmHg·L−1·min−1 at maximal exercise), and without pulmonary hypertension (PHnone). Patients' characteristics, haemodynamics and follow up data were compared between groups.72 SSc patients were followed for median (interquartile range) 33 (15–55) months. Mean (95% CI) survival without transplantation estimated by Kaplan-Meyer analysis was 4.4 (0.8–2.9) years in PHrest (n=17), 5.2 (4.4–6.1) years in PHex (n=28) and 9.5(8.4–10.6) years in PHnone (n=27; p<0.05 versus others). In Cox regression models, the exercise-induced increase in mPAP (hazard ratio (HR) 1.097, 95% CI 1.002–1.200) and the coefficient of pulmonary vascular distensibility alpha (HR 0.100, 95% CI 0.012–0.871) controlled for age, but not resting haemodynamics predicted transplant-free survival.Among SSc patients with normal mPAP at rest, an excessive increase in mPAP during exercise and an impaired vascular distensibility may indicate an early stage of pulmonary vasculopathy, associated with reduced survival similar to resting pulmonary hypertension patients.
Collapse
|
23
|
Machin DR, Clifton HL, Garten RS, Gifford JR, Richardson RS, Wray DW, Frech TM, Donato AJ. Exercise-induced brachial artery blood flow and vascular function is impaired in systemic sclerosis. Am J Physiol Heart Circ Physiol 2016; 311:H1375-H1381. [PMID: 27694218 DOI: 10.1152/ajpheart.00547.2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/26/2016] [Indexed: 11/22/2022]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by debilitating fibrosis and vascular dysfunction; however, little is known about the circulatory response to exercise in this population. Therefore, we examined the peripheral hemodynamic and vasodilatory responses to handgrip exercise in 10 patients with SSc (61 ± 4 yr) and 15 age-matched healthy controls (56 ± 5 yr). Brachial artery diameter, blood flow, and mean arterial pressure (MAP) were determined at rest and during progressive static-intermittent handgrip exercise. Patients with SSc and controls were similar in body stature, handgrip strength, and MAP; however, brachial artery blood flow at rest was nearly twofold lower in patients with SSc compared with controls (22 ± 4 vs. 42 ± 5 ml/min, respectively; P < 0.05). Additionally, SSc patients had an ∼18% smaller brachial artery lumen diameter with an ∼28% thicker arterial wall at rest (P < 0.05). Although, during handgrip exercise, there were no differences in MAP between the groups, exercise-induced hyperemia and therefore vascular conductance were ∼35% lower at all exercise workloads in patients with SSc (P < 0.05). Brachial artery vasodilation, as assessed by the relationship between Δbrachial artery diameter and Δshear rate, was significantly attenuated in the patients with SSc (P < 0.05). Finally, vascular dysfunction in the patients with SSc was accompanied by elevated blood markers of oxidative stress and attenuated endogenous antioxidant activity (P < 0.05). Together, these findings reveal attenuated exercise-induced brachial artery blood flow and conduit arterial vasodilatory dysfunction during handgrip exercise in SSc and suggest that elevated oxidative stress may play a role.
Collapse
Affiliation(s)
- Daniel R Machin
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Heather L Clifton
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Ryan S Garten
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah.,Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jayson R Gifford
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Russell S Richardson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah.,Veterans Affairs Salt Lake City, GRECC, Salt Lake City, Utah; and
| | - D Walter Wray
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah.,Veterans Affairs Salt Lake City, GRECC, Salt Lake City, Utah; and
| | - Tracy M Frech
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Anthony J Donato
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah; .,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah.,Department of Biochemistry, University of Utah, Salt Lake City, Utah.,Veterans Affairs Salt Lake City, GRECC, Salt Lake City, Utah; and
| |
Collapse
|
24
|
Methia N, Latreche S, Ait Mokhtar O, Monsuez JJ, Benkhedda S. Assessment for Pulmonary Artery Hypertension Using Clinical and Echocardiographic Criteria in Patients With Systemic Sclerosis. Am J Med Sci 2016; 352:343-347. [PMID: 27776714 DOI: 10.1016/j.amjms.2016.