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Bairkdar M, Dong Z, Andell P, Hesselstrand R, Holmqvist M. Arrhythmia in patients with systemic sclerosis: incidence, risk factors and impact on mortality in a Swedish register-based study. RMD Open 2024; 10:e004532. [PMID: 39164050 PMCID: PMC11337701 DOI: 10.1136/rmdopen-2024-004532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/03/2024] [Indexed: 08/22/2024] Open
Abstract
OBJECTIVES The objectives of this study are to study the risk of developing cardiac arrhythmia and its subtypes over time in patients with systemic sclerosis (SSc), to assess potential risk factors for arrhythmia in SSc and to explore whether arrhythmia is associated with mortality. METHODS We used nationwide Swedish registers to identify patients with incident SSc 2004-2019 and matched general population comparators (1:10). The primary outcome was incident arrhythmia. Follow-up started at the date of SSc diagnosis and ended at the primary outcome, death, emigration or 31 December 2019. We estimated the incidence of arrhythmia overall and stratified by subtype and explored the relative risk in relation to time since diagnosis using flexible parametric models. We used Cox regression to study risk factors for arrhythmia and the association of arrhythmia with mortality. RESULTS We identified 1565 patients and 16 009 comparators. The overall incidence of arrhythmia was 255 (95% CI 221 to 295) and 119 (95% CI 112 to 127) per 10 000 person years in patients with SSc and comparators, respectively, corresponding to an IRR of 2.1 (95% CI 1.8 to 2.5). The greatest hazard difference between patients with SSc compared with the comparators was seen in the first year of follow-up (HR for arrhythmia 3.0; 95% CI 2.3 to 3.8). Atrial fibrillation and flutter were the most common arrhythmia subtypes. Male sex, index age and pulmonary arterial hypertension were significant risk factors for arrhythmia in SSc. Incident arrhythmia was significantly associated with mortality (HR 2.2; 95% CI 1.6 to 3.0). CONCLUSION SSc is associated with higher incidence of cardiac arrhythmia compared with general population. Arrhythmia seems to be an early manifestation of SSc and is associated with higher mortality.
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Affiliation(s)
- Majd Bairkdar
- Clinical Epidemiology Unit, Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
| | - Zihan Dong
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Pontus Andell
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ME Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Roger Hesselstrand
- Department of Clinical Sciences Lund, Section for Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Marie Holmqvist
- Clinical Epidemiology Unit, Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Medical Unit Gastroenterology, Dermatolgy and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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Sebestyén V, Ratku B, Ujvárosy D, Lőrincz H, Tari D, Végh L, Majai G, Somodi S, Páll D, Szűcs G, Harangi M, Szabó Z. Progranulin, sICAM-1, and sVCAM-1 May Predict an Increased Risk for Ventricular Arrhythmias in Patients with Systemic Sclerosis. Int J Mol Sci 2024; 25:7380. [PMID: 39000486 PMCID: PMC11242860 DOI: 10.3390/ijms25137380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
In systemic sclerosis (SSc), fibrosis of the myocardium along with ongoing autoimmune inflammation can alter the electric function of the cardiac myocytes, which may increase the risk for ventricular arrhythmias and sudden cardiac death. We analyzed the electrocardiographic (ECG) variables describing ventricular repolarization such as QT interval, QT dispersion (QTd), T wave peak-to-end interval (Tpe), and arrhythmogeneity index (AIX) of 26 patients with SSc and 36 healthy controls. Furthermore, echocardiographic and laboratory parameters were examined, with a focus on inflammatory proteins like C-reactive ptotein (CRP), soluble intracellular adhesion molecule-1 (sICAM-1), soluble vascular adhesion molecule-1 (sVCAM-1), and progranulin (PGRN). The CRP, sICAM-1, and sVCAM-1 levels were positively correlated with the length of the QT interval. Although the serum PGRN levels were not increased in the SSc group compared to the controls, in SSc patients, the PGRN levels were positively correlated with the QT interval and the AIX. According to our results, we conclude that there may be a potential association between autoimmune inflammation and the risk for ventricular arrhythmias in patients with SSc. We emphasize that the measurement of laboratory parameters of inflammatory activity including CRP, PGRN, sVCAM-1, and sICAM-1 could be helpful in the prediction of sudden cardiac death in patients with SSc.
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Affiliation(s)
- Veronika Sebestyén
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
- Doctoral School of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Balázs Ratku
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary; (D.P.); (M.H.)
| | - Dóra Ujvárosy
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
| | - Hajnalka Lőrincz
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
| | - Dóra Tari
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (D.T.); (G.S.)
| | - Lilla Végh
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
- Doctoral School of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Gyöngyike Majai
- Division of Clinical Immunology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
| | - Sándor Somodi
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary; (D.P.); (M.H.)
| | - Dénes Páll
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary; (D.P.); (M.H.)
| | - Gabriella Szűcs
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (D.T.); (G.S.)
| | - Mariann Harangi
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary; (D.P.); (M.H.)
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
| | - Zoltán Szabó
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (V.S.); (B.R.); (D.U.); (L.V.); (S.S.)
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Mazza A, Bendini MG, Leggio M, Imberti JF, Valsecchi S, Boriani G. Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients. J Cardiovasc Med (Hagerstown) 2024; 25:551-558. [PMID: 38809231 DOI: 10.2459/jcm.0000000000001641] [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: 05/30/2024]
Abstract
AIMS In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. METHODS We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. RESULTS The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P < 0.001), but not with RBBB. CONCLUSION In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.
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Affiliation(s)
- Andrea Mazza
- Cardiology Division, S. Maria della Stella Hospital, Orvieto
| | | | - Massimo Leggio
- Clinica Salus Infirmorum, S. Filippo Neri Hospital, Rome
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
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Javady-Nejad Z, Jamshidi AR, Aletaha A, Qorbani M, Kavosi H, Soltani A, Gharibdoost F. The presence of abnormal septal motion on echocardiography is a predictor of abnormal cardiac magnetic resonance in systemic sclerosis. Rheumatology (Oxford) 2024; 63:482-489. [PMID: 37216899 DOI: 10.1093/rheumatology/kead235] [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: 10/19/2022] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVES We aimed to perform a comprehensive analysis of the ECG, two-dimensional echocardiography (2DE) and cardiac MRI (CMR) findings in patients with systemic sclerosis (SSc), and also to investigate correlations between CMR findings and some ECG and echocardiography (ECHO) results. METHODS We retrospectively analysed data from patients with SSc who were regularly seen at our outpatient referral centre, all assessed with ECG, Doppler ECHO and CMR. RESULTS Ninety-three patients were included; mean (s.d.) age of 48.5 (10.3) years, 86% female, 52% diffuse SSc. Eighty-four (90%) of the patients had sinus rhythm. The most common ECG finding was the left anterior fascicular block, recorded in 26 patients (28%). The abnormal septal motion (ASM) was found in 43 (46%) patients on ECHO. Myocardial involvement (inflammation or fibrosis), as assessed by multiparametric CMR, was present in >50% of our patients. The age- and sex-adjusted model showed that ASM on ECHO increased significantly the odds of increased extracellular volume [odds ratio (OR) 4.43, 95% CI 1.73, 11.38], increased T1 Relaxation time (OR 2.67, 95% CI 1.09, 6.54), increased T2 Relaxation time (OR 2.56, 95% CI 1.05, 6.22), increased signal intensity ratio in T2-weighted imaging (OR 2.56, 95% CI 1.05, 6.22), presence of late gadolinium enhancement (OR 3.85, 95% CI 1.52, 9.76) and mid-wall fibrosis (OR 3.64, 95% CI 1.48, 8.96). CONCLUSION This study indicates that the presence of ASM on ECHO is a predictor of abnormal CMR in SSc patients, and a precise assessment of ASM may serve as an important point for selecting the patients that should be evaluated by CMR for early detection of myocardial involvement.
