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Kanazawa Y, Goda A, Mohri T, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Soejima K, Kohno T. Exercise pulmonary hypertension in patients with systemic sclerosis based on updated guidelines. Sci Rep 2024; 14:13358. [PMID: 38858443 PMCID: PMC11164881 DOI: 10.1038/s41598-024-63823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024] Open
Abstract
Recent European guidelines have introduced the concept of exercise pulmonary hypertension (ex-PH). However, the clinical characteristics of ex-PH in systemic sclerosis (SSc) remains unknown. We aimed to investigate the characteristics of exercise pulmonary hypertension (ex-PH) in patients with systemic sclerosis (SSc), which are unknown. We retrospectively examined 77 patients with SSc who underwent symptom-limited exercise testing using a cycle ergometer with right heart catheterization at our hospital. Nineteen patients with postcapillary PH were excluded. Fifty-eight patients (median age, 63 years; 55 women) were divided into the overt-PH (n = 18, mean pulmonary arterial pressure [PAP] > 20 mmHg and pulmonary vascular resistance > 2 Wood units at rest), ex-PH (n = 19, mean PAP/cardiac output slope > 3), and non-PH (n = 21) groups. Exercise tolerance and echocardiography results were compared among the groups. Peak oxygen consumption was high in the non-PH group, intermediate in the ex-PH group, and low in the overt-PH group (14.5 vs. 13.0 vs. 12.5 mL/kg/min, p = 0.043), and the minute ventilation/peak carbon dioxide production slope was also intermediate in the ex-PH group (32.2 vs. 32.4 vs. 43.0, p = 0.003). The tricuspid annular plane systolic excursion/systolic PAP ratio decreased from non-PH to ex-PH to overt-PH (0.73 vs. 0.69 vs. 0.55 mm/mmHg, p = 0.018). In patients with SSc, exercise PH may represent an intermediate condition between not having PH and overt PH, according to the new guidelines.
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Affiliation(s)
- Yu Kanazawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Budhram B, Weatherald J, Humbert M. Pulmonary Hypertension in Connective Tissue Diseases Other than Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:419-434. [PMID: 38499196 DOI: 10.1055/s-0044-1782217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Pulmonary hypertension (PH) is a known complication of certain connective tissue diseases (CTDs), with systemic sclerosis (SSc) being the most common in the Western world. However, PH in association with non-SSc CTD such as systemic lupus erythematous, mixed connective tissue disease, and primary Sjögren's syndrome constitutes a distinct subset of patients with inherently different epidemiologic profiles, pathophysiologic mechanisms, clinical features, therapeutic options, and prognostic implications. The purpose of this review is to inform a practical approach for clinicians evaluating patients with non-SSc CTD-associated PH.The development of PH in these patients involves a complex interplay between genetic factors, immune-mediated mechanisms, and endothelial cell dysfunction. Furthermore, the broad spectrum of CTD manifestations can contribute to the development of PH through various pathophysiologic mechanisms, including intrinsic pulmonary arteriolar vasculopathy (pulmonary arterial hypertension, Group 1 PH), left-heart disease (Group 2), chronic lung disease (Group 3), chronic pulmonary artery obstruction (Group 4), and unclear and/or multifactorial mechanisms (Group 5). The importance of diagnosing PH early in symptomatic patients with non-SSc CTD is highlighted, with a review of the relevant biomarkers, imaging, and diagnostic procedures required to establish a diagnosis.Therapeutic strategies for non-SSc PH associated with CTD are explored with an in-depth review of the medical, interventional, and surgical options available to these patients, emphasizing the CTD-specific considerations that guide treatment and aid in prognosis. By identifying gaps in the current literature, we offer insights into future research priorities that may prove valuable for patients with PH associated with non-SSc CTD.
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Affiliation(s)
- Brandon Budhram
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marc Humbert
- Université Paris-Saclay, Inserm UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, European Reference Network for Rare Respiratory Diseases (ERN-LUNG), Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Le Kremlin-Bicêtre, France
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Byrne L, McCarthy C, Fabre A, Gupta N. Pulmonary Manifestations of Sjögren's Disease. Semin Respir Crit Care Med 2024; 45:397-410. [PMID: 38621712 DOI: 10.1055/s-0044-1785675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Sjögren's disease (SjD) is a chronic, progressive autoimmune condition of exocrine and extraglandular tissues. It can present with isolated disease characterized by lymphocytic infiltration of salivary or lacrimal glands, but in approximately one-third of the patients, lymphocytic infiltration extends beyond exocrine glands to involve extraglandular organs such as the lungs. Pulmonary complications have been reported to occur between 9 and 27% of patients with SjD across studies. Respiratory manifestations occur on a spectrum of severity and include airways disease, interstitial lung disease, cystic lung disease, and lymphoma. Lung involvement can greatly affect patients' quality of life, has a major impact on the overall prognosis, and frequently leads to alteration in the treatment plans, highlighting the importance of maintaining a high index of clinical suspicion and taking appropriate steps to facilitate early recognition and intervention.
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Affiliation(s)
- Louise Byrne
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Cormac McCarthy
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Aurelie Fabre
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Nishant Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio
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Cullivan S, Cronin E, Gaine S. Pulmonary Hypertension in Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:411-418. [PMID: 38531379 DOI: 10.1055/s-0044-1782607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Systemic sclerosis is a multisystem connective tissue disease that is associated with substantial morbidity and mortality. Visceral organ involvement is common in patients with systemic sclerosis and occurs independently of skin manifestations. Pulmonary hypertension (PH) is an important and prevalent complication of systemic sclerosis. The clinical classification of PH cohorts conditions with similar pathophysiological mechanisms into one of five groups. While patients with systemic sclerosis can manifest with a spectrum of pulmonary vascular disease, notable clinical groups include group 1 pulmonary arterial hypertension (PAH) associated with connective tissues disease, PAH with features of capillary/venous involvement, group 2 PH associated with left heart disease, and group 3 PH associated with interstitial lung disease. Considerable efforts have been made to advance screening methods for PH in systemic sclerosis including the DETECT and ASIG (Australian Scleroderma Interest Group) composite algorithms. Current guidelines recommend annual assessment of the risk of PAH as early recognition may result in attenuated hemodynamic impairment and improved survival. The treatment of PAH associated with systemic sclerosis requires a multidisciplinary team including a PH specialist and a rheumatologist to optimize immunomodulatory and PAH-specific therapies. Several potential biomarkers have been identified and there are several promising PAH therapies on the horizon such as the novel fusion protein sotatercept. This chapter provides an overview of PH in systemic sclerosis, with a specific focus on group 1 PAH.
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Affiliation(s)
- Sarah Cullivan
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eleanor Cronin
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- Department of Respiratory Medicine and Pulmonary Hypertension, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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De Angelis R, Riccieri V, Cipolletta E, Del Papa N, Ingegnoli F, Bosello S, Spinella A, Pellegrino G, de Pinto M, Papa S, Armentaro G, Giuggioli D. Significant nailfold capillary loss and late capillaroscopic pattern are associated with pulmonary arterial hypertension in systemic sclerosis. Rheumatology (Oxford) 2024; 63:1616-1623. [PMID: 37624917 DOI: 10.1093/rheumatology/kead445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE To evaluate differences in nailfold videocapillaroscopy (NVC) findings between SSc patients with and without a diagnosis of pulmonary arterial hypertension (PAH). METHODS One hundred and ten SSc patients were enrolled in this cross-sectional, case-control, multicentre study. Patients were divided into cases (SSc-PAH confirmed by right heart catheterization) and controls (SSc-nonPAH with low probability of PAH). NVC patterns (early, active and late) and morphological parameters (microvascular density, non-specific abnormalities, giant capillaries, micro-haemorrhages, avascular areas) were considered using a semiquantitative scoring system. RESULTS SSc-PAH patients showed higher frequencies of late pattern (P < 0.01), non-specific abnormalities (P < 0.01), lower capillary density (P < 0.01), higher avascular areas (P < 0.01) and a higher mean NVC score (P < 0.01). Contrarily, the early/active pattern (P < 0.01) and a higher rate of micro-haemorrhages (P = 0.04) were more frequent in non-PAH patients. By a multivariate analysis, SSc-PAH patients, compared with non-PAH, had more non-specific abnormalities [27/55, 49.1% vs 10/55, 18.2%; adjusted odd ratio (OR) 16.89; 95% CI: 3.06, 93.16], a lower capillary density (grade 3, 20/55, 36.4% vs 5/55, 9.1%; adjusted OR 38.33; 95% CI: 2.34, 367.80) and avascular areas (18/55, 32.7% vs 10/55, 18.2%; adjusted OR 16.90; 95% CI: 2.64, 44.35). A correlation was found between the mean pulmonary arterial pressure and avascular areas (P < 0.01), capillary density (P < 0.01) and non-specific abnormalities (P < 0.01). A clinical model including the NVC variables may be able to predict a diagnosis of PAH. CONCLUSION Our results indicate that the distinctive peripheral microcirculatory injury of SSc, i.e. capillary loss and morphological abnormalities, appear more severe and pronounced in patients with SSc-PAH.
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Affiliation(s)
- Rossella De Angelis
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
| | - Valeria Riccieri
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
| | - Nicoletta Del Papa
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesca Ingegnoli
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Silvia Bosello
- Institute of Rheumatology and Affine Sciences, Division of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Amelia Spinella
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Greta Pellegrino
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Marco de Pinto
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Papa
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Armentaro
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Dilia Giuggioli
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
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Thoreau B, Mouthon L. Pulmonary arterial hypertension associated with connective tissue diseases (CTD-PAH): Recent and advanced data. Autoimmun Rev 2024; 23:103506. [PMID: 38135175 DOI: 10.1016/j.autrev.2023.103506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 12/24/2023]
Abstract
Pulmonary arterial hypertension (PAH), corresponding to group 1 of pulmonary hypertension classification, is a rare disease with a major prognostic impact on morbidity and mortality. PAH can be either primary in idiopathic and heritable forms or secondary to other conditions including connective tissue diseases (CTD-PAH). Within CTD-PAH, the leading cause of PAH is systemic sclerosis (SSc) in Western countries, whereas systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD) are predominantly associated with PAH in Asia. Although many advances have been made during the last two decades regarding classification, definition early screening and risk stratification and therapeutic aspects with initial combination treatment, the specificities of CTD-PAH are not yet clear. In this manuscript, we review recent literature data regarding the updated definition and classification of PAH, pathogenesis, epidemiology, detection, prognosis and treatment of CTD-PAH.
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Affiliation(s)
- Benjamin Thoreau
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, AP-HP.Centre, Université Paris Cité, Hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Cedex 14 Paris, France; Université Paris Cité, F-75006 Paris, France; INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France.
| | - Luc Mouthon
- Department of Internal Medicine, Referral Center for Rare Autoimmune and Systemic Diseases, AP-HP.Centre, Université Paris Cité, Hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Cedex 14 Paris, France; Université Paris Cité, F-75006 Paris, France; INSERM U1016, Cochin Institute, CNRS UMR 8104, Université Paris Cité, Paris, France
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7
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Corona LFV, Reyna TSR. Right Ventricle and Autoimmune Diseases. Curr Rheumatol Rev 2024; 20:127-132. [PMID: 37861019 DOI: 10.2174/0115733971262676230920102922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 10/21/2023]
Abstract
Autoimmune diseases can express pathologies in specific organs (e.g. thyroid, pancreas, skin) or generate systemic pathologies (generalized lupus erythematosus, rheumatoid arthritis, systemic sclerosis), the latter usually present systemic inflammatory phenomena. Some studies have reported alterations in right ventricular contractility in patients with rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and juvenile idiopathic arthritis, which may contribute to the known outcome of increased cardiovascular risk. However, there is not much information available on the causes that generate these alterations, the most likely being small vessel damage and fibrosis due to subclinical inflammation.1-5 In this sense, the disease in which the alterations of the right ventricle have been more studied is systemic sclerosis, specifically at the changes induced due to pulmonary arterial hypertension, this being one of the main causes of death in this group of patients after the significant decrease in mortality associated with the sclerodermic renal crisis with the treatment of angiotensin-converting enzyme inhibitors. In this review, we will focus on explaining the structural and functional changes that occur in the right ventricle of patients with systemic sclerosis, from early alterations to late complications. In this context, it is necessary to distinguish between right heart alterations that occur in patients with systemic sclerosis and pulmonary arterial hypertension and those that occur without pulmonary arterial hypertension and that can be attributed to other causes such as microvascular damage or myocardial fibrosis.