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/11/2016] [Accepted: 07/11/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prognosis of systemic sclerosis (SSc) is affected by pulmonary artery hypertension (PAH). METHODS Among 202 patients (mean age: 46.1 ± 13.3 years; 177 women) with SSc, those with a tricuspid regurgitation (TR) jet maximal velocity at 2D-echocardiography (2DE) < 2.8m/second were not considered at high risk for PAH, whereas those with a TR velocity >3m/second or between 2.8 and 3m/second and associated with dyspnea were. RESULTS Among 22 patients at risk, 15 (mean age: 50.4 ± 14.3 years) had definite precapillary PAH on right heart catheterization (RHC). The delay period between recognitions of SSc and PAH was 12.9 ± 5.2 years. Dyspnea was present in all 15 patients, 11 (73.3%) being in the New York Heart Association class III or IV. The 2DE showed normal left ventricular geometrics and function (n = 15), enlargement of the right-sided cardiac chambers (n = 12), increased pulmonary arterial resistances with a TR velocity to pulmonary time-velocity integral ratio of > 0.2 (n = 15) and impaired right ventricle function (n = 15). RHC showed severe PAH in all 15 patients (mean pulmonary artery pressure: 48 ± 17mmHg and mean right atrial pressure: 11.8 ± 4.4mmHg) and a reduced cardiac index (2.2L/m²). There was no statistical difference between patients with and without PAH regarding age, sex ratio, duration from onset of disease, diffuse or cutaneous limited type of SSc, Rodnan severity score and presence of digital ulcerations or autoantibodies. Telangiectasia (P = 0.01) and New York Heart Association class III or IV heart failure (P = 0.001) were more frequent in patients with PAH. CONCLUSION A combined clinical and Doppler-coupled 2DE screening of PAH risk in patients with SSc is useful to select those who can undergo RHC.
Collapse
Affiliation(s)
- Nadera Methia
- Department of Cardiology, service de cardiologie A2, CHU Mustapha Alger, and Cardiology Oncology Research Collaborative Group, University of medicine of Algiers Benyoucef Benkhedda, Algiers, Algeria
| | - Samia Latreche
- Department of Cardiology, service de cardiologie A2, CHU Mustapha Alger, and Cardiology Oncology Research Collaborative Group, University of medicine of Algiers Benyoucef Benkhedda, Algiers, Algeria
| | - Omar Ait Mokhtar
- Department of Cardiology, service de cardiologie A2, CHU Mustapha Alger, and Cardiology Oncology Research Collaborative Group, University of medicine of Algiers Benyoucef Benkhedda, Algiers, Algeria
| | - Jean-Jacques Monsuez
- APHP Hôpital R Muret, Hôpitaux Universitaires de Paris Seine Saint Denis, Sevran, France.
| | - Salim Benkhedda
- Department of Cardiology, service de cardiologie A2, CHU Mustapha Alger, and Cardiology Oncology Research Collaborative Group, University of medicine of Algiers Benyoucef Benkhedda, Algiers, Algeria
| |
Collapse
|
25
|
Vandecasteele E, De Pauw M, De Keyser F, Decuman S, Deschepper E, Piette Y, Brusselle G, Smith V. Six-minute walk test in systemic sclerosis: A systematic review and meta-analysis. Int J Cardiol 2016; 212:265-73. [DOI: 10.1016/j.ijcard.2016.03.084] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/19/2016] [Indexed: 01/17/2023]
|
26
|
Varga J, Roberson EDO. Editorial: genomic advances in systemic sclerosis: it is time for precision. Arthritis Rheumatol 2016; 67:2801-5. [PMID: 26239971 DOI: 10.1002/art.39285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/14/2015] [Indexed: 01/12/2023]
Affiliation(s)
- John Varga
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | |
Collapse
|
27
|
García Hernández FJ, Castillo Palma MJ, Montero Mateos E, González León R, López Haldón JE, Sánchez Román J. [Screening of pulmonary hypertension in a Spanish cohort of patients with systemic sclerosis]. Med Clin (Barc) 2015; 146:1-7. [PMID: 26169331 DOI: 10.1016/j.medcli.2015.04.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/27/2015] [Accepted: 04/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary arterial hypertension (PAH) is an important cause of morbimortality in systemic sclerosis (SSc). Evolution is worse than that of subjects with idiopathic PAH, but prognosis improves when PAH is diagnosed early. The aim of this research is to describe results of a screening program for diagnosis of pulmonary hypertension (PH) carried out in a cohort of Spanish patients with SSc. PATIENTS AND METHOD PH screening was performed by transthoracic doppler echocardiography (TTDE) in 184 patients with SSc. Patients with systolic pulmonary arterial pressure estimated by TTDE>35 mmHg were evaluated per protocol to confirm diagnosis and type of PH. RESULTS PAH was diagnosed in 25 patients (13.6%). Patients with diffuse and limited SSc developed PAH in a similar degree, 9/60 (15%) vs. 16/100 (16%), with no cases among patients with SSc "sine scleroderma" or "pre-scleroderma" (P<.001). The only clinical or epidemiological data characterizing patients with PAH were older age (mean age 67 years for patients with PAH vs. 56 years for those without PAH, P=.007), limited SSc, a trend toward shorter evolution of the underlying disease (median 8 years for patients with PAH vs. 10 years for those without PAH, P=.73), and a higher frequency of positive anticentromere antibodies (16 patients [64%] with PAH vs. 70 (48,3%) without PAH, P=.19). CONCLUSIONS Prevalence of PAH in SSc was high and supports the implementation of a regular screening program.