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Affiliation(s)
- Zahra Javady-Nejad
- Rheumatology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad-Reza Jamshidi
- Rheumatology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Aletaha
- Evidence-Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Department of Epidemiology and Biostatistics, Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Hoda Kavosi
- Rheumatology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Akbar Soltani
- Evidence-Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Gharibdoost
- Rheumatology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
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De Luca G, Matucci-Cerinic M, Mavrogeni SI. Diagnosis and management of primary heart involvement in systemic sclerosis. Curr Opin Rheumatol 2024; 36:76-93. [PMID: 37962165 DOI: 10.1097/bor.0000000000000990] [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: 11/15/2023]
Abstract
PURPOSE OF REVIEW In systemic sclerosis (SSc) primary heart involvement (pHI) is frequent, even though often unrecognized due to its occult nature and to the lack of a specific diagnostic algorithm. The purpose of this review is to report the state of the art of the evidence in the current literature, as well as the overall diagnostic modalities and therapeutic strategies for primary heart involvement in SSc. RECENT FINDINGS SSc-pHI is defined by the presence of cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications; it may be sub-clinical and must be confirmed through diagnostic investigations. Novel electrocardiographic analysis and cardiac magnetic resonance (CMR) with mapping techniques have been recently proposed, showing a great utility in the early identification of SSc-pHI and in the noninvasive characterization of myocardial tissue. Immunosuppressive therapy emerged as fundamental to curb myocardial inflammation, and recent preclinical and clinical data support the role of antifibrotic drugs to treat SSc-pHI. SUMMARY our review will help clinicians to properly integrate the available diagnostic modalities for the assessment of SSc-pHI. The ultimate goal is to propose a feasible diagnostic algorithm for the early identification of patients with SSc-pHI, and a schematic therapeutic approach to manage SSc-pHI.
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Affiliation(s)
- Giacomo De Luca
- Vita-Salute San Raffaele University
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sophie I Mavrogeni
- Onassis Cardiac Surgery Center
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Healthcare, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Fairley JL, Ross L, Quinlivan A, Hansen D, Paratz E, Stevens W, Kistler PM, McLellan A, La Gerche A, Nikpour M. Sudden cardiac death, arrhythmias and abnormal electrocardiography in systemic sclerosis: A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 62:152229. [PMID: 37354723 DOI: 10.1016/j.semarthrit.2023.152229] [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: 03/03/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To calculate the frequency of sudden cardiac death(SCD), arrhythmia and conduction defects in SSc. METHODS MEDLINE/EMBASE were searched to January 2023. English-language studies reporting the incidence/frequency of SCD, arrhythmia and electrocardiography(ECG) abnormalities in SSc were included. Odds ratios(OR), estimations of annual incidence or pooled frequencies were calculated. RESULTS Seventy-nine studies(n = 13,609 participants with SSc) were included in the meta-analysis. Methodology and outcomes were heterogeneous. Ten studies included cohorts with known/suspected SSc-associated heart involvement(SHI), generally defined as clinically-manifest cardiac disease/abnormal cardiac investigations. The incidence of SCD in SHI was estimated to be 3.3% annually(n = 4 studies, 301PY follow-up). On ambulatory ECG, 18% of SHI cohorts had non-sustained ventricular tachycardia(NSVT; n = 4, 95%CI3.2-39.3%), 70% frequent premature ventricular complexes (PVCs; n = 1, 95%CI34.8-93.3%), and 8% atrial fibrillation (AF; n = 1, 95%CI4.2-13.6%). Nineteen studies included participants without SHI, defined as normal cardiac investigations/absence of cardiac disease. The estimated incidence of SCD was approximately 2.9% annually (n = 1, 67.5PY). Compared to healthy controls, individuals without SHI demonstrated NSVT 13.3-times more frequently (n = 2, 95%CI2-102), and paroxysmal supraventricular tachycardia 7-times more frequently (n = 4, 95%CI3-15). Other ambulatory ECG abnormalities included NSVT in 9% (n = 7, 95%CI6-14%), >1000 PVCs/24 h in 6% (n = 2, 95%CI1-13%), and AF in 7% (n = 5, 0-21%). Fifty studies included general SSc cohorts unselected for cardiac disease. The incidence of SCD was estimated to be 2.0% annually(n = 4 studies, 1646PY). Unselected SSc cohorts were 10.5-times more likely to demonstrate frequent PVCs (n = 2, 95%CI 2-59) and 2.5-times more likely to have an abnormal electrocardiography (n = 2, 95%CI1-4). CONCLUSIONS The incidence of SCD in SSc is estimated to be 1.0-3.3% annually, at least 10-fold higher than general population estimates. Arrhythmias including NSVT and frequent PVCs appear common, including amongst those without known/suspected SHI.
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Affiliation(s)
- Jessica L Fairley
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Laura Ross
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alannah Quinlivan
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dylan Hansen
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Paratz
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Wendy Stevens
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The University of Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Australia
| | - Alex McLellan
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andre La Gerche
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- The University of Melbourne, Melbourne, Victoria, Australia; St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
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López Núñez L, Carrión-Barberà I, Molina L, Padró I, Ciria M, Salman-Monte TC, Pros A. Left ventricular dysfunction and arrhythmias in asymptomatic patients with systemic sclerosis. Med Clin (Barc) 2023; 160:434-442. [PMID: 36813685 DOI: 10.1016/j.medcli.2022.11.022] [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: 09/14/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 02/22/2023]
Abstract
INTRODUCTION AND AIMS Cardiac involvement in systemic sclerosis (SS) is frequently silent and a major cause of mortality in these patients. This work aims to study the prevalence and associations of left ventricular dysfunction (LVD) and arrhythmias in SS. METHODS AND RESULTS Prospective study of SS patients (n=36), excluding those with symptoms of (or) cardiac disease, pulmonary arterial hypertension or cardiovascular risk factors (CVRF). A clinical, analytical, electrocardiogram (EKG), Holter, and echocardiogram with global longitudinal strain (GLS) assessment were performed. Arrhythmias were classified into clinically significant arrhythmias (CSA) and non-significant. Twenty-eight percent had left ventricular diastolic dysfunction (LVDD), 22% LV systolic dysfunction (LVSD) according to the GLS, 11.1% both, and 16.7% cardiac dysautonomia. Fifty percent presented alterations by EKG (44% CSA), 55.6% by Holter (75% CSA) and 8.3% CSA by both. An association was found between the elevation of troponin T (TnTc) and CSA and between the elevation of both NT-proBNP and TnTc with LVDD. CONCLUSIONS We found a higher prevalence of LVSD than in the literature, detected by GLS and being 10 times higher than that detected by LVEF, which justifies the need to incorporate this technique in the routine evaluation of these patients. The association of TnTc and NT-proBNP with LVDD suggests that they can be used as minimally invasive biomarkers of this affectation. The absence of correlation between LVD and CSA indicates that the arrhythmias could be due, not only to a supposed structural alteration of the myocardium, but to an independent and early cardiac involvement, which should be actively investigated even in asymptomatic patients without CVRF.
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Affiliation(s)
- Lilian López Núñez
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain
| | | | - Luis Molina
- Cardiology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain
| | - Isabel Padró
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain
| | - Manel Ciria
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain
| | | | - Ana Pros
- Rheumatology Department, Hospital del Mar/Parc de Salut Mar, Barcelona, Spain
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Lee KI, Manuntag LJ, Kifayat A, Manuntag SE, Sperber K, Ash JY, Frishman WH, Wasserman A. Cardiovascular Manifestations of Systemic Sclerosis: An Overview of Pathophysiology, Screening Modalities, and Treatment Options. Cardiol Rev 2023; 31:22-27. [PMID: 34619709 DOI: 10.1097/crd.0000000000000420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Systemic sclerosis, previously known as scleroderma, is a heterogeneous, systemic disease that is defined by its 3 pathological hallmarks: the production of autoantibodies, small vessel vasculopathy, and fibroblast dysfunction, leading to an increased deposition of extracellular matrix. We conducted a review of the available literature that covers the cardiovascular manifestations of SSc: electrical conduction abnormalities, pulmonary hypertension, pericardial disease, and atherosclerosis. Within each major category, we will discuss the definition, diagnostics, and available treatment options. Increased mortality from cardiovascular complications necessitates early screening and management. Annual screening with noninvasive modalities is encouraged. The current management of each complication generally follows the management algorithms of patients regardless of SSc status and is dependent on the severity of the patient's clinical presentation.