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8
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Lichtblau M, Titz A, Bahrampoori B, Schmiedeskamp M, Ulrich S. What changed after the 2022 guidelines for pulmonary hypertension? Eur J Intern Med 2023; 118:1-5. [PMID: 37673774 DOI: 10.1016/j.ejim.2023.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
With an estimated prevalence of around 1%, pulmonary hypertension (PH) presents a relevant burden worldwide. In this review, we aim to give an overview of the novelties from the revised European Society of Cardiology (ESC) /European Respiratory Society (ERS) guidelines for the diagnosis and treatment of PH and their implication for the everyday clinical practice.
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Affiliation(s)
- Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | | | - Mark Schmiedeskamp
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
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9
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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10
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Simpson CE, Ambade AS, Harlan R, Roux A, Aja S, Graham D, Shah AA, Hummers LK, Hemnes AR, Leopold JA, Horn EM, Berman-Rosenzweig ES, Grunig G, Aldred MA, Barnard J, Comhair SAA, Tang WHW, Griffiths M, Rischard F, Frantz RP, Erzurum SC, Beck GJ, Hill NS, Mathai SC, Hassoun PM, Damico RL. Kynurenine pathway metabolism evolves with development of preclinical and scleroderma-associated pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2023; 325:L617-L627. [PMID: 37786941 PMCID: PMC11068393 DOI: 10.1152/ajplung.00177.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023] Open
Abstract
Understanding metabolic evolution underlying pulmonary arterial hypertension (PAH) development may clarify pathobiology and reveal disease-specific biomarkers. Patients with systemic sclerosis (SSc) are regularly surveilled for PAH, presenting an opportunity to examine metabolic change as disease develops in an at-risk cohort. We performed mass spectrometry-based metabolomics on longitudinal serum samples collected before and near SSc-PAH diagnosis, compared with time-matched SSc subjects without PAH, in a SSc surveillance cohort. We validated metabolic differences in a second cohort and determined metabolite-phenotype relationships. In parallel, we performed serial metabolomic and hemodynamic assessments as the disease developed in a preclinical model. For differentially expressed metabolites, we investigated corresponding gene expression in human and rodent PAH lungs. Kynurenine and its ratio to tryptophan (kyn/trp) increased over the surveillance period in patients with SSc who developed PAH. Higher kyn/trp measured two years before diagnostic right heart catheterization increased the odds of SSc-PAH diagnosis (OR 1.57, 95% CI 1.05-2.36, P = 0.028). The slope of kyn/trp rise during SSc surveillance predicted PAH development and mortality. In both clinical and experimental PAH, higher kynurenine pathway metabolites correlated with adverse pulmonary vascular and RV measurements. In human and rodent PAH lungs, expression of TDO2, which encodes tryptophan 2,3 dioxygenase (TDO), a protein that catalyzes tryptophan conversion to kynurenine, was significantly upregulated and tightly correlated with pulmonary hypertensive features. Upregulated kynurenine pathway metabolism occurs early in PAH, localizes to the lung, and may be modulated by TDO2. Kynurenine pathway metabolites may be candidate PAH biomarkers and TDO warrants exploration as a potential novel therapeutic target.NEW & NOTEWORTHY Our study shows an early increase in kynurenine pathway metabolism in at-risk subjects with systemic sclerosis who develop pulmonary arterial hypertension (PAH). We show that kynurenine pathway upregulation precedes clinical diagnosis and that this metabolic shift is associated with increased disease severity and shorter survival times. We also show that gene expression of TDO2, an enzyme that generates kynurenine from tryptophan, rises with PAH development.
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Affiliation(s)
- Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Anjira S Ambade
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Robert Harlan
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Aurelie Roux
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Susan Aja
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - David Graham
- Johns Hopkins All Children's Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, United States
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Cornell University Medical Center, New York, New York, United States
| | - Erika S Berman-Rosenzweig
- Division of Pediatric Cardiology, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
| | - Gabriele Grunig
- Divisions of Environmental and Pulmonary Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, United States
| | - Micheala A Aldred
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - John Barnard
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Suzy A A Comhair
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - W H Wilson Tang
- Division of Heart Failure and Transplant Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, United States
| | - Megan Griffiths
- Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Franz Rischard
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, Arizona, United States
| | - Robert P Frantz
- Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Serpil C Erzurum
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Gerald J Beck
- Department of Inflammation and Immunity, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
| | - Nicholas S Hill
- Pulmonary, Critical Care and Sleep Division, Tufts University, Boston, Massachusetts, United States
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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11
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Kularatne M, Boucly A, Savale L, Solinas S, Cheron C, Roche A, Jevnikar M, Jaïs X, Montani D, Humbert M, Sitbon O. Pharmacological management of connective tissue disease-associated pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:2101-2115. [PMID: 37869785 DOI: 10.1080/14656566.2023.2273395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, progressive pulmonary vasculopathy (Group 1 Pulmonary Hypertension (PH)) that complicates the course of many connective tissue diseases (CTD). Detailed testing is required to differentiate PAH from other types of PH caused by CTD such as left heart disease (Group 2 PH), pulmonary parenchymal disease (Group 3 PH), and chronic thromboembolic pulmonary hypertension (Group 4 PH). PAH is most frequently seen in systemic sclerosis but can also be seen with systemic lupus erythematosus, mixed CTD, and primary Sjogren's syndrome. AREAS COVERED This review discusses the epidemiology of CTD-associated PAH, outlines the complex diagnosis approach, and finishes with an in-depth discussion on the current treatment paradigm. Focus is placed on challenges faced in the treatment of CTD-associated PAH, (decreased efficacy and poorer tolerance of pharmacological therapies) and includes a discussion on the future investigational treatments. EXPERT OPINION Despite significant advances over the past decades with more aggressive treatment algorithms, CTD-associated PAH patients continue to have poorer survival compared to those with idiopathic PAH. This review highlights factors leading to disparate outcomes compared to other forms of PAH, and discusses on further improvements that may increase quality of life and survival for CTD-associated PAH patients.
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Affiliation(s)
- Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Céline Cheron
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Virsinskaite R, Karia N, Kotecha T, Schreiber BE, Coghlan JG, Knight DS. Pulmonary hypertension - the latest updates for physicians. Clin Med (Lond) 2023; 23:449-454. [PMID: 37775164 PMCID: PMC10541269 DOI: 10.7861/clinmed.2023-23.5.cardio4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Pulmonary hypertension (PH) is common, with an estimated prevalence of approximately 1% that increases with age. Prompt and accurate diagnosis is key to institute timely and appropriate therapy to improve symptoms and prognosis. The international guidelines for the diagnosis and management of PH have recently been updated, with a lowering of the haemodynamic threshold for diagnosis to a mean pulmonary artery pressure >20 mmHg. New diagnostic algorithms and revised indications for screening in at-risk groups have been developed to facilitate early referral to specialist PH centres. This includes fast-track referral pathways for patients who are either clinically high-risk or are at-risk for pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH). This review summarises key changes in the PH guidelines for general physicians who are, most often, the first healthcare professionals to encounter these patients and consequently have a key role as referrers into specialist PH services.
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Affiliation(s)
- Ruta Virsinskaite
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
| | - Nina Karia
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
| | - Tushar Kotecha
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
| | - Benjamin E Schreiber
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
| | - J Gerry Coghlan
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
| | - Daniel S Knight
- National Pulmonary Hypertension Service, Royal Free Hospital. consultant cardiologist, National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, London, UK
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13
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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14
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Primary Cardiac Involvement in Systemic Sclerosis. Rheum Dis Clin North Am 2023; 49:483-488. [PMID: 37028848 DOI: 10.1016/j.rdc.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Primary cardiac involvement in systemic sclerosis (SSc) is an important cause of morbidity and mortality. Abnormalities of cardiac structure and function can be detected on routine cardiopulmonary screening that is the standard of care for SSc monitoring. Cardiovascular magnetic resonance-extracellular volume (indicating diffuse fibrosis) and cardiac biomarkers may identify at-risk patients who would benefit from further evaluation including screening for atrial and ventricular arrhythmias with implantable loop recorders. The role of algorithm-based cardiac evaluation both before and after therapeutic initiation is one of the many unmet needs for SSc clinical care.
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15
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De Angelis R, Ferri C, Giuggioli D, Bajocchi G, Dagna L, Bellando-Randone S, Zanframundo G, Foti R, Cacciapaglia F, Cuomo G, Ariani A, Rosato E, Lepri G, Girelli F, Riccieri V, Zanatta E, Bosello SL, Cavazzana I, Ingegnoli F, De Santis M, Murdaca G, Abignano G, Romeo N, Della Rossa A, Caminiti M, Iuliano AM, Ciano G, Beretta L, Bagnato G, Lubrano E, De Andres I, Giollo A, Saracco M, Agnes C, Cipolletta E, Lumetti F, Spinella A, Magnani L, Campochiaro C, De Luca G, Codullo V, Visalli E, Di Vico C, Gigante A, Pellagrino G, Pigatto E, Lazzaroni MG, Franceschini F, Generali E, Mennillo G, Barsotti S, Mariano GP, Furini F, Vultaggio L, Parisi S, Peroni CL, Rozza D, Zanetti A, Carrara G, Landolfi G, Scirè CA, Bianchi G, Fusaro E, Sebastiani GD, Govoni M, D'Angelo S, Cozzi F, Guiducci S, Doria A, Salvarani C, Iannone F, Matucci-Cerinic M. Systemic sclerosis sine scleroderma: clinical and serological features and relationship with other cutaneous subsets in a large series of patients from the national registry 'SPRING' of the Italian Society for Rheumatology. RMD Open 2023; 9:rmdopen-2022-002890. [PMID: 36868782 PMCID: PMC9990652 DOI: 10.1136/rmdopen-2022-002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVE To describe demographic, clinical and laboratory features of systemic sclerosis sine scleroderma (ssSSc) in a large multicentre systemic sclerosis (SSc) cohort. METHODS Data involving 1808 SSc patients from Italian Systemic sclerosis PRogression INvestiGation registry were collected. The ssSSc was defined by the absence of any cutaneous sclerosis and/or puffy fingers. Clinical and serological features of ssSSc were compared with limited cutaneous (lcSSc) and diffuse cutaneous (dcSSc) subsets. RESULTS Among patients with SSc, only 61 (3.4%) were classified as having ssSSc (F/M=19/1). Time from Raynaud's phenomenon (RP) onset to diagnosis was longer in ssSSc (3 years, IQR 1-16.5) than lcSSc (2 years, IQR 0-7), and dcSSc (1 year, IQR 0-3) (p<0.001). Clinical ssSSc phenotype was comparable to lcSSc, except for digital pitting scars (DPS) (19.7% vs 42%, p=0.01), but significantly milder than dcSSc, particularly for digital ulcers (DU) (6.6% vs 35.7%, p<0.001), oesophagus (46.2% vs 63.5%, p=0.009), lung (mean diffusion capacity for carbon monoxide 72.2±19.6 vs 62.4±22.8, p=0.009; mean forced vital capacity 105.6±21.7 vs 89.2±20.9, p<0.001) and major videocapillaroscopic alterations (late pattern 8.6% vs 47.6%, p<0.001). Moreover, in ssSSc the percentages of anticentromere and antitopoisomerase were comparable to lcSSc (40% and 18.3% vs 36.7% and 26.6%), but divergent respect to dcSSc (8.6% and 67.4%, p<0.001). CONCLUSION The ssSSc is a quite rare disease variant characterised by clinico-serological features comparable to lcSSc, but significantly different from dcSSc. Overall, longer RP duration, low percentages of DPS and peripheral microvascular abnormalities, and increased anti-centromere seropositivity distinguish ssSSc. Further investigations based on national registries might provide useful insights on the actual relevance of the ssSSc within the scleroderma spectrum.
