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Papadimitriou TI, Lemmers JMJ, van Caam APM, Vos JL, Vitters EL, Stinissen L, van Leuven SI, Koenders MI, van der Kraan PM, Koenen HJPM, Smeets RL, Nijveldt R, Vonk MC, Thurlings RM. Systemic sclerosis-associated pulmonary arterial hypertension is characterized by a distinct peripheral T helper cell profile. Rheumatology (Oxford) 2024; 63:2525-2534. [PMID: 38552313 PMCID: PMC11371376 DOI: 10.1093/rheumatology/keae190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/17/2024] [Indexed: 09/05/2024] Open
Abstract
OBJECTIVES Systemic sclerosis (SSc) is characterized by multiple clinical manifestations. Vasculopathy is a main disease hallmark and ranges in severity from an exacerbated Raynaud phenomenon to pulmonary arterial hypertension (PAH). The potential involvement of the immune system in SSc-associated vascular abnormalities is not clear. Here, we set out to study SSc-related immune parameters and determine whether and which peripheral T cell subsets associate with vascular severity in SSc patients. METHODS Peripheral blood and clinical data were collected from 30 SSc patients, 5 patients with idiopathic PAH and 15 age and sex-matched healthy donors (HD). In this cross-sectional cohort, SSc patients with PAH (n = 15) were matched for their age, sex and medication with SSc patients with no signs of PAH (n = 15). Lymphocyte subsets were quantified by multi-colour flow cytometry. RESULTS SSc patients exhibited elevated percentages of T peripheral helper cells (Tph), CD4+GZMB+ T cells and decreased levels of Th1 cells compared with HD. Increased presence of both CD4+ and CD8+ exhausted-like (CD28-) T cells, characterized by raised cytokine and cytotoxic signature, was also observed in SSc compared with HD blood. Furthermore, IL-4 expressing CD4+CD8+ T cells were significantly increased in SSc peripheral blood. Interestingly, the presence of PAH in SSc was accompanied by a distinct T helper profile, characterized by raised percentages of Th17 and Tph cells. CONCLUSION SSc patients with severe vasculopathy (presence of PAH) exhibited a distinct T cell profile, suggesting a potential role of auto-immune inflammation in SSc vascular complications.
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Affiliation(s)
- Theodoros Ioannis Papadimitriou
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
- Department of Laboratory Medicine – Medical Immunology, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Elly L Vitters
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Lizan Stinissen
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Hans J P M Koenen
- Department of Laboratory Medicine – Medical Immunology, Radboudumc, Nijmegen, The Netherlands
| | - Ruben L Smeets
- Department of Laboratory Medicine – Medical Immunology, Radboudumc, Nijmegen, The Netherlands
- Radboudumc Laboratory for Diagnostics, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Madelon C Vonk
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
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2
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Fairley JL, Ross L, Burns A, Prior D, Conron M, Rouse H, McDonald J, MacIsaac A, La Gerche A, Morrisroe K, Ferdowsi N, Quinlivan A, Brown Z, Stevens W, Nikpour M. Multidisciplinary team discussion: the emerging gold standard for management of cardiopulmonary complications of connective tissue disease. Intern Med J 2023; 53:1919-1924. [PMID: 37772776 PMCID: PMC10947227 DOI: 10.1111/imj.16233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/28/2023] [Indexed: 09/30/2023]
Abstract
Cardiopulmonary complications of connective tissue diseases (CTDs), particularly pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD), are major determinants of morbidity and mortality. Multidisciplinary meetings may improve diagnostic accuracy and optimise treatment. We review the literature regarding multidisciplinary meetings in CTD-ILD and PAH and describe our tertiary centre experience of the role of the multidisciplinary meeting in managing CTD-PAH.