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Affiliation(s)
- Kyu-In Lee
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Levy Jo Manuntag
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Alina Kifayat
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | | | - Kirk Sperber
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Julia Yegudin Ash
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Allergy/Immunology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Amy Wasserman
- Department of Rheumatology, Westchester Medical Center/New York Medical College, Valhalla, NY
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9
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Arrhythmias and Conduction Disturbances in Patients with Systemic Sclerosis—A Systematic Literature Review. Int J Mol Sci 2022; 23:ijms232112963. [PMID: 36361752 PMCID: PMC9658897 DOI: 10.3390/ijms232112963] [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: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/29/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease characterized by skin and internal organ fibrosis and microvascular impairment, which can affect major organs, including the heart. Arrhythmias are responsible for approximately 6% of deaths in patients with SSc, and mainly occur due to myocardial fibrosis, which causes electrical inhomogeneity. The aim of this study was to determine the frequency of arrhythmias and conduction disturbances in SSc cohorts, and to identify the characteristics and risk factors associated with the occurrence of dysrhythmias in patients with SSc. A systematic literature review using PubMed, Embase, Web of Science and Scopus databases was performed. Full-text articles in English with arrhythmias as the main topic published until 21 April 2022 were included. Most prevalent arrhythmias were premature supraventricular and ventricular contractions, while the most frequent conduction disturbance was represented by right bundle branch block (RBBB). Elevated concentrations of N-terminal prohormones of brain natriuretic peptides (NT-pro BNP) were associated with numerous types of atrial and ventricular arrhythmias, and with the occurrence of RBBB. A lower value of the turbulence slope (TS) emerged as an independent predictor for ventricular arrhythmias. In conclusion, dysrhythmias are frequent in SSc cohorts. Paraclinical and laboratory parameters are useful instruments that could lead to early diagnosis in the course of the disease.
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10
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Paul A, Paul A, Subhash I, Yadav B, Jacob JR, Christopher DJ, Balamugesh T. Atrial depolarization abnormalities in pulmonary sarcoidosis. Egypt Heart J 2022; 74:74. [PMID: 36209309 PMCID: PMC9547766 DOI: 10.1186/s43044-022-00312-7] [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: 02/09/2022] [Accepted: 09/22/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiac sarcoidosis, often manifested as sudden death, can be the first manifestation of sarcoidosis. Since 12-lead electrocardiogram (ECG) is recommended as an initial screening tool for cardiac sarcoidosis, the recognition of subtle abnormalities assumes utmost significance. The objective of this study was to identify the electrocardiographic abnormalities in patients with pulmonary sarcoidosis. RESULTS A detailed analysis of 12-lead ECGs obtained from sixty patients with histopathologically proven pulmonary sarcoidosis and no overt cardiac involvement was done. The findings were compared with those of an age-matched control group. Varying degrees of intraventricular conduction defects were common in the study group [67%], as well as the control group [57%] [P = 0.23]. There was a higher prevalence of biphasic P wave [P = 0.003] and bifid P wave [P = 0.029] in lead III and rsr' in lead aVF [P = 0.03] in the study group as compared to the control group. CONCLUSIONS Our study demonstrates a greater prevalence of subtle ECG abnormalities in patients with pulmonary sarcoidosis as compared to patients with other forms of pulmonary disease. Atrial depolarization abnormalities were commoner in patients with pulmonary sarcoidosis.
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Affiliation(s)
- Amal Paul
- grid.11586.3b0000 0004 1767 8969Department of Cardiology, Christian Medical College and Hospital (CMCH), Vellore, India ,grid.416265.20000 0004 1767 487XMOSC Medical Mission Hospital, Aduputty Hills, Kunnamkulam, Thrissur, Kerala 680503 India
| | - Akhil Paul
- grid.11586.3b0000 0004 1767 8969Department of Pulmonary Medicine, Christian Medical College and Hospital (CMCH), Vellore, India
| | - Immanuel Subhash
- grid.11586.3b0000 0004 1767 8969Department of Pulmonary Medicine, Christian Medical College and Hospital (CMCH), Vellore, India
| | - Bijesh Yadav
- grid.11586.3b0000 0004 1767 8969Department of Biostatistics, Christian Medical College and Hospital (CMCH), Vellore, India
| | - John Roshan Jacob
- grid.11586.3b0000 0004 1767 8969Department of Cardiology and Cardiac Electrophysiology, Christian Medical College and Hospital (CMCH), Vellore, India
| | - D. J. Christopher
- grid.11586.3b0000 0004 1767 8969Department of Pulmonary Medicine, Christian Medical College and Hospital (CMCH), Vellore, India
| | - T. Balamugesh
- grid.11586.3b0000 0004 1767 8969Department of Pulmonary Medicine, Christian Medical College and Hospital (CMCH), Vellore, India
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11
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Glynn P, Hale S, Hussain T, Freed BH. Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management. Front Cardiovasc Med 2022; 9:846213. [PMID: 35433887 PMCID: PMC9008238 DOI: 10.3389/fcvm.2022.846213] [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: 12/30/2021] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations. SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis. While cardiac involvement is the second leading SSc-related cause of death, it is frequently clinically silent in early disease and often missed with routine screening. To facilitate identification of cardiac disease in this susceptible population, we present here a review of cardiac imaging modalities and potential uses in the SSc patient population. We describe well-characterized techniques including electrocardiography and 2D echocardiography with Doppler, but also discuss more advanced imaging approaches, such as speckle-tracking echocardiography, cardiovascular magnetic resonance imaging (CMR), and stress imaging, among others. We also suggest an algorithm for the appropriate application of these modalities in the workup and management of patients with SSc. Finally, we discuss future opportunities for cardiac imaging in SSc research to achieve early detection and to optimize treatment.
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Affiliation(s)
- Peter Glynn
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sarah Hale
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Tasmeen Hussain
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Benjamin H. Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- *Correspondence: Benjamin H. Freed,
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12
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Radwan YA, Kurmann RD, Sandhu AS, El-Am EA, Crowson CS, Matteson EL, Osborn TG, Warrington KJ, Mankad R, Makol A. Systemic Sclerosis Portends Increased Risk of Conduction and Rhythm Abnormalities at Diagnosis and During Disease Course: A US Population-Based Cohort. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 6:277-285. [PMID: 35295788 DOI: 10.1177/23971983211034074] [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: 11/17/2022]
Abstract
Objectives To study the incidence, risk factors and outcomes of conduction and rhythm disorders in a population-based cohort of patients with systemic sclerosis (SSc) vs. non-SSc comparators. Methods An incident cohort of patients with SSc (1980-2016) from Olmsted County, MN was compared to age- and sex-matched non-SSc subjects (1:2). Electrocardiograms (ECGs), Holter ECGs, and need for cardiac interventions were reviewed to determine the occurrence of any conduction or rhythm abnormalities. Results 78 incident SSc cases and 156 comparators were identified (mean age 56 y, 91% female). The prevalence of any conduction disorder prior to SSc diagnosis compared to non-SSc subjects was 15% vs. 7% (p=0.06), and any rhythm disorder was 18% vs. 13% (p=0.33). During a median follow-up of 10.5 years in patients with SSc and 13.0 years in non-SSc comparators, conduction disorders developed in 25 patients with SSc with cumulative incidence of 20.5% (95% CI: 12.4-34.1%) vs. 28 non-SSc patients with cumulative incidence of 10.4% (95% CI: 6.2-17.4%) (HR: 2.57; 95% CI: 1.48-4.45), while rhythm disorders developed in 27 patients with SSc with cumulative incidence of 27.3% (95% CI: 17.9-41.6%) vs. 43 non-SSc patients with cumulative incidence of 18.0% (95% CI: 12.3-26.4%) (HR: 1.62; 95% CI: 1.00-2.64). Age, pulmonary hypertension and smoking were identified as risk factors. Conclusion Patients with SSc have an increased risk of conduction and rhythm disorders both at disease onset and over time, compared to non-SSc patients. These findings warrant increased vigilance and screening for ECG abnormalities in SSc patients with pulmonary hypertension.
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Affiliation(s)
- Yasser A Radwan
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Reto D Kurmann
- Division of Cardiovascular Disease, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Avneek S Sandhu
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Edward A El-Am
- Division of Cardiovascular Disease, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Thomas G Osborn
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Rekha Mankad
- Division of Cardiovascular Disease, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ashima Makol
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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13
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Ross L, Paratz E, Baron M, La Gerche A, Nikpour M. Sudden Cardiac Death in Systemic Sclerosis: Diagnostics to Assess Risk and Inform Management. Diagnostics (Basel) 2021; 11:1781. [PMID: 34679479 PMCID: PMC8534599 DOI: 10.3390/diagnostics11101781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Cardiac disease is a leading cause of death in systemic sclerosis (SSc) and sudden cardiac death (SCD) is thought to occur more commonly in SSc than in the general population. Diffuse myocardial fibrosis, myocarditis and ischaemic heart disease are all prevalent in SSc and can be reasonably hypothesised to contribute to an increased risk of SCD. Despite this, SCD remains a relatively understudied area of SSc with little understood about SSc-specific risk factors and opportunities for primary prevention. In this review, we present an overview of the possible mechanisms of SCD in SSc and our current understanding of how each of these mechanisms may contribute to cardiac death. This review highlights the need for a future research agenda that addresses the underlying epidemiology of SCD in SSc and identifies opportunities for intervention to modify the disease course of heart disease in SSc.