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Affiliation(s)
- Rossella De Angelis
- Rheumatology Unit - Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy
| | - Dilia Giuggioli
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy
| | - Gianluigi Bajocchi
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy, Reggio Emilia, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, Milano, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence & Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | | | - Rosario Foti
- Rheumatology Unit, A.O.U Policlinico S. Marco, Catania, Italy, Catania, Italy
| | - Fabio Cacciapaglia
- Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Giovanna Cuomo
- Department of Precision Medicine - University of Campania "Luigi Vanvitelli", Naples, Italy, Caserta, Italy
| | - Alarico Ariani
- Department of Medicine, Internal Medicine and Rheumatology, Azienda Ospedaliero Universitaria di Parma, Parma, Italy, Parma, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy, Roma, Italy
| | - Gemma Lepri
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence & Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Francesco Girelli
- Department of Medicine, Rheumatology Unit, Ospedale GB Morgagni - L Pierantoni, Forlì, Italy, Forlì, Italy
| | - Valeria Riccieri
- Department of Rheumatology, Sapienza University of Rome, Rome, Italy, Rome, Italy
| | | | - Silvia Laura Bosello
- Institute of Rheumatology and Affine Sciences, Division of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy, Rome, Italy
| | - Ilaria Cavazzana
- Rheumatology and Clinical Immunology, ASST Spedali Civili of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, Brescia, Italy
| | - Francesca Ingegnoli
- Division of Clinical Rheumatology, ASST Pini, Dept. of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Research Center for Environmental Health, Università degli Studi di Milano, Milan, Italy, Milano, Italy
| | - Maria De Santis
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, and Humanitas University, Pieve Emanuele, Milan, Italy, Rozzano, Italy
| | - Giuseppe Murdaca
- Research Hospital San Martino, University of Genoa, Genoa, Italy, Genova, Italy
| | - Giuseppina Abignano
- Rheumatology Institute of Lucania (IReL) and Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy, Potenza, Italy
| | | | | | - Maurizio Caminiti
- Departmental Rheumatology Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy, Italy
| | | | - Giovanni Ciano
- Hospital of Ariano Irpino, Local Health Department, Ariano Irpino, Avellino, Italy
| | - Lorenzo Beretta
- Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Gianluca Bagnato
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Ennio Lubrano
- Department of Rheumatology, University of Molise, Campobasso, Italy
| | - Ilenia De Andres
- Rheumatology Unit, Azienda Ospedaliera di Rilievo Nazionale ed Alta Specializzazione "Garibaldi", Catania, Italy
| | - Alessandro Giollo
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Marta Saracco
- Rheumatology Unit, Mauriziano-Umberto I Hospital, Torino, Italy
| | | | - Edoardo Cipolletta
- Rheumatology Unit - Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Federica Lumetti
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy
| | - Amelia Spinella
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy
| | - Luca Magnani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy, Reggio Emilia, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, Milano, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, Milano, Italy
| | - Veronica Codullo
- Department of Rheumatology, Policlinico San Matteo, Pavia, Italy, Pavia, Italy
| | - Elisa Visalli
- Rheumatology Unit, A.O.U Policlinico S. Marco, Catania, Italy, Catania, Italy
| | - Claudio Di Vico
- Department of Precision Medicine - University of Campania "Luigi Vanvitelli", Naples, Italy, Caserta, Italy
| | - Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy, Roma, Italy
| | - Greta Pellagrino
- Department of Rheumatology, Sapienza University of Rome, Rome, Italy, Rome, Italy
| | - Erika Pigatto
- Department of Medicine, Villa Salus Hospital, Venice, Italy
| | - Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology, ASST Spedali Civili of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology, ASST Spedali Civili of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, Brescia, Italy
| | - Elena Generali
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, and Humanitas University, Pieve Emanuele, Milan, Italy, Rozzano, Italy
| | - Gianna Mennillo
- Rheumatology Institute of Lucania (IReL) and Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy, Potenza, Italy
| | - Simone Barsotti
- Department of Rheumatology, University of Pisa, Pisa, Italy, Italy
| | - Giuseppa Pagano Mariano
- Departmental Rheumatology Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy, Italy
| | - Federica Furini
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria S. Anna di Ferrara, Ferrara, Italy
| | - Licia Vultaggio
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria S. Anna di Ferrara, Ferrara, Italy
| | - Simone Parisi
- Rheumatology Unit, Città della Salute e della Scienza, Turin, Italy
| | | | - Davide Rozza
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Anna Zanetti
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | | | - Carlo Alberto Scirè
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria S. Anna di Ferrara, Ferrara, Italy.,Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Gerolamo Bianchi
- Rheumatology Unit, Department of Musculoskeletal Sciences, Local Health Trust 3, La Colletta Hospital, Genoa, Italy
| | - Enrico Fusaro
- Rheumatology Unit, Città della Salute e della Scienza, Turin, Italy
| | | | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria S. Anna di Ferrara, Ferrara, Italy
| | - Salvatore D'Angelo
- Rheumatology Institute of Lucania (IReL) and Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy, Potenza, Italy
| | - Franco Cozzi
- Department of Medicine, Villa Salus Hospital, Venice, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence & Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Andrea Doria
- Department of Rheumatology, University of Padua, Padua, Italy
| | - Carlo Salvarani
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, Milano, Italy.,Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence & Division of Rheumatology AOUC, University of Florence, Florence, Italy
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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17
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Hassan HJ, Naranjo M, Ayoub N, Housten T, Hsu S, Balasubramanian A, Simpson CE, Damico RL, Mathai SC, Kolb TM, Hassoun PM. Improved Survival for Patients with Systemic Sclerosis-associated Pulmonary Arterial Hypertension: The Johns Hopkins Registry. Am J Respir Crit Care Med 2023; 207:312-322. [PMID: 36173815 PMCID: PMC9896646 DOI: 10.1164/rccm.202204-0731oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/29/2022] [Indexed: 02/03/2023] Open
Abstract
Rationale: To date, it remains unclear whether recent changes in the management of patients with systemic sclerosis-associated pulmonary hypertension (SSc-PH) have improved survival. Objectives: To describe a cohort of patients with SSc-PH and compare their characteristics and survival between the last two decades. Methods: Patients with SSc-PH prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Center Registry were grouped into two cohorts based on the date of diagnostic right heart catheterization: cohort A included patients whose disease was diagnosed between 1999 and 2010, and cohort B included those whose disease was diagnosed between 2010 and 2021. Patients' characteristics were compared between the two cohorts. Measurements and Main Results: Of 504 patients with SSc-PH distributed almost equally between the two cohorts, 308 (61%) had World Symposium on Pulmonary Hypertension group 1, 43 (9%) had group 2, and 151 (30%) had group 3 disease. Patients with group 1 disease in cohort B had significantly better clinical and hemodynamic characteristics at diagnosis, were more likely to receive upfront combination pulmonary arterial hypertension therapy, and had a nearly 4-year increase in median transplant-free survival in univariable analysis than those in cohort A (P < 0.01). Improved transplant-free survival was still observed after adjusting for patients' baseline characteristics. In contrast, for group 2 or 3 patients with SSc-PH, there were no differences in baseline clinical, hemodynamic, or survival characteristics between the two cohorts. Conclusions: This is the largest single-center study that compares clinical characteristics of patients with SSc-PH between the last two decades. Transplant-free survival has improved significantly for those with group 1 disease over the last decade, possibly secondary to earlier detection and better therapeutic management. Conversely, those with group 2 or 3 disease continue to have dismal prognosis.
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Affiliation(s)
| | - Mario Naranjo
- Division of Pulmonary and Critical Care Medicine and
| | - Nour Ayoub
- Division of Pulmonary and Critical Care Medicine and
| | - Traci Housten
- Division of Pulmonary and Critical Care Medicine and
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine and
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18
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 397] [Impact Index Per Article: 397.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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19
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Kida T, Matsuzaki K, Yokota I, Kawase N, Kadoya M, Inoue H, Kukida Y, Kaneshita S, Inoue T, Wada M, Kohno M, Fukuda W, Kawahito Y, Iwami T. Latent trajectory modelling of pulmonary artery pressure in systemic sclerosis: a retrospective cohort study. RMD Open 2022; 8:rmdopen-2022-002673. [PMID: 36581382 PMCID: PMC9806097 DOI: 10.1136/rmdopen-2022-002673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/15/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To visualise the trajectories of pulmonary arterial pressure (PAP) in systemic sclerosis (SSc) and identify the clinical phenotypes for each trajectory, by applying latent trajectory modelling for PAP repeatedly estimated by echocardiography. METHODS This was a multicentre, retrospective cohort study conducted at four referral hospitals in Kyoto, Japan. Patients with SSc who were treated at study sites between 2008 and 2021 and who had at least three echocardiographic measurements of systolic PAP (sPAP) were included. A group-based trajectory model was applied to the change in sPAP over time, and patients were classified into distinct subgroups that followed similar trajectories. Pulmonary hypertension (PH)-free survival was compared for each trajectory. Multinomial logistic regression analysis was performed for baseline clinical characteristics associated with trajectory assignment. RESULTS A total of 236 patients with 1097 sPAP measurements were included. We identified five trajectories: rapid progression (n=9, 3.8%), early elevation (n=30, 12.7%), middle elevation (n=54, 22.9%), late elevation (n=24, 10.2%) and low stable (n=119, 50.4%). The trajectories, in the listed order, showed progressively earlier elevation of sPAP and shorter PH-free survival. In the multinomial logistic regression analysis with the low stable as a reference, cardiac involvement was associated with rapid progression, diffuse cutaneous SSc was associated with early elevation and anti-centromere antibody was associated with middle elevation; older age of onset was associated with all three of these trajectories. CONCLUSION The pattern of changes in PAP over time in SSc can be classified into five trajectories with distinctly different clinical characteristics and outcomes.