Collapse
Affiliation(s)
| | | | | | - Rocío González León
- Servivio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España
| | | | - Julio Sánchez Román
- Servivio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España
| |
Collapse
|
28
|
Affiliation(s)
- C Hong
- From the Louise Coote Lupus Unit, Gassiot House, St Thomas' Hospital, London, UK and Department of Cardiology, Royal Free Hospital, London, UK
| | - S R Sangle
- From the Louise Coote Lupus Unit, Gassiot House, St Thomas' Hospital, London, UK and Department of Cardiology, Royal Free Hospital, London, UK
| | - J G Coghlan
- From the Louise Coote Lupus Unit, Gassiot House, St Thomas' Hospital, London, UK and Department of Cardiology, Royal Free Hospital, London, UK
| | - D P D'Cruz
- From the Louise Coote Lupus Unit, Gassiot House, St Thomas' Hospital, London, UK and Department of Cardiology, Royal Free Hospital, London, UK david.d'
| |
Collapse
|
29
|
Valenzuela A, Nandagopal S, Steen VD, Chung L. Monitoring and Diagnostic Approaches for Pulmonary Arterial Hypertension in Patients with Systemic Sclerosis. Rheum Dis Clin North Am 2015. [PMID: 26210131 DOI: 10.1016/j.rdc.2015.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary arterial hypertension (PAH) is one of the leading causes of death in patients with systemic sclerosis (SSc). Given the high prevalence and poor survival of SSc-PAH, and that aggressive management of mild disease may be associated with better outcomes, screening is critical. Right heart catheterization (RHC) is the gold standard for the definitive diagnosis of PAH, and should be performed in those patients in whom this diagnosis is suspected. Once a diagnosis of PAH is confirmed by RHC, treatment with PAH-specific therapies should be initiated as soon as possible.
Collapse
Affiliation(s)
- Antonia Valenzuela
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA
| | - Saranya Nandagopal
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 2nd Floor, Redwood City, CA 94063, USA
| | - Virginia D Steen
- Division of Rheumatology, Allergy, and Immunology, Georgetown University School of Medicine, Pasquerilla Health Center, 6th Floor 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Road, Suite 203, MC 5755, Palo Alto, CA 94304, USA.
| |
Collapse
|
30
|
Denton CP, Ong VH. Pulmonary management of systemic sclerosis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00145-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
31
|
Mortality in systemic sclerosis: lessons learned from population-based and observational cohort studies. Curr Opin Rheumatol 2014; 26:131-7. [PMID: 24441644 DOI: 10.1097/bor.0000000000000027] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Systemic sclerosis (SSc) has a case-based mortality that is one of the highest among the rheumatic diseases. This article is an appraisal of current knowledge regarding survival, causes of death and risk factors for reduced life-expectancy in systemic sclerosis (SSc). RECENT FINDINGS Recent systematic reviews of cohorts studies published worldwide have revealed a pooled standardized mortality ratio in SSc of 3.5, and reiterated the importance of heart-lung involvement as a major cause of death in this disease. Indeed, the pooled hazard ratio (HR) of mortality in SSc patients with pulmonary arterial hypertension (PAH) compared with those without is 3.5, while the pooled HR for mortality in those with interstitial lung disease is 2.6. The average life expectancy of patients with SSc is 16-34 years less than age-matched and sex-matched population peers. Current research efforts are focused on quantifying early as well as late mortality, and modeling for predictors of death in SSc, with the ultimate goal of attenuating this risk and improving survival, as new therapies emerge. SUMMARY Studies have consistently shown a substantially increased mortality in SSc, predominantly due to cardio-pulmonary complications. A better understanding of risk factors for mortality holds the promise of improving outcomes in this devastating multiorgan autoimmune disease.