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Affiliation(s)
- Laura Ross
- Department of Rheumatology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia;
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
| | - Elizabeth Paratz
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
- Department of Cardiology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Murray Baron
- Department of Rheumatology, Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T 1E2, Canada;
| | - André La Gerche
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
- Department of Cardiology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia;
- Department of Medicine, The University of Melbourne at St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; (E.P.); (A.L.G.)
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14
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Lui JK, Sangani RA, Chen CA, Bujor AM, Trojanowski MA, Gopal DM, LaValley MP, Soylemez Wiener R, Klings ES. The Prognostic Value of Cardiac Axis Deviation in Systemic Sclerosis-related Pulmonary Hypertension. Arthritis Care Res (Hoboken) 2021; 74:1219-1226. [PMID: 34085410 DOI: 10.1002/acr.24724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/01/2021] [Accepted: 06/01/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Systemic sclerosis-related pulmonary hypertension (SSc-PH) is a common complication of SSc associated with accelerated mortality. We hypothesized that cardiac axis deviation may indicate abnormalities in cardiac function allowing for prognostication of disease severity and mortality. METHODS This was a retrospective study where electrocardiograms (ECGs) were reviewed for cardiac axis deviation and their association with echocardiography and cardiopulmonary hemodynamics on right heart catheterization. The primary outcome observed was all-cause mortality from the time of PH diagnosis. RESULTS ECGs were reviewed from 169 patients with SSc-PH. Right axis deviation (RAD) and left axis deviation (LAD) occurred in 28.4% and 30.8% of patients with SSc-PH, respectively. Compared to those without, patients with RAD exhibited predominantly right-sided cardiac disease on echocardiography and increased PH severity by cardiopulmonary hemodynamics including a greater mean pulmonary artery pressure (42.0 ± 12.5 mm Hg vs. 29.8 ± 7.0 mm Hg) and pulmonary vascular resistance (645.6 ± 443.2 dyn·s/cm5 vs. 286.3 ± 167.7 dyn·s/cm5 ). LAD was associated with predominantly left-sided cardiac disease on echocardiography but was not associated with PH severity on cardiopulmonary hemodynamics. Both RAD (HR: 10.36; 95% CI: 4.90 - 21.93; p < 0.001) and LAD (HR: 2.94; 95% CI: 1.53 - 5.68; p = 0.001) were associated with an increased hazard for all-cause mortality. CONCLUSION RAD and LAD reflect structural cardiac abnormalities and are associated with poor prognosis in patients with SSc-PH. These findings support the importance of electrocardiography, an inexpensive, widely available non-invasive test, in risk stratification.
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Affiliation(s)
- Justin K Lui
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Clara A Chen
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Deepa M Gopal
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Renda Soylemez Wiener
- Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts
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15
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Abstract
Primary systemic sclerosis heart involvement (pSHI) is an important disease manifestation that accounts for a significant proportion of systemic sclerosis (SSc)-associated mortality. A broad clinical spectrum of pSHI exists, which ranges from asymptomatic perfusion abnormalities to diastolic dysfunction or acute myocarditis and congestive heart failure. With improving sensitivity of cardiac investigations, it is increasingly recognized that there is a large burden of subclinical cardiac disease in patients with SSc. Early signs of pSHI can be subtle and determining the etiology of cardiac abnormalities from other causes of cardiomyopathy such as hypertension, ischemic heart disease (IHD), and pulmonary vascular disease remain challenging. Early identification of pSHI potentially provides clinicians with a window of opportunity for intervention to avert progression to heart failure. However, optimal screening and treatment guidelines are lacking, and it is an area of much needed further clinical research.
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16
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Gaba P, Pedrotty D, DeSimone CV, Bonikowske AR, Allison TG, Kapa S. Mortality in Patients With Right Bundle-Branch Block in the Absence of Cardiovascular Disease. J Am Heart Assoc 2020; 9:e017430. [PMID: 32924743 PMCID: PMC7792408 DOI: 10.1161/jaha.120.017430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Right bundle-branch block (RBBB) occurs in 0.2% to 1.3% of people and is considered a benign finding. However, some studies have suggested increased risk of cardiovascular morbidity and mortality. We sought to evaluate risk attributable to incidental RBBB in patients without prior diagnosis of cardiovascular disease (CVD). Methods and Results We reviewed the Mayo Clinic Integrated Stress Center database for exercise stress tests performed from 1993 to 2010. Patients with no known CVD-defined as absence of coronary disease, structural heart disease, heart failure, or cerebrovascular disease-were selected. Only Minnesota residents were included, all of whom had full mortality and outcomes data. There were 22 806 patients without CVD identified; 220 of whom (0.96%) had RBBB, followed for 6 to 23 years (mean 12.4±5.1). There were 8256 women (36.2%), mean age was 52±11 years; and 1837 deaths (8.05%), including 645 cardiovascular-related deaths (2.83%), occurred over follow-up. RBBB was predictive of all-cause (hazard ratio [HR], 1.5; 95% CI, 1.1-2.0; P=0.0058) and cardiovascular-related mortality (HR,1.7; 95% CI, 1.1-2.8; P=0.0178) after adjusting for age, sex, diabetes mellitus, hypertension, obesity, current and past history of smoking, and use of a heart rate-lowering drug. Patients with RBBB exhibited more hypertension (34.1% versus 23.7%, P<0.0003), decreased functional aerobic capacity (82±25% versus 90±24%; P<0.0001), slower heart rate recovery (13.5±11.5 versus 17.1±9.4 bpm; P<0.0001), and more dyspnea (28.2% versus 22.4%; P<0.0399) on exercise testing. Conclusions Patients with RBBB without CVD have increased risk of all-cause mortality, cardiovascular-related mortality, and lower exercise tolerance. These data suggest RBBB may be a marker of early CVD and merit further prospective evaluation.
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Affiliation(s)
- Prakriti Gaba
- Department of Medicine Columbia University Medical Center New York NY
| | - Dawn Pedrotty
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | | | - Amanda R Bonikowske
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
| | - Thomas G Allison
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
| | - Suraj Kapa
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
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17
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Sebestyén V, Szűcs G, Páll D, Ujvárosy D, Ötvös T, Csige I, Pataki T, Lőrincz I, Szabó Z. Electrocardiographic markers for the prediction of ventricular arrhythmias in patients with systemic sclerosis. Rheumatology (Oxford) 2020; 59:478-486. [PMID: 31943100 PMCID: PMC7032033 DOI: 10.1093/rheumatology/kez644] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/02/2019] [Indexed: 12/27/2022] Open
Abstract
SSc is an autoimmune disease characterized by microvascular damage, endothelial dysfunction and fibrosis of the skin and the internal organs. Cardiac manifestation in patients with SSc is one of the major organ involvements. Approximately 20% of SSc patients suffer from primary cardiovascular disease and another 20% may have secondary cardiac involvement. Although cardiac arrhythmias are mostly linked to myocardial fibrosis, atrioventricular conduction abnormalities are secondary to the fibrosis of the pulse conduction system. Despite the severe consequences of ventricular rhythm disturbances in patients with SSc, the exact role of electrocardiographic markers in the prediction of these arrhythmias has not yet been clearly elucidated. Therefore, the question is whether certain ECG parameters reflecting ventricular repolarization may help to recognize scleroderma patients with increased risk for ventricular arrhythmias and sudden cardiac death.