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Affiliation(s)
- Takashi Kida
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan,Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Matsuzaki
- Agency for Health, Safety and Environment, Kyoto University, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Kawase
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hironori Inoue
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Shunya Kaneshita
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Takuya Inoue
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Department of Rheumatology, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Makoto Wada
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Iwami
- Department of Preventive Services, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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20
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Sympatho-Vagal Dysfunction in Systemic Sclerosis: A Follow-Up Study. Life (Basel) 2022; 13:life13010034. [PMID: 36675983 PMCID: PMC9863978 DOI: 10.3390/life13010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/25/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Systemic sclerosis (SSc) patients often present cardiovascular autonomic dysfunction, which is associated with the risk of arrhythmic complications and mortality. However, little is known regarding the progression of cardiac autonomic impairment over time. We aimed to evaluate the cardiac autonomic modulation among SSc with limited cutaneous (lcSSc), diffuse cutaneous (dcSSc) subset, and age-matched healthy control (HC) at baseline (t0) and five-year follow-up (t1). In this follow-up study, ECG was recorded at t0 and t1 in twenty-four SSc patients (dcSSc; n = 11 and lcSSc; n = 13) and 11 HC. The heart rate variability (HRV) analysis was conducted. The spectral analysis identified two oscillatory components, low frequency (LF) and high frequency (HF), and the sympatho-vagal balance was assessed by the LF/HF ratio. The LF/HF increased (p = 0.03), and HF reduced at t1 compared to t0 in dcSSc (p = 0.03), which did not occur in the lcSSc and HC groups. Otherwise, both lcSSc and dcSSc groups presented augmented LF/HF at t0 and t1 compared to HC (p < 0.01). In conclusion, a worsening of cardiac autonomic dysfunction is related to the dcSSc subset, in which a more extent of skin fibrosis and internal organs fibrosis is present.
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21
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Bendstrup E, Kronborg-White S, Møller J, Prior TS. Current best clinical practices for monitoring of interstitial lung disease. Expert Rev Respir Med 2022; 16:1153-1166. [PMID: 36572644 DOI: 10.1080/17476348.2022.2162504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Interstitial lung diseases (ILDs) are a heterogeneous group of inflammatory and/or fibrotic conditions with variable outcome and often a dismal prognosis. Since many ILDs are progressive in nature, monitoring of signs and symptoms of progression is essential to inform treatment decisions and patient counseling. Monitoring of ILDs is a multimodality process and includes all aspects of the disease, e.g. measurement of pulmonary function and exercise capacity, symptom registration and quality of life (QoL), imaging, comorbidities and/or involvement of other organs to assess disease activity, symptom burden, treatment effects, adverse events, the need for supportive and palliative care, and lung transplantation. AREAS COVERED For this narrative review, we searched the PUBMED database to identify articles relevant for monitoring ILDs, including pulmonary function tests, exercise capacity, imaging, telemedicine, symptoms, and QoL. EXPERT OPINION Due to the high heterogeneity of the ILDs and their disease course, an individualized multimodality approach must be applied. Future strategies include use of telemedicine for home monitoring of lung function and symptoms, use of artificial intelligence to support automatized guidance of patients, computerized evaluation of ILD changes on imaging, and new imaging tools with less radiation dosage.
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Affiliation(s)
- Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Sissel Kronborg-White
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Møller
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Skovhus Prior
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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22
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 949] [Impact Index Per Article: 474.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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23
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Chennakesavulu PV, Uppaluri S, Koyi J, Jhaveri S, Avanthika C, Sakhamuri LT, Ashokbhai PK, Singh P. Pulmonary Hypertension in Scleroderma- Evaluation and Management. Dis Mon 2022:101468. [PMID: 36163292 DOI: 10.1016/j.disamonth.2022.101468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary Arterial Hypertension (PAH) is a clinical syndrome consisting of physiologic/hemodynamic criteria that are a consequence of several etiologies. Systemic Sclerosis (SSc), one of the most common causes of PAH, is an autoimmune disorder of the connective tissue leading to fibrosis that involves the skin, gastrointestinal tract, lungs, heart, kidney etc. SSc has an annual prevalence of one to five cases for every 1000 individuals and nearly 15 percent of all cases develop PAH. At its core, Pulmonary hypertension (PH) in SSc is an obliterative vasculopathy in small to medium-sized pulmonary arterioles. A host of other local and systemic mechanisms operate in concert to gradually alter the hemodynamics resulting in elevated pulmonary vascular resistance and thus right ventricular afterload. A diagnosis of PAH in SSc is virtually a death sentence, with studies reporting a mortality rate of 50 per cent in the 3 years of diagnosis. Therefore, developing and implementing a robust screening and diagnosis protocol is crucial in the fight against this pervasive disease. This review aims to summarize the current literature of PAH in SSc, with a special focus on the screening and diagnosis protocols, newer treatment options and prognostic indicators for the same.
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Affiliation(s)
| | - Srikar Uppaluri
- Kamineni Academy of medical sciences and research centre, Hyderabad, India.
| | | | | | | | | | | | - Priyanka Singh
- United health services hospital, Wilson medical center, New York
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24
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Lin CY, Chen HA, Chang TW, Hsu TC, Su YJ. Association of Systemic Sclerosis With Incident Clinically Evident Heart Failure. Arthritis Care Res (Hoboken) 2022. [PMID: 36071607 DOI: 10.1002/acr.25016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 07/28/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Primary myocardial involvement is an important cause of death in systemic sclerosis (SSc). Subclinical diastolic/systolic heart dysfunction is recognized; however, whether this indicates a subsequent increased risk of clinically overt heart failure (HF) remains largely unknown. We aimed to investigate the risk of clinically overt HF in a large, unselected SSc cohort. METHODS This matched, retrospective cohort study was conducted using a nationwide insurance database in Taiwan. Incident SSc patients with no history of HF were identified, and non-SSc comparison groups were selected and matched to the SSc groups by age, sex, and cohort entry time. The cumulative HF incidence was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazards regression was used to calculate adjusted hazard ratios (HRs) for HF hospitalization. RESULTS A total of 1,830 SSc patients and 27,981 controls were identified. The cumulative incidence of hospitalized HF at 3, 5, and 10 years among patients with SSc were 3.5%, 5.3%, and 9.7%, respectively. Compared with non-SSc individuals, SSc patients had an increased risk of HF (adjusted HR 3.26 [95% confidence interval (95% CI) 2.49-4.28]). Subgroup analyses revealed that the impact of SSc on the occurrence of HF was greater among patients ages <50 years than those ages ≥50 years (HR 7.8 [95% CI 4.03-15.1] versus HR 2.78 [95% CI 2.06-3.76]). CONCLUSION SSc is associated with a markedly higher risk of clinically evident HF and not asymptomatic ventricular dysfunction alone. These findings provide real-world evidence suggesting the use of appropriate screening strategies to detect these lethal complications early in SSc.
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Affiliation(s)
- Chun-Yu Lin
- Division of Rheumatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hung-An Chen
- Division of Rheumatology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Tsang-Wei Chang
- National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | | | - Yu-Jih Su
- Kaohsiung Chang Gung Memorial Hospital and School of Medicine, Chang Gung University, Taoyuan, Taiwan
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25
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Giuggioli D, Riccieri V, Cipolletta E, Del Papa N, Ingegnoli F, Spinella A, Pellegrino G, Risa AM, de Pinto M, Papa S, Armentaro G, De Angelis R. Peripheral Microangiopathy Changes in Pulmonary Arterial Hypertension Related to Systemic Sclerosis: Data From a Multicenter Observational Study. Front Cardiovasc Med 2022; 9:924899. [PMID: 35898279 PMCID: PMC9309490 DOI: 10.3389/fcvm.2022.924899] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a connective tissue disease characterized by immune-system alterations, fibrosis involving the skin and internal organs and diffuse microangiopathy. Pulmonary arterial hypertension (PAH) is a severe complication of SSc affecting about 10–15% of the patients and it is a leading cause of mortality. Due to the devastating nature of SSc-PAH, there is a clear need to systematically adopt appropriate screening programs. Nail fold videocapillaroscopy (NVC) studies have shown a more severe peripheral microvascular dysfunction in SSc patients with PAH suggesting that abnormalities in peripheral microcirculation may correlate with pulmonary microangiopathy. This is a cross-sectional study involving four tertiary University Rheumatology Units in the Center-North of Italy. Seventy patients, 35 adults with SSc and PAH confirmed by RHC (F/M 34/1; median age 65.2 ± 8.9 SD yrs), and 35 SSc patients without PAH were enrolled (F/M 3471; median age 63.3 ± 10.3 SD yrs). Clinical, laboratoristic and instrumental data were collected and NVC was performed in all patient. Specific NVC parameters were evaluated and a semi-quantitative rating scale was adopted to score these changes. Finally, patients were distributed into the suitable NVC pattern belonging to the scleroderma pattern. Our aim was to compare the peripheral microangiopathy changes in SSc patients with and without PAH, and to investigate the relationship between NVC findings and the main hemodynamic parameters of pulmonary vasculopathy. Patients with SSc-PAH+ showed a significant higher frequency of interstitial lung disease (ILD). No significant differences regarding clinical and laboratoristic parameters were observed. NVC abnormalities, avascular areas were more frequent in SSc patients with PAH, respect to those without (p = 0.03), and capillary density was significantly lower when considering grade 3 (p = 0.02). A higher NVC semiquantitative mean was found in SSc-PAH+ patients and a greater rate of the “late” pattern was detected in SSc-PAH+ subjects in respect to PAH- (57.1% vs. 25.7%) (p = 0.03). A significant correlations between pulmonary pressure values (sPAP by TTE and mPAP by RHC) and the capillary density (Spearman's rho 0.35, p = 0.04 for both). Our findings provide additional evidence to the literature data, confirming that a higher degree of peripheral nailfold microangiopathy is more common in SSc-PAH patients, and further strengthening the concept that NVC changes may run parallel with similar abnormalities inside pulmonary microcirculation.
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Affiliation(s)
- Dilia Giuggioli
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
- *Correspondence: Dilia Giuggioli
| | - Valeria Riccieri
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Nicoletta Del Papa
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesca Ingegnoli
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Amelia Spinella
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Greta Pellegrino
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Anna Maria Risa
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Marco de Pinto
- Scleroderma Unit, Rheumatology Unit, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Papa
- Scleroderma Clinic, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Armentaro
- Clinical Rheumatology Unit, ASST Pini-CTO, Department of Clinical Science and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Rossella De Angelis
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
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26
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Rodrigues GD, Vicenzi M, Bellocchi C, Beretta L, Carandina A, Tobaldini E, Carugo S, Montano N. The Systolic Pulmonary Arterial Pressure Liaises Impaired Cardiac Autonomic Control to Pro-inflammatory Status in Systemic Sclerosis Patients. Front Cardiovasc Med 2022; 9:899290. [PMID: 35845065 PMCID: PMC9283676 DOI: 10.3389/fcvm.2022.899290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022] Open
Abstract
The current study was undertaken to test the hypothesis that systemic sclerosis (SSc) patients with higher systolic pulmonary arterial pressures (PAPs) present a blunted cardiac autonomic modulation and a pro-inflammatory profile. Thirty-nine SSc patients were enrolled (mean age 57 ± 11 years). ECG and respiration were recorded in the supine (SUP) position and during the active standing (ORT). Heart rate variability (HRV) analysis was performed on samples of 300 beats. The symbolic analysis identified three patterns, 0V%, (sympathetic) and 2UV% and 2LV%, (vagal). The %ΔORT was calculated from the differences between HRV in ORT and SUP, normalized (%) by the HRV values at rest. The PAPs was obtained non-invasively through echocardiography. For the inter-group analysis, participants were allocated in groups with higher (+PAPs ≥ median) and lower PAPs (–PAPs < median) values. At rest, the cardiac sympathetic modulation (represented by 0V%) was positively correlated with PAPs, while parasympathetic modulation (represented by 2LV%) was negatively correlated with PAPs. The dynamic response to ORT (represented by Δ0V% and Δ2LV%), sympathetic and parasympathetic were negatively and positively correlated with PAPs, respectively. The +PAPs group presented a higher inflammatory status and a blunted cardiac autonomic response to ORT (↓Δ0V% and ↑Δ2LV%) compared to the –PAPs group. These findings suggest an interplay among cardiac autonomic control, inflammatory status, and cardiopulmonary mechanics that should be considered for the assessment, monitoring, and treatment of SSc patients.