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Affiliation(s)
- Jessica L. Fairley
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Laura Ross
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Andrew Burns
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of CardiologySt Vincent's Hospital MelbourneMelbourneAustralia
| | - David Prior
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of CardiologySt Vincent's Hospital MelbourneMelbourneAustralia
| | - Matthew Conron
- Department of Respiratory MedicineSt Vincent's Hospital MelbourneMelbourneAustralia
| | - Hannah Rouse
- Department of RadiologySt Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Julie McDonald
- Department of Respiratory MedicineSt Vincent's Hospital MelbourneMelbourneAustralia
| | - Andrew MacIsaac
- Department of CardiologySt Vincent's Hospital MelbourneMelbourneAustralia
| | - André La Gerche
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Baker Heart and Diabetes InstituteVictoriaAustralia
| | - Kathleen Morrisroe
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Nava Ferdowsi
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Alannah Quinlivan
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Zoe Brown
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Wendy Stevens
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Mandana Nikpour
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
- Department of RheumatologySt. Vincent's Hospital MelbourneMelbourneVictoriaAustralia
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3
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Moccaldi B, De Michieli L, Binda M, Famoso G, Depascale R, Perazzolo Marra M, Doria A, Zanatta E. Serum Biomarkers in Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24044178. [PMID: 36835590 PMCID: PMC9967966 DOI: 10.3390/ijms24044178] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening complication of connective tissue diseases (CTDs) characterised by increased pulmonary arterial pressure and pulmonary vascular resistance. CTD-PAH is the result of a complex interplay among endothelial dysfunction and vascular remodelling, autoimmunity and inflammatory changes, ultimately leading to right heart dysfunction and failure. Due to the non-specific nature of the early symptoms and the lack of consensus on screening strategies-except for systemic sclerosis, with a yearly transthoracic echocardiography as recommended-CTD-PAH is often diagnosed at an advanced stage, when the pulmonary vessels are irreversibly damaged. According to the current guidelines, right heart catheterisation is the gold standard for the diagnosis of PAH; however, this technique is invasive, and may not be available in non-referral centres. Hence, there is a need for non-invasive tools to improve the early diagnosis and disease monitoring of CTD-PAH. Novel serum biomarkers may be an effective solution to this issue, as their detection is non-invasive, has a low cost and is reproducible. Our review aims to describe some of the most promising circulating biomarkers of CTD-PAH, classified according to their role in the pathophysiology of the disease.
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Affiliation(s)
- Beatrice Moccaldi
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Marco Binda
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-0498212190
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, 35128 Padova, Italy
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4
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Puebla-Aldama D, Cueto-Robledo G, Barragan-Martinez MDP, Roldan-Valadez E, Navarro-Vergara DI, Garcia-Cesar M, Heredia-Flores KL, Torres-Rojas MB, Garcia-Treminio CF, Cueto-Romero HD. Review of functional status and hemodynamic parameters in patients diagnosed with Chronic Thromboembolic Pulmonary Hypertension (CTEPH) with and without Antiphospholipid Syndrome (APLS). Curr Probl Cardiol 2022; 48:101154. [PMID: 35192873 DOI: 10.1016/j.cpcardiol.2022.101154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023]
Affiliation(s)
- David Puebla-Aldama
- Iztacala Faculty of Higher Studies, National Autonomous University of Mexico, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Guillermo Cueto-Robledo
- Pulmonary Circulation Clinic, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico; Cardiorespiratory Emergencies, Hospital General de Mexico "Dr Eduardo Liceaga", Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico.
| | - María-Del-Pilar Barragan-Martinez
- Iztacala Faculty of Higher Studies, National Autonomous University of Mexico, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico; Department of Radiology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
| | | | - Marisol Garcia-Cesar
- Pulmonary Circulation Clinic, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
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5
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Tobal R, Potjewijd J, van Empel VPM, Ysermans R, Schurgers LJ, Reutelingsperger CP, Damoiseaux JGMC, van Paassen P. Vascular Remodeling in Pulmonary Arterial Hypertension: The Potential Involvement of Innate and Adaptive Immunity. Front Med (Lausanne) 2022; 8:806899. [PMID: 35004784 PMCID: PMC8727487 DOI: 10.3389/fmed.2021.806899] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe disease with high morbidity and mortality. Current therapies are mainly focused on vasodilative agents to improve prognosis. However, recent literature has shown the important interaction between immune cells and stromal vascular cells in the pathogenic modifications of the pulmonary vasculature. The immunological pathogenesis of PAH is known as a complex interplay between immune cells and vascular stromal cells, via direct contacts and/or their production of extra-cellular/diffusible factors such as cytokines, chemokines, and growth factors. These include, the B-cell—mast-cell axis, endothelium mediated fibroblast activation and subsequent M2 macrophage polarization, anti-endothelial cell antibodies and the versatile role of IL-6 on vascular cells. This review aims to outline the major pathophysiological changes in vascular cells caused by immunological mechanisms, leading to vascular remodeling, increased pulmonary vascular resistance and eventually PAH. Considering the underlying immunological mechanisms, these mechanisms may be key to halt progression of disease.