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Affiliation(s)
- Veronika Sebestyén
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | | | - Dénes Páll
- Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dóra Ujvárosy
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Tamás Ötvös
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Imre Csige
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Public HealthUniversity of Debrecen, Debrecen, Hungary
| | - Tamás Pataki
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
| | - István Lőrincz
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
| | - Zoltán Szabó
- Department of Emergency Medicine, Faculty of MedicineUniversity of Debrecen, Debrecen, Hungary
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18
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Hung G, Mercurio V, Hsu S, Mathai SC, Shah AA, Mukherjee M. Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis. Curr Rheumatol Rep 2019; 21:68. [PMID: 31813082 PMCID: PMC11151284 DOI: 10.1007/s11926-019-0867-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW Systemic sclerosis (scleroderma) is a complex autoimmune disease that commonly involves the cardiovascular system. Even if often subclinical, cardiac involvement is considered a poor prognostic factor as it is a leading cause of death in scleroderma patients. We review the cardiac manifestations of scleroderma, the diagnostic methods useful in detection, and current advances in therapeutic management. RECENT FINDINGS Beside the routine exams for the assessment of cardiac status (including EKG, standard echocardiography, provocative tests) novel techniques such as myocardial strain imaging on echocardiography, cardiac magnetic resonance imaging, invasive hemodynamic assessment, and endomyocardial biopsy have been demonstrated to be useful in understanding the cardiac alterations that typically affect scleroderma patients. Recent application of novel cardiac detection strategies is providing increased insight into the breadth and pathogenesis of cardiac complications of scleroderma. Further studies coupling exercise provocation, invasive and imaging assessment, and mechanistic studies in scleroderma cardiac tissue are needed to develop the optimal approach to early detection of cardiac disease in scleroderma and targeted therapies.
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Affiliation(s)
- George Hung
- Division of Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4100, Baltimore, MD, 21224, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA.
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19
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Defining primary systemic sclerosis heart involvement: A scoping literature review. Semin Arthritis Rheum 2019; 48:874-887. [DOI: 10.1016/j.semarthrit.2018.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/09/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
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20
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Bosello S, De Luca G, Berardi G, Canestrari G, de Waure C, Gabrielli FA, Di Mario C, Forni F, Gremese E, Ferraccioli G. Cardiac troponin T and NT-proBNP as diagnostic and prognostic biomarkers of primary cardiac involvement and disease severity in systemic sclerosis: A prospective study. Eur J Intern Med 2019; 60:46-53. [PMID: 30366614 DOI: 10.1016/j.ejim.2018.10.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/27/2018] [Accepted: 10/16/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The aim of our study was to define the role of high-sensitive cardiac troponin T (hs-cTnT) and NT-proBNP in identifying Systemic Sclerosis (SSc) patients with cardiac involvement and at higher risk of cardiac death. METHODS Plasma hs-cTnT and NT-proBNP concentrations were measured in 245 SSc-patients. RESULTS hs-cTnT and NT-proBNP levels were higher in SSc-patients than in healthy controls. Hs-cTnT levels were higher than 0.014 ng/ml in 32.3% SSc-patients, while NT-proBNP was above 125 pg/ml in 31.8% of them, irrespective of classical cardiovascular risk factor and of pulmonary arterial hypertension. Elevated hs-cTnT and NT-proBNP were associated with diffuse skin involvement and directly correlated with the skin score. Patients with increased cardiac markers presented a lower left-ventricular ejection fraction (LVEF) and a higher rate of right bundle branch block (RBBB) on electrocardiogram (ECG) compared to patients with normal cardiac enzymes. During the follow-up, 12 SSc-patients experience a disease-related death; 9 of these were directly related to cardiac involvement (sudden cardiac death or heart failure) and the majority of them occurred among patients with increase of at least one cardiac biomarker. Long-term survival was worse in patients with increase of both cardiac biomarkers. CONCLUSIONS Evaluation of hs-cTnT and NT-proBNP levels may provide a tool to screen non-invasively SSc-patients for heart involvement. A higher incidence of impaired systolic function, ECG abnormalities and a poor outcome in SSc-patients with elevated cardiac enzymes suggests that they may be valuable screening biomarkers to detect a cardiac damage at early stages and to improve risk stratification.
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Affiliation(s)
- Silvia Bosello
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, 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.
| | - Giorgia Berardi
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Giovanni Canestrari
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Chiara de Waure
- Department of Experimental Medicine, University of Perugia, Italy.
| | | | - Clara Di Mario
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy; Institute of Biochemistry, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Franca Forni
- Institute of Biochemistry, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Elisa Gremese
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Gianfranco Ferraccioli
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
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21
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Javinani A, Javady Nejad Z, Gharibdoost F, Jamshidi AR, Yekta RA, Alvand S, Imeni V, Hashemi SN, Kavosi H. Bundle Branch Blocks and Fragmented QRS Complex in Iranian Patients with Systemic Sclerosis. J Tehran Heart Cent 2019; 14:6-11. [PMID: 31210764 PMCID: PMC6560258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Cardiac involvement, as one of the life-threatening manifestations of systemic sclerosis (SSc), is chiefly caused by collagen fiber deposition in the myocardium, which subsequently leads to conduction abnormalities. In the present study, we aimed to investigate the prevalence and clinical significance of bundle branch blocks (BBBs) and the fragmented QRS complex (fQRS) in Iranian patients with SSc. Methods: Forty-one patients with SSc were enrolled from the outpatient SSc clinic of Shariati Hospital, Tehran University of Medical Sciences, between October 2016 and February 2017. Twelve-lead ECG was obtained and interpreted for BBBs and the fQRS. To adjust for the confounding effects of non-SSc-related cardiovascular risk factors, we calculated the Framingham risk score to estimate the risk of cardiovascular diseases. The associations between the studied conduction abnormalities and SSc cutaneous subtypes; disease duration; and the Medsger SSc severity scale of cutaneous, pulmonary, and vascular involvements were also analyzed. Results: The study population consisted of 41 Iranian patients with SSc at a mean age of 47.48±11.57 years (82.9% female). The prevalence of BBBs and the fQRS was 26.8% and 36.6%, respectively. The fQRS was associated with the limited cutaneous SSc subtype (OR: 0.100, 95%CI: 0.018-0.553, and P=0.028). BBBs and the fQRS were not associated with either the Framingham risk score or the rest of the clinicodemographic variables. Conclusion: BBBs and the fQRS were more prevalent in our patients with SSc, without any association with the involvement of the other organs. These findings may suggest the independent pathophysiology of cardiac involvement in SSc.
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Affiliation(s)
- Ali Javinani
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Zahra Javady Nejad
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Farhad Gharibdoost
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ahmad Reza Jamshidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Reza Atef Yekta
- Department of Anesthesiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Saba Alvand
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Vahide Imeni
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyed Naser Hashemi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hoda Kavosi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Corresponding Author: Hoda Kavosi, Assistant Professor of Rheumatology Research Center, Shariati Hospital, Jalal-e-Al-e-Ahmad Hwy., Tehran, Iran. 1411713137. Tel: +98 218 8220067. Fax: +98 218 8220067. E-mail: .
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22
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Electrocardiographic Findings in Systemic Sclerosis. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2018. [DOI: 10.2478/sjecr-2018-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Systemic sclerosis (SSc) is an autoimmune connective tissue disease which affects various tissues and organs, including skin, lungs, kidneys, gastrointestinal tract and cardiovascular system. Cardiac involvement is the most commonly recognized problem and a significant cause of morbidity. Abnormal ECG is present in 25-75% of patients with SSc and is considered to be an independent predictor of mortality. It is known that the supraventricular arrhythmias are considered as more common in SSc patients, occurring in about two-thirds of the cases, and more often than ventricular tachyarrhythmias. It has been established that right bundle branch block is associated with an increased risk of mortality and that it is an independent predictor of mortality, and should be considered as a marker of the severity of the disease in SSc. Th e prolonged QTc interval is an independent risk factor for a sudden cardiac death reflecting the instability of repolarization and predisposing the onset of cardiac arrhythmias.The prognosis of the disease depends on the SSc subtype and the involvement of internal organs. SSc is a lifelong disease and cannot be cured, but knowing that cardiac dysfunction significantly worsens the prognosis, early detection of cardiac complications and appropriate therapy can influence its progress and improve the patients’ quality of life.