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Affiliation(s)
- Gabriel D. Rodrigues
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Post Graduation Program in Cardiovascular Sciences, Federal Fluminense University, Niterói, Brazil
- *Correspondence: Gabriel D. Rodrigues,
| | - Marco Vicenzi
- Cardiovascular Disease Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Chiara Bellocchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Beretta
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelica Carandina
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eleonora Tobaldini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Carugo
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Disease Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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27
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Tu J, Jin J, Chen X, Sun L, Cai Z. Altered Cellular Immunity and Differentially Expressed Immune-Related Genes in Patients With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension. Front Immunol 2022; 13:868983. [PMID: 35663995 PMCID: PMC9159786 DOI: 10.3389/fimmu.2022.868983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is the most common connective tissue disease causing pulmonary hypertension (PAH). However, the cause and potential immune molecular events associated with PAH are still unclear. Therefore, it is particularly essential to analyze the changes in SSc-PAH–related immune cells and their immune-related genes. Three microarray datasets (GSE22356, GSE33463, and GSE19617) were obtained by the Gene Expression Omnibus (GEO). Compared with SSc, we found neutrophils have a statistically higher abundance, while T-cell CD4 naive and T-cell CD4 memory resting have a statistically lower abundance in peripheral blood mononuclear cells (PBMCs). Moreover, the results of Gene Set Enrichment Analysis (GSEA) showed there is a differential enrichment of multiple pathways between SSc and SSc-PAH. By combining differentiated expressed genes (DEGs) and immune-related genes (IRGs), fifteen IRGs were selected. In addition, we also analyzed the first five rich Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways and the most abundant Gene Ontology (GO)-molecular functional terms. Furthermore, interleukin-7 receptor (IL-7R), tyrosine–protein kinase (LCK), histone deacetylase 1 (HDAC1), and epidermal growth factor receptor (EGFR) genes were identified as hub genes via protein–protein interaction (PPI) network analysis. The Comparative Toxic Genomics Database (CTD) analysis result showed that LCK, HDAC1, and EGFR have a higher score with SSc. Coexpression network analysis confirmed that IL-7R, LCK, and HDAC1 are key genes related to immune regulation in SSc without PAH and are involved in T-cell immune regulation. Subsequently, using GSE22356 and GSE33463 as the test sets and GSE19617 as the verification set, it was verified that the mRNA expression levels of the three central genes of SSc-PAH were significantly lower than those of the SSc without PAH samples. Consistent with previous predictions, the expressions of IL-7R, LCK, and HDAC1 are positively correlated with the numbers of T-cell CD4 naive and T-cell CD4 memory, while the expressions of IL-7R and LCK are negatively correlated with the numbers of neutrophils in the peripheral blood. Therefore, this evidence may suggest that these three immune-related genes: IL-7R, LCK, and HDAC1, may be highly related to the immunological changes in SSc-PAH. These three molecules can reduce T cells in SSc-PAH PBMCs through the regulation of T-cell activation, which suggests that these three molecules may be involved in the development of SSc-PAH. Meanwhile, the low expression of IL-7R, LCK, and HDAC1 detected in the peripheral blood of SSc may indicate the possibility of PAH and hopefully become a biomarker for the early detection of SSc-PAH. Finally, 49 target miRNAs of 3 specifically expressed hub genes were obtained, and 49 mRNA–miRNA pairs were identified, which provided directions for our further research.
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Affiliation(s)
- Jianxin Tu
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Rheumatology, The First Affiliated Hospital of Wenzhou University, Wenzhou, China
| | - Jinji Jin
- Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou University, Wenzhou, China
| | - Xiaowei Chen
- Department of Rheumatology, The First Affiliated Hospital of Wenzhou University, Wenzhou, China
| | - Li Sun
- Department of Rheumatology, The First Affiliated Hospital of Wenzhou University, Wenzhou, China
| | - Zhen Cai
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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28
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Humbert M. The Long March to a Cure for Pulmonary Hypertension. JACC: ASIA 2022; 2:215-217. [PMID: 36338397 PMCID: PMC9627941 DOI: 10.1016/j.jacasi.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Impact of interstitial lung disease on the survival of systemic sclerosis with pulmonary arterial hypertension. Sci Rep 2022; 12:5289. [PMID: 35347225 PMCID: PMC8960788 DOI: 10.1038/s41598-022-09353-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/11/2022] [Indexed: 11/08/2022] Open
Abstract
To assess severity markers and outcomes of patients with systemic sclerosis (SSc) with or without pulmonary arterial hypertension (PAH-SSc/non-PAH-SSc), and the impact of interstitial lung disease (ILD) on PAH-SSc. Non-PAH-SSc patients from the Spanish SSc registry and PAH-SSc patients from the Spanish PAH registry were included. A total of 364 PAH-SSc and 1589 non-PAH-SSc patients were included. PAH-SSc patients had worse NYHA-functional class (NYHA-FC), worse forced vital capacity (FVC) (81.2 ± 20.6% vs 93.6 ± 20.6%, P < 0.001), worse tricuspid annular plane systolic excursion (TAPSE) (17.4 ± 5.2 mm vs 19.9 ± 6.7 mm, P < 0.001), higher incidence of pericardial effusion (30% vs 5.2%, P < 0.001) and similar prevalence of ILD (41.8% vs. 44.9%). In individuals with PAH-SSc, ILD was associated with worse hemodynamics and pulmonary function tests (PFT). Up-front combination therapy was used in 59.8% and 61.7% of patients with and without ILD, respectively. Five-year transplant-free survival rate was 41.1% in PAH-SSc patients and 93.9% in non-PAH-SSc patients (P < 0.001). Global survival of PAH-SSc patients was not affected by ILD regardless its severity. The multivariate survival analysis in PAH-SSc patients confirmed age at diagnosis, worse NYHA-FC, increased PVR, reduced DLCO, and lower management with up-front combination therapy as major risk factors. In conclusion, in PAH-SSc cohort risk of death was greatly increased by clinical, PFT, and hemodynamic factors, whereas it was decreased by up-front combination therapy. Concomitant ILD worsened hemodynamics and PFT in PAH-SSc but not survival regardless of FVC impairment.
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30
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Zaaroor Levy M, Rabinowicz N, Yamila Kohon M, Shalom A, Berl A, Hornik-Lurie T, Drucker L, Tartakover Matalon S, Levy Y. MiRNAs in Systemic Sclerosis Patients with Pulmonary Arterial Hypertension: Markers and Effectors. Biomedicines 2022; 10:biomedicines10030629. [PMID: 35327430 PMCID: PMC8945806 DOI: 10.3390/biomedicines10030629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/03/2022] [Accepted: 03/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a major cause of death in systemic sclerosis (SSc). Early detection may improve patient outcomes. Methods: We searched for circulating miRNAs that would constitute biomarkers in SSc patients with PAH (SSc-PAH). We compared miRNA levels and laboratory parameters while evaluating miRNA levels in white blood cells (WBCs) and myofibroblasts. Results: Our study found: 1) miR-26 and miR-let-7d levels were significantly lower in SSc-PAH (n = 12) versus SSc without PAH (SSc-noPAH) patients (n = 25); 2) a positive correlation between miR-26 and miR-let-7d and complement-C3; 3) GO-annotations of genes that are miR-26/miR-let-7d targets and that are expressed in myofibroblast cells, suggesting that these miRNAs regulate the TGF-β-pathway; 4) reduced levels of both miRNAs accompanied fibroblast differentiation to myofibroblasts, while macitentan (endothelin receptor-antagonist) increased the levels. WBCs of SSc-noPAH and SSc-PAH patients contained equal amounts of miR-26/miR-let-7d. During the study, an echocardiograph that predicted PAH development, showed increased pulmonary artery pressure in three SSc-noPAH patients. At study initiation, those patients and an additional SSc-noPAH patient, who eventually developed PAH, had miR-let-7d/miR-26 levels similar to those of SSc-PAH patients. This implies that reduced miR-let-7d/miR-26 levels might be an early indication of PAH. Conclusions: miR-26 and miR-let-7d may be serological markers for SSc-PAH. The results of our study suggest their involvement in myofibroblast differentiation and complement pathway activation, both of which are active in PAH development.
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Affiliation(s)
- Mor Zaaroor Levy
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Autoimmune Research Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Noa Rabinowicz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Autoimmune Research Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Maia Yamila Kohon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Autoimmune Research Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Avshalom Shalom
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Department of Plastic Surgery, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Ariel Berl
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Department of Plastic Surgery, Meir Medical Center, Kfar Saba 4428164, Israel
| | | | - Liat Drucker
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Oncogenetic Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Shelly Tartakover Matalon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Autoimmune Research Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
- Correspondence: (S.T.M.); (Y.L.); Tel./Fax: +972-9-74721992 (S.T.M.)
| | - Yair Levy
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (M.Z.L.); (N.R.); (M.Y.K.); (A.S.); (A.B.); (L.D.)
- Autoimmune Research Laboratory, Meir Medical Center, Kfar Saba 4428164, Israel
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba 4428164, Israel
- Correspondence: (S.T.M.); (Y.L.); Tel./Fax: +972-9-74721992 (S.T.M.)
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31
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Mohri T, Goda A, Takeuchi K, Kikuchi H, Inami T, Kohno T, Sakata K, Soejima K, Satoh T. High prevalence of occult left ventricular diastolic dysfunction detected by exercise stress test in systemic sclerosis. Sci Rep 2022; 12:2423. [PMID: 35165319 PMCID: PMC8844378 DOI: 10.1038/s41598-022-06400-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the poor prognosis of systemic sclerosis (SSc) due to the co-occurrence of left ventricular diastolic dysfunction (LVDD), presence of occult LVDD has not been sufficiently investigated. This retrospective study aimed to reveal the prevalence and determinants of occult LVDD in patients with SSc by exercise stress test. Forty-five SSc patients (age, 63 ± 13 years; men/women, 6/39) with normal pulmonary artery pressure and pulmonary artery wedge pressure (PAWP) at rest underwent a symptom-limited exercise test with right heart catheterization using a supine cycle ergometer; haemodynamic parameters at rest, leg raise and during exercise were evaluated. Occult LVDD defined PAWP ≥ 25 mmHg during exercise was seen in 13 patients (29%). Higher PAWP, lower pulmonary vascular resistance and diastolic pulmonary pressure gradient, larger left atrium at rest, and higher PAWP during leg raise (15 ± 4 vs 10 ± 4 mmHg in non-LVDD group, p < 0.001) were observed in the occult LVDD group. The area under the ROC curve for PAWP after leg raise was largest at 0.83 (95% CI: 0.70–0.95, p = 0.001). About one-third (29%) of SSc patients with normal haemodynamics at rest showed occult LVDD. A higher PAWP after leg raise could be useful for detecting occult LVDD.