Collapse
|
32
|
Boueiz A, Hassoun PM. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pulmonary arterial hypertension associated with connective tissue diseases. Ann Thorac Med 2014; 9:S26-37. [PMID: 25076994 PMCID: PMC4114266 DOI: 10.4103/1817-1737.134016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 12/22/2022] Open
Abstract
The explosive growth of medical literature on pulmonary hypertension (PH) has led to a steady increase in awareness of this disease within the medical community during the past decade. The recent revision of the classification of PH is presented in in the main guidelines. Group 1 PH or pulmonary arterial hypertension (PAH) is a heterogeneous group and includes PH due to inheritable, drug-induced, and toxin-induced causes and to such underlying systemic causes as connective tissue diseases, human immunodeficiency viral infection, portal hypertension, congenital heart disease, and schistosomiasis. Systemic sclerosis (SSc) is an autoimmune multisystem disorder, which affects over 240 persons per million in the United States.[1] Its manifestations are not confined to the skin but may also involve the lungs, kidneys, peripheral circulation, musculoskeletal system, gastrointestinal tract, and heart. The outcome of PAH associated with SSc is worse when compared to other subtypes of PAH. In this review, we summarize available information about the pulmonary vascular and cardiac manifestations of SSc with special emphasis on their prognostic implications as well as the peculiarity of their detection.
Collapse
Affiliation(s)
- Adel Boueiz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
33
|
Marini C, Formichi B, Bauleo C, Michelassi C, Pancani R, Prediletto R, Miniati M, Catapano G, Monti S, Mannucci F, Tavoni A, D'Ascanio A, Pastormerlo LE, Giannoni A, Giuntini C. Improved survival in limited scleroderma-related pulmonary artery hypertension. Intern Emerg Med 2014; 9:385-96. [PMID: 23361526 DOI: 10.1007/s11739-013-0900-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 01/02/2013] [Indexed: 11/28/2022]
Abstract
Reportedly, patients with scleroderma-related pulmonary hypertension (SSc-PAH) respond poorly to new vasoactive drugs (NVD). Forty-nine SSc-PAH patients underwent right heart catheterization (RHC) and, according to NVD availability, divided as follows: Group 1 (n = 23, from 1999 to 2004, poor availability), and Group 2 (n = 26, from 2005 to 2010, good availability). Before diagnostic RHC, NVD had been given to 30 % of the patients in Group 1, and 58 % of those in Group 2 (p = 0.049). At diagnosis, patients in Group 1 had greater heart dilatation (p < 0.01), higher mean pulmonary artery pressure (p < 0.05), lower pulmonary artery capacitance (p < 0.05), and lower carbon monoxide lung diffusing capacity (DLco, p < 0.05) than those in Group 2. At a median follow-up time of 15.5 months, DLco further decreased in Group 1 (p < 0.05), whereas cardiac index increased in Group 2 (p < 0.05). At 36 months of follow-up, 72.4 % of the patients in Group 2 were still alive as opposed to 30.4 % in Group 1 (p = 0.02). In multivariate analysis, DLco and mixed venous oxygen saturation (SvO2) were independent predictors of survival. A value of DLco <7.2 mL/mmHg/min was associated with a hazard ratio (HR) of 5.3 (p < 0.001); for SvO2 <63.8 %, the HR was 3.7 (p < 0.01).NVD have beneficial effects in patients with SSc-PAH. Both DLco and SvO2 are predictors of survival and may assist in planning treatment.