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Wang Q, Shang Y, Li S, Wu Y, Wang C, Yan X. Complete heart block in systemic sclerosis: A case report and literature review. Medicine (Baltimore) 2018; 97:e13226. [PMID: 30431601 PMCID: PMC6257444 DOI: 10.1097/md.0000000000013226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Complete heart block (CHB) is a common clinical manifestation. Systemic sclerosis (SSc) is a rare etiology of CHB that has not received enough attention. Whether pacemaker implantation is required remains inconclusive, especially when patients have no symptoms or mild symptoms of CHB. PATIENT CONCERNS In this study, we report the case of a 48-year-old Chinese male who suffers from SSc and CHB. DIAGNOSE The patient was previously diagnosed with left anterior hemiblock (LAHB) and right bundle block with normal heart function. CHB was observed on a regular follow-up electrocardiogram (ECG) examination 1 month before his hospitalization. INTERVENTIONS A permanent dual chamber pacemaker was implanted. OUTCOMES The patient responded well to pacemaker implantation treatment, and his exertional dyspnea disappeared. LESSONS The occurrence of heart block associated with SSc often appears concealed. The case highlights the importance of regular follow-up of a patient with SSc. Pacemaker implantation might be unavoidable if CHB is secondary to SSc, even if it is asymptomatic.
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Affiliation(s)
- Qinghai Wang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing
| | - Yinghui Shang
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Shicheng Li
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing
| | - Yanxiang Wu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing
| | - Chenyu Wang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing
| | - Xiaowei Yan
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing
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Hu S, Hou Y, Wang Q, Li M, Xu D, Zeng X. Prognostic profile of systemic sclerosis: analysis of the clinical EUSTAR cohort in China. Arthritis Res Ther 2018; 20:235. [PMID: 30348207 PMCID: PMC6235213 DOI: 10.1186/s13075-018-1735-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Systemic sclerosis is a disease that has significant clinical heterogeneity. This study aims to determine the causes and risk factors of death in a single center European League Against Rheumatism Scleroderma Trials and Research Group (EUSTAR) cohort at the Peking Union Medical College Hospital (PUMCH) in China. METHODS Patients clinically diagnosed with systemic sclerosis (SSc) between Feb 2009 and Dec 2015 were prospectively recruited from the EUSTAR database and Chinese Rheumatism Data Center (CRDC) of the PUMCH. Baseline and follow-up data were collected. Kaplan-Meier analysis was used to estimate survival, and Cox proportional hazards regression analysis was used to identify factors associated with mortality. RESULTS A total of 448 patients were included in the cohort, of whom 56.7% had limited cutaneous systemic sclerosis (lcSSc). The average age at diagnosis was 42.8 ± 12.1 years. The prevalence of interstitial lung disease (ILD) was 382/447 (85.5%). Among 402 patients, 348 of them took glucocorticoid during the disease course; 374 patients received immunosuppressors. Across 2167 patient-years, 40 patients died. Of these, 27 deaths were attributable to SSc, with pulmonary arterial hypertension (PAH) being the leading cause of death. The median survival time was 53 months. Survival rates from disease diagnosis were 97.0%, 94.6%, 91.1% and 87.8% at 1, 3, 5 and 10 years, respectively. Independent prognostic factors for mortality were PAH (HR 6.248, 95% CI 2.855, 13.674) and arrhythmia (HR 4.729, 95% CI 1.588, 14.082). Tripterygium wilfordii Hook F (TwHF) (log-rank test 7.851, p 0.005) and methotrexate (MTX) (log-rank test 7.925, p = 0.005) were found in survival analysis to be protective treatments against mortality. Patients who used cyclophosphamide (CTX) during the disease course had poorer prognosis (log-rank test 5.177, p = 0.023). CONCLUSIONS In china, although there is a high prevalence of ILD in patients with SSc (85.5%), most of them have reserved pulmonary function, which means that interstitial lung disease (ILD) is not the most important factor in the death of patients with SSc and also is not a risk factor for poor prognosis. Only ILD with pulmonary dysfunction is associated with poor outcome. The 10-year cumulative rate (87.8%) in patients with SSc in China is slightly lower than the Europe, and pulmonary arterial hypertension (PAH) and arrhythmia at baseline are independent prognostic factors, whereas PAH instead of ILD is the leading cause of death in patients with SSc. Interestingly, the Chinese traditional medicine TwHF, as a protective factor for survival deserves further study.
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Affiliation(s)
- Shasha Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
| | - Yong Hou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730 China
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Differences in Right Ventricular Functional Changes during Treatment between Systemic Sclerosis-associated Pulmonary Arterial Hypertension and Idiopathic Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2018; 14:682-689. [PMID: 28282243 DOI: 10.1513/annalsats.201608-655oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Patients with systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) continue to have an unacceptably high mortality rate despite the progress achieved with pulmonary arterial vasodilator therapies. OBJECTIVES We sought to determine whether SSc-PAH is a clinically distinct pulmonary vascular disease phenotype when compared with idiopathic pulmonary arterial hypertension (IPAH) on the basis of progression of echocardiographic right ventricular (RV) dysfunction. METHODS Retrospective analysis of echocardiographic data in 13 patients with SSc-PAH and 11 patients with IPAH was used to delineate the progression of RV dysfunction during single or combination pulmonary arterial vasodilator therapy. All patients had right heart catheterization-confirmed pulmonary arterial hypertension as well as complete baseline (at the time of diagnosis) and follow-up (most recent) echocardiograms. We excluded patients with significant scleroderma-associated interstitial lung disease. Adjusting for time of follow-up and disease duration, we performed mixed model regression analyses comparing the changes between the two groups for different echocardiographic variables: tricuspid annular plane systolic excursion, tricuspid regurgitation jet velocity, right atrial area, and RV diameter. RESULTS The mean ages for the SSc-PAH and IPAH groups were 60.8 and 48.2 years, respectively. The mean follow-up periods for the two groups were 3.8 and 1.95 years, respectively. Tricuspid annular plane systolic excursion did not improve in patients with SSc-PAH, whereas it increased in the patients with IPAH (-0.38 mm, P = 0.87; vs. +5.6 mm, P = 0.02). The other echocardiographic variables showed a trend toward worsening in the SSc-PAH group and improvement in the IPAH group. CONCLUSIONS Our results indicate that, in patients with SSc-PAH, echocardiographic RV function does not improve over time compared with that of patients with IPAH, despite institution of pulmonary artery vasodilator therapies.
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Lamela Domenech AE, López-Candales A. Is the electrocardiogram still useful in detecting right ventricular abnormalities in patients with pulmonary hypertension when compared to echocardiography? THE CLINICAL RESPIRATORY JOURNAL 2018; 12:1300-1301. [PMID: 28052531 DOI: 10.1111/crj.12607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/29/2016] [Indexed: 06/06/2023]
Affiliation(s)
| | - Angel López-Candales
- The Cardiovascular Medicine Division, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
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Cardiovascular involvement in systemic rheumatic diseases: An integrated view for the treating physicians. Autoimmun Rev 2018; 17:201-214. [DOI: 10.1016/j.autrev.2017.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/12/2017] [Indexed: 02/07/2023]
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Bournia VK, Tountas C, Protogerou AD, Panopoulos S, Mavrogeni S, Sfikakis PP. Update on assessment and management of primary cardiac involvement in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:53-65. [PMID: 35382127 PMCID: PMC8892878 DOI: 10.1177/2397198317747441] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2017] [Indexed: 09/26/2023]
Abstract
Primary cardiac involvement is a common and severe complication of systemic sclerosis, which may affect all of the hearts' structural components, including pericardium, myocardium, endocardium, cardiac valves, and conduction system. While cardiac disease can be clinically silent and only diagnosed in autopsy, new imaging modalities such as speckle-tracking echocardiography and cardiovascular magnetic resonance may reveal various abnormal findings in the majority of patients. Cardiovascular magnetic resonance evaluation should include assessment of left and right ventricular function, inflammation (STIR T2-weighted sequences (T2-W) for edema detection), and fibrosis (T1-weighted sequences 15 min after Gd-DTPA contrast medium injection (late-gadolinium enhancement). Notably, cardiac disease is responsible for about one-fourth of systemic sclerosis-related deaths. Systematic studies for the assessment and therapy of systemic sclerosis-related cardiac complications, as well as relevant guidelines from the European League Against Rheumatism and the American College of Rheumatology, are currently lacking. However, research advances reviewed herein allow for a better understanding of the mechanisms that alter cardiac function. Implementation of such knowledge should reduce cardiac morbidity and mortality in systemic sclerosis patients.