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32
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Han Z, Li X, Cui X, Yuan H, Wang H. The roles of immune system and autoimmunity in pulmonary arterial hypertension: A Review. Pulm Pharmacol Ther 2021; 72:102094. [PMID: 34740751 DOI: 10.1016/j.pupt.2021.102094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/08/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a chronic disease characterized by increased pulmonary artery pressure which if left untreated, can lead to poor quality of life and ultimately death. It is a group of conditions and includes idiopathic PAH, familial/hereditary PAH and associated PAH. The condition has been studied for many years and its association with the immune system and in particular autoimmunity has been investigated. The mechanisms for the pathobiology of PAH are unclear although research has highlighted the role of adaptive and innate immune systems in its development. Diagnostics and therapeutic approaches range from cytokine treatments to the use of immunomodulating drugs, although there is still scope for improvements in the field. This article discusses the mechanisms linked to PAH, its association with other conditions and recent therapeutic interventions.
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Affiliation(s)
- Zhijie Han
- Department of Rheumatology and Immunology, Laizhou People's Hospital, Laizhou 261400, Shandong Province, China
| | - Xiujuan Li
- Department of Cardiology, Laizhou People's Hospital, Laizhou 261400,Shandong Province, China
| | - Xiuli Cui
- Department of Cardiology, Laizhou People's Hospital, Laizhou 261400,Shandong Province, China
| | - Hongjuan Yuan
- Department of Cardiology, Laizhou People's Hospital, Laizhou 261400,Shandong Province, China
| | - Haiping Wang
- Department of Cardiology, Laizhou People's Hospital, Laizhou 261400,Shandong Province, China.
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33
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Haque A, Kiely DG, Kovacs G, Thompson AAR, Condliffe R. Pulmonary hypertension phenotypes in patients with systemic sclerosis. Eur Respir Rev 2021; 30:30/161/210053. [PMID: 34407977 DOI: 10.1183/16000617.0053-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/04/2021] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension (PH) commonly affects patients with systemic sclerosis (SSc) and is associated with significant morbidity and increased mortality. PH is a heterogenous condition and several different forms can be associated with SSc, including pulmonary arterial hypertension (PAH) resulting from a pulmonary arterial vasculopathy, PH due to left heart disease and PH due to interstitial lung disease. The incidence of pulmonary veno-occlusive disease is also increased. Accurate and early diagnosis to allow optimal treatment is, therefore, essential. Recent changes to diagnostic haemodynamic criteria at the 6th World Symposium on Pulmonary Hypertension have resulted in therapeutic uncertainty regarding patients with borderline pulmonary haemodynamics. Furthermore, the optimal pulmonary vascular resistance threshold for diagnosing PAH and the role of exercise in identifying early disease require further elucidation. In this article we review the epidemiology, diagnosis, outcomes and treatment of the spectrum of pulmonary vascular phenotypes associated with SSc.
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Affiliation(s)
- Ashraful Haque
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Dept of Rheumatology, Royal Hallamshire Hospital, Sheffield, UK.,Both authors contributed equally
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK .,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Both authors contributed equally
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34
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Syed Gaggatur N, Sange AH, Srinivas N, Sarnaik MK, Modi S, Pisipati Y, Vaidya S, Sange I. Systemic Sclerosis: Highlighting Respiratory Complications and Significance of Early Screening. Cureus 2021; 13:e17291. [PMID: 34552830 PMCID: PMC8448757 DOI: 10.7759/cureus.17291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/30/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease that leads the patient to have a diverse clinical presentation encompassing several systems and a worse prognosis, mainly when complications arise. Most SSc-related deaths are caused by pulmonary hypertension (PH) and interstitial lung disease (ILD). This article focuses on pulmonary artery hypertension (PAH) and ILD as pulmonary consequences of SSc. We examined the grave effects regarding SSc's respiratory complications, which are concealed by the disease's clinical heterogeneity. In this article, we briefly reviewed the discussion of clinical features and management and the mortality associated with the sequelae. We further addressed the benefits and significance of screening for the disease and associated respiratory complications in SSc patients in this study.
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Affiliation(s)
| | - Aliya H Sange
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Natasha Srinivas
- Research, B. G. S. Global Institute of Medical Sciences, Bangalore, IND
| | | | - Srimy Modi
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Yasaswi Pisipati
- Internal Medicine, M. S. Ramaiah Medical College, Bangalore, IND
| | - Sarayoo Vaidya
- Internal Medicine, M. S. Ramaiah Medical College, Bangalore, IND
| | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, K. J. Somaiya Medical College, Mumbai, IND
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35
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Ulrich S, Mathai SC. Performance Under Pressure: The Relevance of Pulmonary Vascular Response to Exercise Challenge in Scleroderma. Chest 2021; 159:481-483. [PMID: 33563435 DOI: 10.1016/j.chest.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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36
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Rallidis LS, Papangelopoulou K, Makavos G, Varounis C, Anthi A, Orfanos SE. Low-Dose Dobutamine Stress Echocardiography for the Early Detection of Pulmonary Arterial Hypertension in Selected Patients with Systemic Sclerosis Whose Resting Echocardiography Is Non-Diagnostic for Pulmonary Hypertension. J Clin Med 2021; 10:jcm10173972. [PMID: 34501420 PMCID: PMC8432002 DOI: 10.3390/jcm10173972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) has limited application in systemic sclerosis (SSc). We examined DSE usefulness in revealing pulmonary arterial hypertension (PAH) in selected SSc patients whose resting echocardiography for pulmonary hypertension (PH) was non-diagnostic. METHODS Forty SSc patients underwent right heart catheterization (RHC) and, simultaneously, low-dose DSE (incremental doses up to 20 μg/kg/min). Inclusion criteria were: preserved left and right ventricular (RV) function (tricuspid annulus plane systolic excursion [TAPSE] ≥ 16 mm and tissue Doppler imaging-derived systolic velocity of tricuspid annulus [RVS'] > 10 cm/s), normal pulmonary function tests, and baseline maximal tricuspid regurgitation (TR) velocity of 2.7-3.2 m/s. RESULTS Of 36 patients who completed DSE, resting RHC diagnosed PAH in 12 patients (33.3%). At 20 μg/kg/min, patients with PAH had higher TR velocity, higher pulmonary arterial pressure measured by RHC, and lower RV inotropic response compared with patients without PAH. A cut-off value of maximal TR velocity >3.1 m/s had a sensitivity of 80%, a specificity of 84.2%, and an accuracy of 82.4% for the detection of PAH. CONCLUSIONS Low-dose DSE has a satisfactory diagnostic accuracy for the early detection of PAH in highly selected SSc patients whose baseline echocardiographic measurements for PH lie in the gray zone.
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Affiliation(s)
- Loukianos S. Rallidis
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
- Correspondence: ; Tel.: +30-210-992-9106
| | - Konstantina Papangelopoulou
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Georgios Makavos
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Christos Varounis
- Second Department of Cardiology and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece; (K.P.); (G.M.); (C.V.)
| | - Anastasia Anthi
- Second Department of Critical Care and Pulmonary Hypertension Clinic, Attikon Hospital, School of Medicine, National & Kapodistrian University of Athens, 16462 Athens, Greece;
| | - Stylianos E. Orfanos
- First Department of Critical Care and Pulmonary Hypertension Center, Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece;
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37
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Hjalmarsson C, Kjellström B, Jansson K, Nisell M, Kylhammar D, Kavianipour M, Rådegran G, Söderberg S, Wikström G, Wuttge DM, Hesselstrand R. Early risk prediction in idiopathic versus connective tissue disease-associated pulmonary arterial hypertension: call for a refined assessment. ERJ Open Res 2021; 7:00854-2020. [PMID: 34350280 PMCID: PMC8326683 DOI: 10.1183/23120541.00854-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/14/2021] [Indexed: 11/05/2022] Open
Abstract
Despite systematic screening and improved treatment strategies, the prognosis remains worse in patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) compared to patients with idiopathic/hereditary pulmonary arterial hypertension (IPAH). We aimed to investigate differences in clinical characteristics, outcome and performance of the European Society of Cardiology (ESC)/ European Respiratory Society (ERS) risk stratification tool in these patient groups. This retrospective analysis included incident patients with CTD-PAH (n=197, of which 64 had interstitial lung disease, ILD) or IPAH (n=305) enrolled in the Swedish PAH Register (SPAHR) 2008-2019. Patients were classified as low, intermediate or high risk at baseline, according to the "SPAHR-equation". One-year survival, stratified by type of PAH, was investigated by Cox proportional regression. At baseline, CTD-PAH patients had lower diffusing capacity for carbon monoxide and lower haemoglobin but, at the same time, lower N-terminal prohormone-brain natriuretic peptide, longer 6 min walk distance, better haemodynamics and more often a low-risk profile. No difference in age, World Health Organisation functional class (WHO-FC) or renal function between groups was found. One-year survival rates were 75, 82 and 83% in patients with CTD-PAH with ILD, CTD-PAH without ILD and IPAH, respectively. The 1-year mortality rates for low-, intermediate- and high-risk groups in the whole cohort were 0, 18 and 34% (p<0.001), respectively. Corresponding percentages for CTD-PAH with ILD, CTD-PAH without ILD and IPAH patients were: 0, 26, 67% (p=0.008); 0, 19, 39% (p=0.004); and 0, 16, 29% (p=0.001), respectively. The ESC/ERS risk assessment tool accurately identified low-risk patients but underestimated the 1-year mortality rate of CTD-PAH and IPAH patients assessed as having intermediate risk at diagnosis.
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Affiliation(s)
- Clara Hjalmarsson
- Dept of Cardiology, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Barbro Kjellström
- Dept of Clinical Sciences Lund, Clinical Physiology and Skåne University Hospital, Lund University, Lund, Sweden.,Cardiology Unit, Dept of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kjell Jansson
- Division of Diagnostics and Specialist Medicine, Dept of Health, Medicine and Caring Sciences, and Dept of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Magnus Nisell
- Dept of Medicine Solna, Karolinska Institute, Stockholm, Sweden.,Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - David Kylhammar
- Division of Diagnostics and Specialist Medicine, Dept of Health, Medicine and Caring Sciences, and Dept of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Mohammad Kavianipour
- Dept of Public Health and Clinical Medicine, Sundsvall Research Unit, Umeå University, Umeå, Sweden
| | - Göran Rådegran
- Dept of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Stefan Söderberg
- Dept of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Gerhard Wikström
- Dept of Medical Sciences, Cardiology, Uppsala University, and Uppsala Academic Hospital, Uppsala, Sweden
| | - Dirk M Wuttge
- Dept of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roger Hesselstrand
- Dept of Clinical Sciences Lund, Section of Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
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Zubair A, Waheed S, Shuja F. Psychological impact of cadaveric dissection on first-year medical students. J R Coll Physicians Edinb 2021; 51:392-401. [PMID: 34131680 DOI: 10.4997/jrcpe.2021.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This cross-sectional study was carried out to ascertain if first-time cadaver dissections can cause acute stress disorder (ASD) in medical students, and if death anxiety and gender play a role in the development of these symptoms. METHODS A total of 135 first-year medical students at the Services Institute of Medical Sciences and King Edward Medical University, Lahore, Pakistan, who had recently conducted their first ever cadaver dissection filled out three scales: the Impact of Event Scale-Revised (IES-R), the Appraisal of Life Scale (Revised) (ALS-R) and Death Anxiety Inventory. The results were then calculated via SPSS v.23. Any students with a history of psychiatric treatment or disorder were not included in the study. RESULTS Scores on the IES-R showed that the sample suffered from symptoms of ASD (mean = 36.15, standard deviation = 15.99). Multilinear regression showed that death anxiety did not predict any variance on the scores for IES-R, whereas higher scores on the ALS-R threat domain scale predicted higher scores on the IES-R. Death anxiety had little to no impact on the scores for IES-R. CONCLUSIONS Results showed that students who perceived the dissection situation as threatening and anxiety inducing were more likely to test positively for ASD symptoms. A major limitation of the study was that it did not measure whether these symptoms reduced with repeated exposure to cadaver dissection or how symptoms changed over time.