Collapse
Affiliation(s)
- Carlo Marini
- Fondazione Regione Toscana "G. Monasterio", Via G. Moruzzi 1, Ghezzano, 56124, Pisa, Italy,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Akamata K, Asano Y, Aozasa N, Noda S, Taniguchi T, Takahashi T, Ichimura Y, Toyama T, Sato S. Bosentan reverses the pro-fibrotic phenotype of systemic sclerosis dermal fibroblasts via increasing DNA binding ability of transcription factor Fli1. Arthritis Res Ther 2014; 16:R86. [PMID: 24708674 PMCID: PMC4060196 DOI: 10.1186/ar4529] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 03/21/2014] [Indexed: 02/06/2023] Open
Abstract
Introduction Although the pathogenesis of systemic sclerosis (SSc) still remains unknown, recent studies have demonstrated that endothelins are deeply involved in the developmental process of fibrosis and vasculopathy associated with SSc, and a dual endothelin receptor antagonist, bosentan, has a potential to serve as a disease modifying drug for this disorder. Importantly, endothelin-1 (ET-1) exerts a pro-fibrotic effect on normal dermal fibroblasts and bosentan reverses the pro-fibrotic phenotype of SSc dermal fibroblasts. The purpose of this study was to clarify the details of molecular mechanisms underlying the effects of ET-1 and bosentan on dermal fibroblasts, which have not been well studied. Methods The mRNA levels of target genes and the expression and phosphorylation levels of target proteins were determined by reverse transcription real-time PCR and immunoblotting, respectively. Promoter assays were performed using a sequential deletion of human α2 (I) collagen (COL1A2) promoter. DNA affinity precipitation and chromatin immunoprecipitation were employed to evaluate the DNA binding ability of Fli1. Fli1 protein levels in murine skin were evaluated by immunostaining. Results In normal fibroblasts, ET-1 activated c-Abl and protein kinase C (PKC)-δ and induced Fli1 phosphorylation at threonine 312, leading to the decreased DNA binding of Fli1, a potent repressor of the COL1A2 gene, and the increase in type I collagen expression. On the other hand, bosentan reduced the expression of c-Abl and PKC-δ, the nuclear localization of PKC-δ, and Fli1 phosphorylation, resulting in the increased DNA binding of Fli1 and the suppression of type I collagen expression in SSc fibroblasts. In bleomycin-treated mice, bosentan prevented dermal fibrosis and increased Fli1 expression in lesional dermal fibroblasts. Conclusions ET-1 exerts a potent pro-fibrotic effect on normal fibroblasts by activating “c-Abl - PKC-δ - Fli1” pathway. Bosentan reverses the pro-fibrotic phenotype of SSc fibroblasts and prevents the development of dermal fibrosis in bleomycin-treated mice by blocking this signaling pathway. Although the efficacy of bosentan for dermal and pulmonary fibrosis is limited in SSc, the present observation definitely provides us with a useful clue to further explore the potential of the upcoming new dual endothelin receptor antagonists as disease modifying drugs for SSc.
Collapse
|
35
|
Chung L, Domsic RT, Lingala B, Alkassab F, Bolster M, Csuka ME, Derk C, Fischer A, Frech T, Furst DE, Gomberg-Maitland M, Hinchcliff M, Hsu V, Hummers LK, Khanna D, Medsger TA, Molitor JA, Preston IR, Schiopu E, Shapiro L, Silver R, Simms R, Varga J, Gordon JK, Steen VD. Survival and Predictors of Mortality in Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: Outcomes From the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma Registry. Arthritis Care Res (Hoboken) 2014; 66:489-95. [DOI: 10.1002/acr.22121] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 06/02/2013] [Accepted: 08/08/2013] [Indexed: 02/05/2023]
Affiliation(s)
- Lorinda Chung
- Stanford University, Stanford, and VA Palo Alto Health Care System; Palo Alto California
| | | | | | | | | | | | - Chris Derk
- University of Pennsylvania; Philadelphia
| | | | | | | | | | | | - Vivien Hsu
- University of Medicine and Dentistry of New Jersey; Rutgers
| | | | | | | | | | | | | | | | | | - Robert Simms
- Medical University of South Carolina; Charleston
| | | | | | | |
Collapse
|
36
|
Hassoun PM. Therapies for scleroderma-related pulmonary arterial hypertension. Expert Rev Respir Med 2014; 3:187-196. [PMID: 19885388 DOI: 10.1586/ers.09.5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pulmonary arterial hypertension (PAH), a common complication of systemic sclerosis, carries a very severe prognosis and is one of the leading causes of death in patients who suffer from it. Indeed, response to modern medical therapy has been disappointing in scleroderma-related PAH compared with other forms of PAH from the WHO group 1 classification of diseases, despite similar histological changes involving the pulmonary vasculature. This review discusses specific features of scleroderma-related PAH, currently available and US FDA-approved therapy for this syndrome, as well as potential future therapeutic developments based on newly acquired knowledge of this disorder.