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Affiliation(s)
- Vasiliki-Kalliopi Bournia
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | - Christos Tountas
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | - Athanase D. Protogerou
- Cardiovascular Prevention and
Research Unit, Department of Pathophysiology, Medical School, National and
Kapodistrian University of Athens, Athens - Greece
| | - Stylianos Panopoulos
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
| | | | - Petros P. Sfikakis
- First Department of Propaedeutic
and Internal Medicine and Joined Rheumatology Program, Medical School,
National and Kapodistrian University of Athens, Laikon Hospital, Athens -
Greece
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Determinants of mortality in systemic sclerosis: a focused review. Rheumatol Int 2017; 38:1847-1858. [PMID: 29116439 DOI: 10.1007/s00296-017-3826-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/20/2017] [Indexed: 02/06/2023]
Abstract
Scleroderma (systemic sclerosis) is an autoimmune rheumatic disorder that is characterized by fibrosis, vascular dysfunction, and autoantibody production that involves most visceral organs. It is characterized by a high morbidity and mortality rate, mainly due to disease-related complications. Epidemiological data describing mortality and survival in this population have been based on both population and observational studies. Multiple clinical and non-clinical factors have been found to predict higher likelihood of death among thepatients. Here, we do an extensive review of the available literature, utilizing the PubMed database, to describe scleroderma and non-scleroderma related determinants of mortality in this population. We found that even though the mortality among the general population has declined, scleroderma continues to carry a very high morbidity and mortality rate, however we have made some slow progress in improving the mortality among scleroderma patients over the last few decades.
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Bissell LA, Anderson M, Burgess M, Chakravarty K, Coghlan G, Dumitru RB, Graham L, Ong V, Pauling JD, Plein S, Schlosshan D, Woolfson P, Buch MH. Consensus best practice pathway of the UK Systemic Sclerosis Study group: management of cardiac disease in systemic sclerosis. Rheumatology (Oxford) 2017; 56:912-921. [PMID: 28160468 DOI: 10.1093/rheumatology/kew488] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Indexed: 01/09/2023] Open
Abstract
Objective Cardiac disease in SSc can manifest in various ways and is associated with a poor prognosis. There is little evidence on how best to detect and manage cardiac disease in SSc. Our objective was to produce an expert consensus best practice pathway for the management of cardiac disease in SSc. Methods The UK Systemic Sclerosis Study Group set up several working groups to develop a number of consensus best practice pathways for the management of SSc-specific complications, including cardiac disease. A multidisciplinary task force was convened. The guidelines were partly informed by a comprehensive literature review. Results A best practice pathway for cardiac disease (with a focus on primary cardiac disease) in SSc is presented, including approaches for early detection and standard pharmacological and device therapies. Due to the benefits, shared care and a multidisciplinary approach are recommended. A future research agenda has been formulated in response to the relative lack of understanding of the natural history of primary cardiac disease that was highlighted by the initiative. Conclusion The physician should be alert to the possibility of cardiac disease in SSc; it is best managed within a multidisciplinary team including both rheumatologists and cardiologists. This pathway provides a reference for all physicians managing patients with SSc.
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Affiliation(s)
- Lesley-Anne Bissell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Marina Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool
| | - Malcolm Burgess
- Department of Cardiology, Aintree University Hospital, Liverpool
| | - Kuntal Chakravarty
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London
| | - Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London
| | - Raluca B Dumitru
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Lee Graham
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds
| | - Voon Ong
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London
| | - John D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds
| | - Dominik Schlosshan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds
| | - Peter Woolfson
- Department of Cardiology Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds
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Giacomelli R, Di Cesare E, Cipriani P, Ruscitti P, Di Sibio A, Liakouli V, Gennarelli A, Carubbi F, Splendiani A, Berardicurti O, Di Benedetto P, Ciccia F, Guggino G, Radchenko G, Triolo G, Masciocchi C. Pharmacological stress, rest perfusion and delayed enhancement cardiac magnetic resonance identifies very early cardiac involvement in systemic sclerosis patients of recent onset. Int J Rheum Dis 2017; 20:1247-1260. [DOI: 10.1111/1756-185x.13107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Roberto Giacomelli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences; Division of Cardiac Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Paola Cipriani
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Piero Ruscitti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Di Sibio
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Vasiliki Liakouli
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Antonio Gennarelli
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Francesco Carubbi
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
| | - Onorina Berardicurti
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Paola Di Benedetto
- Division of Rheumatology; Department of Biotechnological and Applied Clinical Science; School of Medicine; University of L'Aquila; L'Aquila Italy
| | - Francesco Ciccia
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Giuliana Guggino
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Ganna Radchenko
- Institute of Cardiology of Ukrainian National Academy of Medical Science; Kyiv Ukraine
| | - Giovanni Triolo
- Division of Rheumatology; Department of Internal Medicine; University of Palermo; Palermo Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences; Division of Radiology; Laboratory of Radiobiology; University of L'Aquila; L'Aquila Italy
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Ramalho AR, Costa S, Silva F, Donato P, Franco F, Pêgo GM. Autoimmune myocarditis in systemic sclerosis: an unusual form of scleroderma heart disease presentation. ESC Heart Fail 2017; 4:365-370. [PMID: 28772040 PMCID: PMC5542725 DOI: 10.1002/ehf2.12139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/23/2016] [Accepted: 12/30/2016] [Indexed: 01/13/2023] Open
Abstract
Primary cardiac involvement in systemic sclerosis is common, often subclinical, and is associated with significant mortality. We report the case of a patient who developed autoimmune myocarditis at an early stage of systemic sclerosis, who completely recovered from cardiac dysfunction under optimal medical therapy for heart failure and immunosuppression. This challenging case aims at increasing awareness around the fact that the heart is a target organ of scleroderma disease. It also highlights the importance of screening and early diagnosis of cardiac involvement, because a timely treatment may impact the quality of life of these patients and improve their prognosis.
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Affiliation(s)
- Ana Rita Ramalho
- Coimbra Hospital and University Center, Cardiology Department, Coimbra, Portugal
| | - Susana Costa
- Coimbra Hospital and University Center, Cardiology Department, Coimbra, Portugal
| | - Francisco Silva
- Coimbra Hospital and University Center, Imaging Department, Coimbra, Portugal
| | - Paulo Donato
- Coimbra Hospital and University Center, Imaging Department, Coimbra, Portugal
| | - Fátima Franco
- Coimbra Hospital and University Center, Cardiology Department, Coimbra, Portugal
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Abstract
Purpose Systemic sclerosis (SSc) is a heterogeneous disease that is often divided into subsets to stratify patients and predict prognosis. We hypothesized that individual methods of subsetting would not prognosticate equally well for different outcomes or in patients at different stages of disease. Methods We subsetted subjects with SSc using three approaches: limited versus diffuse cutaneous SSc (lcSSc, dcSSc); grouped by SSc-specific antibodies; and, grouped using unsupervised clustering. We studied patients with <2 years or between 2-4 years of disease duration, separately. Outcomes were time to death and time to development of (a) SF-36 Physical Component Score <40, (b) forced vital capacity <70% predicted, (c) echocardiographic pulmonary hypertension, and (d) interstitial lung disease. We used Cox proportional hazards models to determine the ability of the subsets to predict the outcomes of interest, and Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) to compare the performance of the models. Results In this international, multicentered cohort of over 500 SSc subjects with less than four years of disease duration, none of the three methods of subsetting studied was able to predict all of the outcomes of interest. Different subsetting methods predicted different outcomes within and between each disease duration group. In general, subsetting by skin performed somewhat better than the two other methods, but this was not consistent and there was considerable variability in the models. Conclusions Subsetting SSc to consistently predict morbidity and mortality in subjects at different stages of disease remains an important challenge.