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Affiliation(s)
- Ambreen Zubair
- South Medical Ward, King Edward Medical University, Lahore, Pakistan
| | - Satia Waheed
- Medical Unit IV Service, Institute of Medical Sciences, Lahore, Pakistan,
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Pan J, Lei L, Zhao C, Wen J, Qin F, Dong F. Clinical characteristics and survival of patients with three major connective tissue diseases associated with pulmonary hypertension: A study from China. Exp Ther Med 2021; 22:925. [PMID: 34306194 PMCID: PMC8280713 DOI: 10.3892/etm.2021.10357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
The present cross-sectional study investigated the clinical characteristics and survival of patients with three types of connective tissue disease associated with pulmonary hypertension (CTD-PH) diagnosed early by echocardiography. A total of 218 patients with CTD-PH were included in the present study. Patients with the three major types of CTD, namely systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and primary Sjögren's syndrome (pSS), were included. PH was diagnosed based on pulmonary arterial systolic pressure >35 mmHg, as measured by Doppler echocardiography. Demographic data, clinical features, laboratory results and echocardiographic parameters were collected and analyzed. The Kaplan-Meier method was used to calculate survival rates. Multivariate analysis was used to identify independent factors affecting mortality. Compared with patients with CTD with pSS (6.5%) or SLE (3.8%), those with SSc had a higher prevalance of PH (12.9%). Patients with SSc-PH had the highest rate of lung involvement (81.2%) and 42.2% of patients were classified as World Health Organization-function class III/IV at the time of diagnosis with PH. The overall survival rate among patients with CTD-PH at 1, 3 and 5 years was 81.4, 72.4 and 56.9%, respectively. Patients with SLE-PH appeared to have the most favorable prognosis and patients with SSc-PH had the poorest relative outcomes. Multivariate analysis revealed that age ≥50 years was the only independent risk factor for mortality. In conclusion, among the patients with CTDs investigated, the prevalence of PH was highest among those with SSc. Patients with SSc-PH had the highest prevalence of pulmonary involvement, the lowest survival rate and the worst prognosis.
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Affiliation(s)
- Jie Pan
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Ling Lei
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Cheng Zhao
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Jing Wen
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Fang Qin
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Fei Dong
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
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40
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Launay D, Sanges S, Sobanski V. Time for precision medicine in systemic sclerosis-associated pulmonary arterial hypertension. Eur Respir J 2021; 57:57/6/2100205. [PMID: 34168056 DOI: 10.1183/13993003.00205-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 01/29/2021] [Indexed: 11/05/2022]
Affiliation(s)
- David Launay
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France .,Inserm, Lille, France.,CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
| | - Sébastien Sanges
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France.,Inserm, Lille, France.,CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
| | - Vincent Sobanski
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France.,Inserm, Lille, France.,CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France.,Institut Universitaire de France (IUF), Lille, France
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Giucă A, Mihai C, Jurcuț C, Gheorghiu AM, Groșeanu L, Dima A, Săftoiu A, Coman IM, Popescu BA, Jurcuț R. Screening for Pulmonary Hypertension in Systemic Sclerosis-A Primer for Cardio-Rheumatology Clinics. Diagnostics (Basel) 2021; 11:diagnostics11061013. [PMID: 34206055 PMCID: PMC8229459 DOI: 10.3390/diagnostics11061013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/20/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare disease, with unfavorable clinical course and prognosis, characterized by progressive multisystemic involvement. SSc associated pulmonary hypertension (SSc-PAH) and interstitial lung disease (ILD) are the most important factors for morbi-mortality in these patients, being responsible for more than 60% of total deaths. Though pulmonary arterial hypertension (PAH) is the dominant subtype seen in SSc, PH secondary to ILD, left-heart pathology, and pulmonary veno-occlusive disease (PVOD) are also possible occurrences. Initial evaluation of a SSc case is complex and should be performed with a multidisciplinary approach. Early detection of SSc-PAH is imperative, given the fact that new and effective medications are available and early treatment was shown to improve outcomes. Therefore, screening algorithms must be used adequately and in a cost-effective manner. Sensitivity and negative predictive value (NPV) are the most important performance measures in a screening test. Several algorithms were developed in the last decade (e.g., DETECT and ASIG) and demonstrated higher efficiency when compared to older algorithms. The present manuscript details the risk factors for SSc-PAH and includes a critical description of current detection algorithms, as a primer for clinicians working in the field of cardio-rheumatology.
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Affiliation(s)
- Adrian Giucă
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
| | - Carina Mihai
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Ciprian Jurcuț
- Department of Internal Medicine, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Ana Maria Gheorghiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology and Internal Medicine, Cantacuzino Clinical Hospital, Str.Ion Movilă nr 5-7, 020475 Bucharest, Romania
| | - Laura Groșeanu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Department of Rheumatology, “Sf. Maria” Clinical Hospital, Bd Ion Mihalache nr 37-39, 011172 Bucharest, Romania
| | - Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Sos Stefan cel Mare nr 19-21, 020125 Bucharest, Romania;
| | - Adrian Săftoiu
- Department of Internal Medicine, Craiova University of Medicine and Pharmacy, Str Petru Rares nr 2, 200349 Craiova, Romania;
| | - Ioan Mircea Coman
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
| | - Bogdan A. Popescu
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
| | - Ruxandra Jurcuț
- Department of Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Fundeni Street no. 258, 022328 Bucharest, Romania; (A.G.); (I.M.C.); (B.A.P.)
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Str Dionisie Lupu nr 37, 020021 Bucharest, Romania; (C.M.); (A.M.G.); (L.G.)
- Correspondence:
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Bellan M, Giubertoni A, Piccinino C, Buffa M, Cromi D, Sola D, Pedrazzoli R, Gagliardi I, Calzaducca E, Zecca E, Patrucco F, Patti G, Sainaghi PP, Pirisi M. Cardiopulmonary Exercise Testing Is an Accurate Tool for the Diagnosis of Pulmonary Arterial Hypertension in Scleroderma Related Diseases. Pharmaceuticals (Basel) 2021; 14:ph14040342. [PMID: 33917930 PMCID: PMC8068386 DOI: 10.3390/ph14040342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
The early diagnosis of pulmonary arterial hypertension (PAH) is a major determinant of prognosis in patients affected by connective tissue diseases (CTDs) complicated by PAH. In the present paper we investigated the diagnostic accuracy of cardiopulmonary exercise testing (CPET) in this specific setting. We recorded clinical and laboratory data of 131 patients who underwent a CPET at a pulmonary hypertension clinic. Out of them, 112 (85.5%) had a diagnosis of CTDs; 8 (6.1%) received a diagnosis of CTDs-PAH and 11 (8.4%) were affected PH of different etiology. Among CPET parameters the following parameters showed the best diagnostic performance for PAH: peak volume of oxygen uptake (VO2; AUC: 0.845, CI95% 0.767-0.904), ratio between ventilation and volume of exhaled carbon dioxide (VE/VCO2 slope; AUC: 0.888, CI95%: 0.817-0.938) and end-tidal partial pressures (PetCO2; AUC: 0.792, CI95%: 0.709-0.861). These parameters were comparable among CTDs-PAH and PH of different etiology. The diagnostic performance was even improved by creating a composite score which included all the three parameters identified. In conclusion, CPET is a very promising tool for the stratification of risk of PAH among CTDs patients; the use of composite measures may improve diagnostic performance.
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Affiliation(s)
- Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
- Correspondence:
| | - Ailia Giubertoni
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Cristina Piccinino
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Mariachiara Buffa
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Debora Cromi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Daniele Sola
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Roberta Pedrazzoli
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Ileana Gagliardi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Elisa Calzaducca
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Erika Zecca
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
| | - Filippo Patrucco
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Giuseppe Patti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy; (A.G.); (M.B.); (D.C.); (I.G.); (E.C.); (E.Z.); (F.P.); (G.P.); (P.P.S.); (M.P.)
- “AOU Maggiore della Carità” Hospital, 28100 Novara, Italy; (C.P.); (D.S.); (R.P.)
- CAAD, (Center for Translational Research on Autoimmune and Allergic Disease) Maggiore della Carità Hospital and Università del Piemonte Orientale UPO, 28100 Novara, Italy
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Nailfold Capillaroscopy in Systemic Sclerosis Patients with and without Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10071528. [PMID: 33917407 PMCID: PMC8038744 DOI: 10.3390/jcm10071528] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
Systemic sclerosis (SSc)-related pulmonary arterial hypertension (SSc-PAH) is a leading cause of mortality in SSc. The extent of peripheral microvasculopathy assessed through nailfold capillaroscopy might correlate with the presence of PAH in SSc patients. We searched the PubMed, Cochrane Library, Scopus, and Web of Science databases and performed a random effects meta-analysis of observational studies comparing nailfold capillaroscopic alterations in SSc-PAH versus SSc-noPAH patients. Weighted mean differences (WMD) with the corresponding confidence intervals (CIs) were estimated. The quality of the included studies was evaluated using a modified Newcastle-Ottawa scale. Seven studies with 101 SSc-PAH and 277 SSc-noPAH participants were included. Capillary density was marginally reduced in the SSc-PAH group (WMD: -1.0, 95% CI: -2.0 to 0.0, I2 = 86%). This effect was strengthened once PAH diagnosis was confirmed by right heart catheterization (WMD: -1.2, 95% CI: -2.3 to -0.1, I2 = 85%). An increase in capillary loop width was observed in SSc-PAH compared to SSc-noPAH patients (WMD: 10.9, 95% CI: 2.5 to 19.4, I2 = 78%). Furthermore, SSc-PAH patients had a 7.3 times higher likelihood of active or late scleroderma pattern (95% CI: 3.0 to 18.0, I2 = 4%). SSc-PAH patients presented with worse nailfold capillaroscopic findings compared to SSc-noPAH patients.
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Khanna D, Zhao C, Saggar R, Mathai SC, Chung L, Coghlan JG, Shah M, Hartney J, McLaughlin V. Long-Term Outcomes in Patients With Connective Tissue Disease-Associated Pulmonary Arterial Hypertension in the Modern Treatment Era: Meta-Analyses of Randomized, Controlled Trials and Observational Registries. Arthritis Rheumatol 2021; 73:837-847. [PMID: 33538058 PMCID: PMC8251834 DOI: 10.1002/art.41669] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
Objective Data on the magnitude of benefit of modern therapies for pulmonary arterial hypertension (PAH) in connective tissue disease (CTD)–associated PAH are limited. In this study, we performed meta‐analyses of randomized, controlled trials (RCTs) and registries to quantify the benefit of these modern therapies in patients with CTD‐PAH. Methods The PubMed and Embase databases were searched for articles reporting data from RCTs or registries published between January 1, 2000 and November 25, 2019. Eligibility criteria included multicenter studies with ≥30 CTD‐PAH patients. For an RCT to be included, the trial had to evaluate an approved PAH therapy, and long‐term risks of clinical morbidity and mortality or 6‐minute walk distance had to be reported. For a registry to be included, survival rates had to be reported. Random‐effects models were used to pool the data. Results Eleven RCTs (total of 4,329 patients; 1,267 with CTD‐PAH) and 19 registries (total of 9,739 patients; 4,008 with CTD‐PAH) were included. Investigational therapy resulted in a 36% reduction in the risk of clinical morbidity/mortality events both in the overall PAH population (hazard ratio [HR] 0.64, 95% confidence interval [95% CI] 0.54, 0.75; P < 0.001) and in CTD‐PAH patients (HR 0.64, 95% CI 0.51, 0.81; P < 0.001) as compared to control subjects. The survival rate was lower in CTD‐PAH patients compared to all PAH patients (survival rate 62%, 95% CI 57, 67% versus 72%, 95% CI 69, 75% at 3 years). The survival rate in CTD‐PAH patients treated primarily after 2010 was higher than that in CTD‐PAH patients treated before 2010 (survival rate 73%, 95% CI 62, 81% versus 65%, 95% CI 59, 71% at 3 years). Conclusion Modern therapy provides a similar reduction in morbidity/mortality risk in patients with CTD‐PAH when compared to the PAH population overall. Risk of death is higher in CTD‐PAH patients than in those with PAH overall, but survival has improved in the last 10 years, which may be related to increased screening and/or new treatment approaches. Early detection of PAH in patients with CTD and up‐front intensive treatment are warranted.