Collapse
Affiliation(s)
- Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD 21224, USA, Tel.: +1 410 614 5158, ,
| |
Collapse
|
37
|
Improvement of plasma endothelin-1 and nitric oxide in patients with systemic sclerosis by bosentan therapy. Rheumatol Int 2013; 34:221-5. [PMID: 24071933 DOI: 10.1007/s00296-013-2861-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 09/02/2013] [Indexed: 10/26/2022]
Abstract
The aim of this study was to evaluate the effects of bosentan on plasma endothelin-1 (ET-1) and nitric oxide (NO) as pulmonary hypertension (PH)-associated biochemical markers in patients with systemic sclerosis (SSc). Twenty-four SSc patients receiving bosentan for 24 weeks were registered in this prospective observational study. Ten patients were complicated with clinically suspected PH. Plasma levels of ET-1 and NO were assessed at baseline and after 24 weeks of treatment in SSc patients and in 15 healthy controls. Plasma levels of ET-1 and NO at baseline were significantly higher in SSc patients than in healthy controls (p < 0.000), and they were also significantly higher in SSc patients with PH than in those without PH (p < 0.01). Plasma ET-1 levels were significantly decreased after 24 weeks of bosentan therapy (p < 0.0001), and ET-1 levels of SSc patients with PH decreased to a level comparable to that in patients without PH. In the 10 SSc patients with PH, changes in plasma ET-1 levels during the 24 weeks of the study were significantly larger in the 5 patients whose functional class (FC) improved than in the 5 patients whose FC was unchanged (p < 0.05). Plasma NO levels were also slightly decreased in SSc patients after 24 weeks of bosentan therapy. Plasma ET-1 levels could reflect the presence and severity of PH in SSc patients. Additionally, changes in plasma ET-1 levels may indicate the response to bosentan therapy in SSc patients with PH.
Collapse
|
38
|
Hassoun PM, Shafiq M. Editorial: Tackling the Challenges of Systemic Sclerosis-Associated Pulmonary Hypertension: One Step Forward. ACTA ACUST UNITED AC 2013; 65:2240-2. [DOI: 10.1002/art.38031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/16/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Paul M. Hassoun
- Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Majid Shafiq
- Johns Hopkins University School of Medicine; Baltimore Maryland
| |
Collapse
|
39
|
Költő G, Faludi R, Aradi D, Bartos B, Kumánovics G, Minier T, Czirják L, Komócsi A. Impact of cardiac involvement on the risk of mortality among patients with systemic sclerosis: a 5-year follow-up of a single-center cohort. Clin Rheumatol 2013; 33:197-205. [PMID: 23942767 DOI: 10.1007/s10067-013-2358-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 12/16/2022]
Abstract
Cardiac involvement is among the leading causes of mortality in patients with systemic sclerosis (SSc). Previously, we demonstrated in a single-center, cross-sectional study the frequent coexistence of different forms of cardiac involvement in systemic sclerosis including pulmonary arterial hypertension (PAH), coronary artery disease (CAD), and microvascular dysfunction (MVD). The aim of the present study was to investigate the prognostic significance of cardiac involvement. One hundred twenty patients with SSc were enrolled. All cases underwent a non-invasive cardiovascular protocol. In 30 patients with suspected cardiac involvement, right heart catheterization and intra-coronary pressure-wire-supplemented coronary angiography were performed. Clinical follow-up was 5 years. Patients with CAD at the baseline showed a trend for higher cardiovascular mortality while in patients with MVD this difference was significant (26.7 % versus 9.5 %, p = 0.077 and 30 % versus 10.1 %, p < 0.05, respectively). Cardiovascular mortality of PAH cases was higher but, however, did not reach statistical significance 21.4 % versus 10.4 %, p = 0.261. Cardiovascular event-free survival was significantly lower among patients with combinations of two or three disorders (p < 0.05). Multivariate analysis of organ involvements and comorbidities showed that the diffuse cutaneous subset, the presence of kidney involvement, the velocity of the tricuspid regurgitation, as well as diabetes mellitus were independent predictors of overall mortality. MVD and CAD alone or in combination with PAH significantly affected the 5-year cardiovascular mortality. These findings highlight the prognostic importance of coronary disease in patients with SSc [ www.clinicaltrials.gov (Reg. Nr.: NCT00843102)].
Collapse
Affiliation(s)
- Gyöngyvér Költő
- Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Schioppo T, Artusi C, Ciavarella T, Ingegnoli F, Murgo A, Zeni S, Chighizola C, Meroni PL. N-TproBNP as biomarker in systemic sclerosis. Clin Rev Allergy Immunol 2013; 43:292-301. [PMID: 22669751 DOI: 10.1007/s12016-012-8312-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Systemic sclerosis (SSc) is a connective tissue disorder characterized by tissue fibrosis affecting the skin and internal organs, fibroproliferative vasculopathy, and autoimmune activation. SSc still heralds a poor prognosis with significant morbidity and mortality. Early detection of organ involvement is critical as currently available treatments are most effective when started early. Many candidate biomarkers have been investigated in the past two decades. However, despite the enormous efforts, no accurate tool to predict the pattern of organ involvement and to assess disease activity has been yet identified. The N-terminal fragment of probrain natriuretic peptide (N-TproBNP) is a neurohormone released by ventricular myocytes in response to pressure overload. N-TproBNP is highly relevant for diagnosis, prognosis, and prediction of pulmonary arterial hypertension in SSc. Moreover, several studies support its potential benefit for cardiac assessment of scleroderma patients. Conversely, the role of N-TproBNP as surrogate marker of pulmonary fibrosis and skin involvement is much less clear. We provide an extensive review of the studies that have previously investigated the role of N-TproBNP as candidate biomarker in scleroderma manifestations, presenting also the findings of a recent study we conducted in a cohort of 87 SSc patients.