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Affiliation(s)
- Rachid Tobal
- Division of Nephrology and Clinical and Experimental Immunology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Judith Potjewijd
- Division of Nephrology and Clinical and Experimental Immunology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Renee Ysermans
- Division of Nephrology and Clinical and Experimental Immunology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Chris P Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, Netherlands
| | - Pieter van Paassen
- Division of Nephrology and Clinical and Experimental Immunology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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6
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Koudstaal T, van Hulst JAC, Das T, Neys SFH, Merkus D, Bergen IM, de Raaf MA, Bogaard HJ, Boon L, van Loo G, Aerts JGJV, Boomars KA, Kool M, Hendriks RW. DNGR1-Cre-mediated Deletion of Tnfaip3/A20 in Conventional Dendritic Cells Induces Pulmonary Hypertension in Mice. Am J Respir Cell Mol Biol 2020; 63:665-680. [PMID: 32755457 DOI: 10.1165/rcmb.2019-0443oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic perivascular inflammation is a prominent feature in the lungs of idiopathic pulmonary arterial hypertension. Although the proportions of conventional dendritic cells (cDCs) and plasmacytoid DCs are increased in idiopathic pulmonary arterial hypertension lungs, it remains unknown whether activated cDCs play a pathogenic role. The Tnfaip3 gene encodes the ubiquitin-binding protein A20, which is a negative regulator of NF-κB, critically involved in DC activation. Targeting of Tnfaip3/A20 in cDCs was achieved by Clec9a (DNGR1)-Cre-mediated excision of the Tnfaip3 gene in Tnfaip3DNGR1-KO mice. Mice were evaluated for signs of pulmonary hypertension (PH) using right heart catheterization, echocardiography, and measurement of the Fulton index. Inflammation was assessed by immunohistochemistry and flow cytometry. Pulmonary cDCs and monocyte-derived DCs from 31-week-old Tnfaip3DNGR1-KO mice showed modulated expression of cell surface activation markers compared with Tnfaip3DNGR1-WT mice. Tnfaip3DNGR1-KO mice developed elevated right ventricular systolic pressure and right ventricular hypertrophy. The lungs of these mice displayed increased vascular remodeling and perivascular and peribronchial immune cell infiltration resembling tertiary lymphoid organs. Proportions of activated T cells and expression of IL-1β, IL-6, and IL-10 were enhanced in the lungs of Tnfaip3DNGR1-KO mice. Autoreactive IgA and IgG1 was detected in BAL and autoreactive IgA recognizing pulmonary endothelial antigens was present in the serum of Tnfaip3DNGR1-KO mice. All signs of PH were ameliorated in Tnfaip3DNGR1-KO mice by anti-IL-6 antibody treatment. These results indicate that activation of the NF-κB pathway in DCs, through deletion of A20/Tnfaip3, leads to experimental PH with accompanied pulmonary inflammation in an IL-6-dependent fashion.