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Affiliation(s)
| | - Carol Zhao
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | | | - Stephen C Mathai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Mehul Shah
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
| | - John Hartney
- Actelion Pharmaceuticals US, Inc., South San Francisco, California
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Leuchte HH, Halank M, Held M, Borst M, Ewert R, Klose H, Lange TJ, Meyer FJ, Skowasch D, Wilkens H, Seyfarth HJ. [Differential Diagnosis of Pulmonary Hypertension Using the Example of Collagenosis-associated PAH in the Context of Chronic Lung and Left Heart Disease]. Pneumologie 2021; 75:122-137. [PMID: 33578434 DOI: 10.1055/a-1204-3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension (PH) can be diagnosed in the context of connective tissue diseases (CTD) as well as in elderly patients with multiple comorbidities. A correct clinical differential diagnosis and classification is essential before adequate therapeutic decisions can be made. Differential diagnosis of PH in CTD comprises associated pulmonary arterial hypertension (APAH), group 2 or 3 PH (PH arising from left heart or chronic lung disease), chronic thromboembolic PH (PH) and group 5 (e. g. in the context of terminal renal insufficiency). This is also true of elderly patients in whom the decision has to be made if the increasing number of coincident diseases lead to PH or have to be interpreted as comorbidities. In this manuscript, the differential diagnosis of PH is elucidated, focusing on CTD, in the context of left heart disease and chronic lung disease. Furthermore, criteria are presented facilitating an objective approach in this context.
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Affiliation(s)
- H H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, Mitglied des DZL
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - M Held
- Klinikum Würzburg Mitte, Standort Missioklinik, Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Würzburg
| | - M Borst
- Medizinische Klinik 1 Caritas-Krankenhaus Bad Mergentheim gemeinnützige GmbH, Bad Mergentheim
| | - R Ewert
- Universitätsmedizin Greifswald. Klinik für Innere Medizin B, Bereich Pneumologie, Greifswald
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Pneumologie, Uniklinik Homburg, Homburg
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
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Bruni C, Guignabert C, Manetti M, Cerinic MM, Humbert M. The multifaceted problem of pulmonary arterial hypertension in systemic sclerosis. THE LANCET. RHEUMATOLOGY 2021; 3:e149-e159. [PMID: 38279370 DOI: 10.1016/s2665-9913(20)30356-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/16/2023]
Abstract
Cardiopulmonary complications are a leading cause of death in systemic sclerosis. Pulmonary hypertension in particular carries a high mortality and morbidity burden. Patients with systemic sclerosis can suffer from all of the clinical groups of pulmonary hypertension, particularly pulmonary arterial hypertension and pulmonary hypertension related to interstitial lung disease. Despite a similar pathogenetic background with idiopathic pulmonary arterial hypertension, different mechanisms determine a worse prognostic outcome for patients with systemic sclerosis. In this Viewpoint, we will consider the link between pathogenetic and potential therapeutic targets for the treatment of pulmonary hypertension in the context of systemic sclerosis, with a focus on the current unmet needs, such as the importance of early screening and detection, the absence of agreed criteria to distinguish pulmonary arterial hypertension with interstitial lung disease from pulmonary hypertension due to lung fibrosis, and the need for a holistic treatment approach to target all the vascular, immunological, and inflammatory components of the disease.
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Affiliation(s)
- Cosimo Bruni
- Division of Rheumatology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Christophe Guignabert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Department of Pulmonary Hypertension, Pathophysiology, and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Mirko Manetti
- Section of Anatomy and Histology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Matucci Cerinic
- Division of Rheumatology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Department of Pulmonary Hypertension, Pathophysiology, and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Ferrari A, Scandura J, Masciulli A, Krichevsky S, Gavazzi A, Barbui T. Prevalence and risk factors for Pulmonary Hypertension associated with chronic Myeloproliferative Neoplasms. Eur J Haematol 2020; 106:250-259. [PMID: 33135220 DOI: 10.1111/ejh.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Pulmonary hypertension (PH) is commonly reported in Philadelphia-chromosome negative myeloproliferative neoplasms (MPNs) including polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF). PH may be diagnosed directly by right heart catheterization (RHC) or estimated by transthoracic echocardiography (TTE). Survival is shortened by PH but despite the potential significance of PH to management and prognosis of MPN, estimates of its prevalence in MPNs vary and risk factors for the condition are poorly established. We performed a systematic review and meta-analysis of available studies to fill this void. METHODS We searched EMBASE, MEDLINE, and Clinicaltrials.gov for the terms "pulmonary hypertension," "myeloproliferative disorders," "polycythemia vera," "essential thrombocythemia," and "myelofibrosis." We restricted analysis to the 1999-2019 window to improve uniformity of MPN diagnostic criteria. We retrieved 221 records and, after abstract and full-text screening, identified 17 papers meeting criteria for inclusion in our meta-analysis. A modified Newcastle-Ottawa scale was used to assess quality. RESULTS Results for 935 patients were available, 309 of these having PH (33%). Using logistic mixed-effect regression, we found that diagnosis mode (RHC vs TTE) and MPN duration influenced PH prevalence. Studies employing predominantly TTE yielded prevalence estimates ~5-fold higher than those using RHC (35% vs 7.2%). We identified MF and duration of MPN as significant risk factors for development of PH. CONCLUSIONS Prevalence of PH in MPNs is poorly understood with estimates ranging from 3.8% to 58%. Patients with MF and longer duration of disease seem at particularly high risk and should be carefully monitored for PH.
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Affiliation(s)
- Alberto Ferrari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Joseph Scandura
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Arianna Masciulli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Antonello Gavazzi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Shostak NA, Klimenko AA, Demidova NA. [The place of riociguat in the treatment of patients with pulmonary arterial hypertension associated with systemic connective tissue diseases]. ACTA ACUST UNITED AC 2020; 60:92-101. [PMID: 33131480 DOI: 10.18087/cardio.2020.9.n1189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/14/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension (PH) can develop in different systemic autoimmune rheumatic diseases (SARD), such as systemic scleroderma (SSD), systemic lupus erythematosus, rheumatoid arthritis, and mixed connective tissue disease In most cases, patients with SARD develop WHO group I PH (pulmonary arterial hypertension associated with systemic connective tissue diseases, PAH-SCTD). General prevalence of this pathology reaches 15 cases per million adults. Most cases of PAH-SCTD are induced by SSD. Survival of PAH-SCTD patients is generally lower than survival of patients with other forms of LAH. Treatment of any SARD, including in LAH, implies a complex approach using glucocorticoids, disease-modifying anti-rheumatic drugs (cyclophosphamide, methotrexate, azathioprine, and others), and genetically engineered biologics. Specific targeted therapy is indicated for most patients with PAH-SCTD. The representative of a new class (soluble guanylate cyclase (sGC) stimulators), riociguat, has been approved for the treatment of PAH. This drug has a unique double mechanism of action: (i) sGC sensibilization to endogenous nitric oxide (NO) by stabilizing the NO-sGC bond; and (ii) direct, NO-independent sGC stimulation. For patients with PAH-SCTD, riociguat is the major alternative to phosphodiesterase-5 inhibitors both as monotherapy and combination therapy.
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Affiliation(s)
- N A Shostak
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - A A Klimenko
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - N A Demidova
- Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
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Krikeerati T, Pussadhamma B, Mahakkanukrauh A, Suwannaroj S, Nanagara R, Foocharoen C. Associated factors of early-onset pulmonary hypertension and clinical difference between early- and late-onset pulmonary hypertension in Thai systemic sclerosis. Mod Rheumatol 2020; 31:649-656. [PMID: 32924684 DOI: 10.1080/14397595.2020.1823067] [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: 10/23/2022]
Abstract
OBJECTIVES Pulmonary hypertension (PH) is a major cause of death in systemic sclerosis (SSc). Detection of early-onset PH and its associated factors would be helpful for improving patient care. Our aims were to determine the factors associated with early-onset PH and to define the differences between early- and late-onset PH among SSc patients. METHODS A cohort study was conducted of 409 adult SSc patients who had followed-up between January 2014 and December 2016. Early-PH is defined when the onset of PH is diagnosed within 5 years of the disease. Logistic regression analysis was applied to determine the factors associated with early-PH. RESULTS In 3409 person-years, we diagnosed 50 cases with PH confirmation by right heart catheterization, of whom 26 were early-PH (incidence 0.7 per 100 person-years; 95%CI:0.5-1.1). Among SSc with early-PH, 69.2% had the diffuse cutaneous SSc subset and the most common PH classification was PH due to interstitial lung disease (18 cases;69.2%). According to a logistic regression analysis, early-PH was associated with a WHO functional class (WHO-FC) II and higher, cardiomegaly according to chest radiography, and tricuspid regurgitation jet maximum velocity (TRVmax)>2.8 m/s with the respective OR of 20.12 (95%CI:1.59-255.35), 7.42 (95%CI:1.35-40.88), and 8.20 (95%CI:1.17-57.64). To contrast, early-PH had a negative association with gastrointestinal involvement (OR 0.08; 95%CI:0.01-0.56). CONCLUSIONS Early-PH is prevalent among SSc patients and the most common cause is interstitial lung disease. A poor WHO-FC, cardiomegaly, and a high TRVmax are associated with early-PH. Gastrointestinal involvement is a protective factor for early-PH in SSc.
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Affiliation(s)
- Thanachit Krikeerati
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Burabha Pussadhamma
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ajanee Mahakkanukrauh
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Siraphop Suwannaroj
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ratanavadee Nanagara
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chingching Foocharoen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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50
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Weatherald J, Humbert M. The ‘great wait’ for diagnosis in pulmonary arterial hypertension. Respirology 2020; 25:790-792. [DOI: 10.1111/resp.13814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jason Weatherald
- Section of Respirology, Department of MedicineUniversity of Calgary Calgary AB Canada
- Libin Cardiovascular Institute of Alberta Calgary AB Canada
| | - Marc Humbert
- Faculty of MedicineUniversité Paris‐Saclay Le Kremlin‐Bicêtre France
- Assistance Publique‐Hôpitaux de Paris (AP‐HP), Department of Respiratory and Intensive Care MedicinePulmonary Hypertension National Referral Center, Hôpital Bicêtre Le Kremlin‐Bicêtre France
- INSERM UMR_S 999Hôpital Marie Lannelongue Le Plessis‐Robinson France
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