Collapse
Affiliation(s)
- Tommaso Schioppo
- Chair and Division of Rheumatology, Department of Internal Medicine, Istituto G. Pini, University of Milan & IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | | | | | | | | | | | | |
Collapse
|
41
|
McLaughlin V. Managing pulmonary arterial hypertension and optimizing treatment options: prognosis of pulmonary artery hypertension. Am J Cardiol 2013; 111:10C-5C. [PMID: 23558024 DOI: 10.1016/j.amjcard.2013.01.319] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Survival in patients with pulmonary artery hypertension has improved, but outcomes are still suboptimal. Therapeutic focus must shift from short-term functional changes to improvements in long-term outcomes. Several outcome predictors, both at baseline and on therapy, offer guidance for clinicians treating pulmonary artery hypertension.
Collapse
Affiliation(s)
- Vallerie McLaughlin
- Department of Internal Medicine, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA.
| |
Collapse
|
42
|
Shah AA, Wigley FM. My approach to the treatment of scleroderma. Mayo Clin Proc 2013; 88:377-93. [PMID: 23541012 PMCID: PMC3666163 DOI: 10.1016/j.mayocp.2013.01.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
Systemic sclerosis (scleroderma) is unique among the rheumatic diseases because it presents the challenge of managing a chronic multisystem autoimmune disease with a widespread obliterative vasculopathy of small arteries that is associated with varying degrees of tissue fibrosis. The hallmark of scleroderma is clinical heterogeneity with subsets that vary in the degree of disease expression, organ involvement, and ultimate prognosis. Thus, the term scleroderma is used to describe patients who have common manifestations that link them together, whereas a highly variable clinical course exists that spans from mild and subtle findings to aggressive, life-threatening multisystem disease. The physician needs to carefully characterize each patient to understand the specific manifestations and level of disease activity to decide appropriate treatment. This is particularly important in treating a patient with scleroderma because there is no treatment that has been proven to modify the overall disease course, although therapy that targets specific organ involvement early before irreversible damage occurs improves both quality of life and survival. This review describes our approach as defined by evidence, expert opinion, and our experience treating patients. Scleroderma is a multisystem disease with variable expression; thus, any treatment plan must be holistic, yet at the same time focus on the dominant organ disease. The goal of therapy is to improve quality of life by minimizing specific organ involvement and subsequent life-threatening disease. At the same time the many factors that alter daily function need to be addressed, including nutrition, pain, deconditioning, musculoskeletal disuse, comorbid conditions, and the emotional aspects of the disease, such as fear, depression, and the social withdrawal caused by disfigurement.
Collapse
Affiliation(s)
- Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | |
Collapse
|
43
|
Valerio CJ, Schreiber BE, Handler CE, Denton CP, Coghlan JG. Borderline Mean Pulmonary Artery Pressure in Patients With Systemic Sclerosis: Transpulmonary Gradient Predicts Risk of Developing Pulmonary Hypertension. ACTA ACUST UNITED AC 2013; 65:1074-84. [DOI: 10.1002/art.37838] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 12/18/2012] [Indexed: 02/05/2023]
|
44
|
Abstract
This review updates the clinician on the pathogenesis, differential diagnosis and spectrum of disease in systemic sclerosis. The wide range of current therapeutic options and future targeted molecular therapies are also explored.
Collapse
Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Salford Royal Hospital, Salford, UK.
| | | |
Collapse
|
45
|
Abstract
Pulmonary arterial hypertension (PAH) may complicate diverse connective tissue diseases (CTDs). Approximately 10% of patients with systemic sclerosis develop PAH, the prevalence being much lower in other CTDs. However, PAH is an important contributor to morbidity and mortality in all forms of CTD. Despite similarities in presentation, hemodynamic perturbations, and pathogenesis, patients with CTD-associated PAH (CTD-PAH) usually have a poorer response to PAH-specific medications and poorer prognosis than patients with idiopathic PAH (IPAH). Select patients with CTD-PAH may be candidates for lung transplantation, but results are less favorable than for IPAH because of comorbidities and complications specifically associated with CTD.