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De Luca G, Bosello S, Leone AM, Gabrielli F, Pelargonio G, Inzani F, Crea F, Ferraccioli G. Life-threatening arrhythmias in a scleroderma patient: the role of myocardial inflammation in arrhythmic outburst. Scand J Rheumatol 2016; 46:78-80. [PMID: 27098649 DOI: 10.3109/03009742.2016.1157626] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- G De Luca
- a Department of Rheumatology, Institute of Rheumatology and Affine Sciences , Catholic University of the Sacred Heart , Rome , Italy
| | - S Bosello
- a Department of Rheumatology, Institute of Rheumatology and Affine Sciences , Catholic University of the Sacred Heart , Rome , Italy
| | - A M Leone
- b Institute of Cardiology , Catholic University of the Sacred Heart , Rome , Italy
| | - F Gabrielli
- c Division of Heart Failure and Cardiac Rehabilitation , Columbus Integrated Complex , Rome , Italy
| | - G Pelargonio
- b Institute of Cardiology , Catholic University of the Sacred Heart , Rome , Italy
| | - F Inzani
- d Institute of Pathology , Catholic University of the Sacred Heart , Rome , Italy
| | - F Crea
- b Institute of Cardiology , Catholic University of the Sacred Heart , Rome , Italy
| | - G Ferraccioli
- a Department of Rheumatology, Institute of Rheumatology and Affine Sciences , Catholic University of the Sacred Heart , Rome , Italy
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De Luca G, Bosello SL, Gabrielli FA, Berardi G, Parisi F, Rucco M, Canestrari G, Loperfido F, Galiuto L, Crea F, Ferraccioli G. Prognostic Role of Ventricular Ectopic Beats in Systemic Sclerosis: A Prospective Cohort Study Shows ECG Indexes Predicting the Worse Outcome. PLoS One 2016; 11:e0153012. [PMID: 27101136 PMCID: PMC4839708 DOI: 10.1371/journal.pone.0153012] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/22/2016] [Indexed: 01/29/2023] Open
Abstract
Background Arrhythmias are frequent in Systemic Sclerosis (SSc) and portend a bad prognosis, accounting alone for 6% of total deaths. Many of these patients die suddenly, thus prevention and intensified risk-stratification represent unmet medical needs. The major goal of this study was the definition of ECG indexes of poor prognosis. Methods We performed a prospective cohort study to define the role of 24h-ECG-Holter as an additional risk-stratification technique in the identification of SSc-patients at high risk of life-threatening arrhythmias and sudden cardiac death (SCD). One-hundred SSc-patients with symptoms and/or signs suggestive of cardiac involvement underwent 24h-ECG-Holter. The primary end-point was a composite of SCD or need for implantable cardioverter defibrillator (ICD). Results Fifty-six patients (56%) had 24h-ECG-Holter abnormalities and 24(24%) presented frequent ventricular ectopic beats (VEBs). The number of VEBs correlated with high-sensitive cardiac troponin T (hs-cTnT) levels and inversely correlated with left-ventricular ejection fraction (LV-EF) on echocardiography. During a mean follow-up of 23.1±16.0 months, 5 patients died suddenly and two required ICD-implantation. The 7 patients who met the composite end-point had a higher number of VEBs, higher levels of hs-cTnT and NT-proBNP and lower LV-EF (p = 0.001 for all correlations). All these 7 patients had frequent VEBs, while LV-EF was not reduced in all and its range was wide. At ROC curve, VEBs>1190/24h showed 100% of sensitivity and 83% of specificity to predict the primary end-point (AUROC = 0.92,p<0.0001). Patients with VEBS>1190/24h had lower LV-EF and higher hs-cTnT levels and, at multivariate analysis, the presence of increased hs-cTnT and of right bundle branch block on ECG emerged as independent predictors of VEBs>1190/24h. None of demographic or disease-related characteristics emerged as predictors of poor outcome. Conclusions VEBS>1190/24h identify patients at high risk of life-threatening arrhythmic complications. Thus, 24h-ECG-Holter should be considered a useful additional risk-stratification test to select SSc-patients at high-risk of SCD, in whom an ICD-implantation could represent a potential life-saving intervention.
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Affiliation(s)
- Giacomo De Luca
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Silvia Laura Bosello
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Giorgia Berardi
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Federico Parisi
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Manuela Rucco
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Canestrari
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Loperfido
- Division of Heart Failure and Cardiac Rehabilitation, Complesso Integrato Columbus, Rome, Italy
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Leonarda Galiuto
- Division of Heart Failure and Cardiac Rehabilitation, Complesso Integrato Columbus, Rome, Italy
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Gianfranco Ferraccioli
- Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy
- * E-mail:
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Becker MO, Riemekasten G. Risk factors for severity and manifestations in systemic sclerosis and prediction of disease course. Expert Rev Clin Immunol 2015; 12:115-35. [PMID: 26558747 DOI: 10.1586/1744666x.2016.1115717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Systemic sclerosis (SSc, or scleroderma) is a rheumatic disease with distinct features that encompass autoimmunity, vascular lesions (vasculopathy) and tissue fibrosis. The disease has a high morbidity and mortality compared with other rheumatic diseases. This review discusses risk factors and markers that predict the disease course and the occurrence of disease manifestations, with an emphasis on major organ involvement. In addition, risk factors will be described that are associated with mortality in SSc patients. The review addresses the impact of recent developments on screening, diagnosis and risk stratification as well as the need for further research where data are lacking.
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Affiliation(s)
- Mike O Becker
- a Department of Rheumatology and Clinical Immunology , University Hospital Charité Berlin , Berlin , Germany
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Fernández-Codina A, Simeón-Aznar CP, Pinal-Fernandez I, Rodríguez-Palomares J, Pizzi MN, Hidalgo CE, Guillén-Del Castillo A, Prado-Galbarro FJ, Sarria-Santamera A, Fonollosa-Plà V, Vilardell-Tarrés M. Cardiac involvement in systemic sclerosis: differences between clinical subsets and influence on survival. Rheumatol Int 2015; 37:75-84. [PMID: 26497313 DOI: 10.1007/s00296-015-3382-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
Abstract
Cardiac involvement (CI) is a known complication of SSc associated with increased mortality. Our objective was to describe a cohort of patients with SSc and CI and to assess the differences between cutaneous subsets regarding their presentation and survival. Three hundred and ninety-three Spanish patients from a single center, diagnosed with SSc, were retrospectively studied for evidence of CI using noninvasive and invasive tests from 1976 to 2011. Clinical, epidemiological, immunological and therapeutic features of patients with CI were compared to those without it and within the different cutaneous subsets of SSc. CI was present in 173 (44 %) patients. Mitral regurgitation (67 %), conduction alterations (45 %) and left ventricle diastolic dysfunction (40 %) were the most common findings. Pericardial involvement and heart failure were more frequent in diffuse SSc (dcSSc) than in limited or sine scleroderma SSc. CI accounted for 20 % of deaths, and it was an independent mortality risk factor (HR 2.1, P = 0.02), but once CI was established, classical dcSSc mortality risk factors determined mortality. Patients with dcSSc developed CI faster than limited (HR 1.9, P = 0.003) or sine SSc patients (HR 2.5, P = 0.002), specially during the first year after SSc onset. We found statistically significant differences between the 3 SSc subsets in the presentation of pericardial involvement and heart failure. CI increased the mortality and appeared at a higher rate, especially during the first year after SSc onset. Screening for heart involvement should be performed at diagnosis and during follow-up.
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Affiliation(s)
- Andreu Fernández-Codina
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Carmen Pilar Simeón-Aznar
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Iago Pinal-Fernandez
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - José Rodríguez-Palomares
- Cardiology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Nazarena Pizzi
- Nuclear Medicine Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Eve Hidalgo
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Alfredo Guillén-Del Castillo
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | | | | | - Vicent Fonollosa-Plà
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Miquel Vilardell-Tarrés
- Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, 3rd floot, Hospital General Vall d'Hebron building, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Meune C, Avouac J, Aïssou L, Allanore Y. Systemic sclerosis-related acute myocardial infarction: definition. Am J Med 2014; 127:e37. [PMID: 25205275 DOI: 10.1016/j.amjmed.2014.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/31/2014] [Accepted: 01/31/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Christophe Meune
- Cardiology Department, Paris 13 University, University Hospital of Paris-Seine-Saint-Denis, Bobigny, France
| | - Jérôme Avouac
- Rheumatology A Department, Paris Descartes University, Sorbonne Paris Cité, Cochin Hospital, Paris, France; Paris Descartes University, INSERM U1016 and CNRS UMR8104, Cochin Institute, Paris, France
| | - Linda Aïssou
- Cardiology Department, Paris 13 University, University Hospital of Paris-Seine-Saint-Denis, Bobigny, France
| | - Yannick Allanore
- Rheumatology A Department, Paris Descartes University, Sorbonne Paris Cité, Cochin Hospital, Paris, France; Paris Descartes University, INSERM U1016 and CNRS UMR8104, Cochin Institute, Paris, France
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The reply. Am J Med 2014; 127:e39. [PMID: 25205276 DOI: 10.1016/j.amjmed.2014.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 05/27/2014] [Accepted: 05/28/2014] [Indexed: 11/22/2022]
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