Collapse
Affiliation(s)
- Stephen C Mathai
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, Baltimore, MD 21205, USA
| | | |
Collapse
|
46
|
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.
Collapse
|
47
|
Ngian GS, Stevens W, Prior D, Gabbay E, Roddy J, Tran A, Minson R, Hill C, Chow K, Sahhar J, Proudman S, Nikpour M. Predictors of mortality in connective tissue disease-associated pulmonary arterial hypertension: a cohort study. Arthritis Res Ther 2012; 14:R213. [PMID: 23039366 PMCID: PMC3580525 DOI: 10.1186/ar4051] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 10/05/2012] [Indexed: 01/14/2023] Open
Abstract
Introduction Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). We sought to quantify survival and determine factors predictive of mortality in a cohort of patients with CTD-associated PAH (CTD-PAH) in the current era of advanced PAH therapy. Methods Patients with right heart catheter proven CTD-PAH were recruited from six specialised PAH treatment centres across Australia and followed prospectively. Using survival methods including Cox proportional hazards regression, we modelled for all-cause mortality. Independent variables included demographic, clinical and hemodynamic data. Results Among 117 patients (104 (94.9%) with systemic sclerosis), during 2.6 ± 1.8 (mean ± SD) years of follow-up from PAH diagnosis, there were 32 (27.4%) deaths. One-, two- and three-year survivals were 94%, 89% and 73%, respectively. In multiple regression analysis, higher mean right atrial pressure (mRAP) at diagnosis (hazard ratio (HR) = 1.13, 95% CI: 1.04 to 1.24, P = 0.007), lower baseline six-minute walk distance (HR = 0.64, 95% CI: 0.43 to 0.97, P = 0.04), higher baseline World Health Organization functional class (HR = 3.42, 95% CI: 1.25 to 9.36, P = 0.04) and presence of a pericardial effusion (HR = 3.39, 95% CI: 1.07 to 10.68, P = 0.04) were predictive of mortality. Warfarin (HR = 0.20, 95% CI: 0.05 to 0.78, P = 0.02) and combination PAH therapy (HR = 0.20, 95% CI: 0.05 to 0.83, P = 0.03) were protective. Conclusions In this cohort of CTD-PAH patients, three-year survival was 73%. Independent therapeutic predictors of survival included warfarin and combination PAH therapy. Our findings suggest that anticoagulation and combination PAH therapy may improve survival in CTD-PAH. This observation merits further evaluation in randomised controlled trials.
Collapse
|
48
|
Vera-Lastra O, Porres-Aguilar M. Pulmonary arterial hypertension associated with systemic sclerosis: Current diagnostic approach and therapeutic strategies. World J Rheumatol 2012; 2:12-20. [DOI: 10.5499/wjr.v2.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) represents a devastating vascular complication of systemic sclerosis (SSc) and is found in 10%-15% of cases carrying a severe prognosis. PAH has a dramatic impact on the clinical course and overall survival, being the single most common cause of death in patients with this entity. The clinical course and aggressive progression of PAH has led clinicians to perform annual screening for it, since early detection and diagnosis are the cornerstone of a prompt therapeutic intervention. The diagnosis of PAH can be challenging to clinicians, particularly in its early stages, since in the context of SSc, the multiple causes of dyspnea need to be assessed. Doppler echocardiography represents the best initial screening tool, however, right heart catheterization remains the gold standard and definitive diagnostic means. Remarkable advances have been achieved in elucidating the pathogenesis of PAH in the past two decades, leading to the development of disease-specific targeted therapies: prostacyclin analogues, endothelin receptor antagonists and inhibitors of five phosphodiesterase pathways. However, the clinical response to these therapies in SSc-associated PAH has not been as great as the one seen with idiopathic PAH. This review also focuses on the diagnosis and novel therapies that are currently available for PAH, as well as potential future therapeutic developments based on newly acquired knowledge of diverse pathogenic mechanisms.
Collapse
|
49
|
Nitsche A. Raynaud, úlceras digitales y calcinosis en esclerodermia. ACTA ACUST UNITED AC 2012; 8:270-7. [DOI: 10.1016/j.reuma.2012.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 02/23/2012] [Accepted: 02/29/2012] [Indexed: 12/17/2022]
|
50
|
|