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Affiliation(s)
| | | | | | | | | | | | - Michiel A de Raaf
- Department of Neonatology, Erasmus Medical Centre, Rotterdam, the Netherlands.,VU Medical Centre, Amsterdam, the Netherlands
| | | | - Louis Boon
- Polpharma Biologics, Utrecht, the Netherlands
| | - Geert van Loo
- VIB Center for Inflammation Research, Ghent, Belgium; and.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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7
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Polytarchou K, Varvarousis D, Manolis AS. Cardiovascular Disease in Antiphospholipid Syndrome. Curr Vasc Pharmacol 2020; 18:538-548. [DOI: 10.2174/1570161117666190830101341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/18/2019] [Accepted: 08/18/2019] [Indexed: 12/13/2022]
Abstract
:
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by venous,
arterial or microvascular thrombosis or obstetric events in the presence of persistently positive
antiphospholipid antibodies and constitutes a major cause of cardiovascular events in young people.
Τhis review highlights the pathophysiology of cardiovascular complications in patients with APS and
possible treatment options.
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Patients with APS have endothelial dysfunction, accelerated endothelial proliferation and intimal hyperplasia,
atherogenesis, platelet activation, inflammatory products secretion and coagulation-fibrinolytic
dysregulation. Cardiovascular complications include accelerated atherosclerosis, acute coronary syndrome,
Libman-Sacks endocarditis, cardiomyopathy and venous, arterial or intracardiac thrombi.
Moreover, pulmonary hypertension and peripheral microvascular dysfunction are common findings.
:
Management of these patients is not well documented. The role of primary thrombosis prevention remains
controversial in individuals with positive antiphospholipid antibodies. Treatment of traditional
cardiovascular risk factors according to current guidelines for the prevention of cardiovascular disease
in the general population is recommended for primary prevention of APS. Anticoagulation therapy with
unfractionated or low-molecular-weight heparin overlapped with a vitamin K antagonist remains the
mainstay of the treatment for APS patients with venous thrombosis, whereas direct oral anticoagulants
are not yet recommended. Data are scarce regarding the secondary arterial thrombosis prevention and it
is not clear whether dual or triple antithrombotic therapy is necessary. To date, it is recommended to
follow current guidelines for the management of acute coronary syndrome in the general population.
New treatment targets are promising options for patients with catastrophic APS.
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Affiliation(s)
- Kali Polytarchou
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Dimitrios Varvarousis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Antonis S. Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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8
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Cheng CY, Zhang YX, Denas G, Du Y, Jing ZC, Pengo V. Prevalence of antiphospholipid (aPL) antibodies among patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Intern Emerg Med 2019; 14:521-527. [PMID: 30603858 DOI: 10.1007/s11739-018-02021-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
How thrombophilia may contribute to the development of chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. We searched on PubMed and EMBASE (until 15 April 2018), studies on CTEPH reporting data on inherited or acquired thrombophilia. Starting from 367 articles mentioning the search terms, 347 were excluded mainly as duplicate articles or articles not in English. After reading the full text of remaining articles, ten were excluded for being reviews, editorials, letters or case reports, and two were further removed from the analysis because of the potential selection bias. All the eight considered studies provided the proportion of patients positive for antiphospholipid (aPL) antibodies. The crude rate of aPL in CTPEH patients is 11.8% (95% CI 10.09-13.8%). The meta-analysis considering the weighted mean proportion and 95% confidence intervals (CIs) yields a rate of aPL antibody-positive profile of 12.06% (95% CI 8.12-16.65%) among the patients with CTEPH in the random effects model (I2 76.33%; 95% CI 52.75-88.14%, p = 0.0001). The sensibility analysis confirms the result. No predictors of heterogeneity are found in a meta-regression analysis. Our results suggest that aPL antibodies are frequently associated with CTEPH underlining the need to test for aPL antibodies in young patients with "idiopathic" and "provoked" PE caused by mild provoking risk factors.
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Affiliation(s)
- Chun-Yan Cheng
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yi-Xin Zhang
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yao Du
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Zhi-Cheng Jing
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Kolitz T, Shiber S, Sharabi I, Winder A, Zandman-Goddard G. Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form. Front Immunol 2019; 10:941. [PMID: 31134062 PMCID: PMC6522847 DOI: 10.3389/fimmu.2019.00941] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/11/2019] [Indexed: 01/09/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a multisystem autoimmune disease most commonly associated with recurrent arterial and venous thromboembolism and recurrent fetal loss. Other possible antiphospholipid antibody (aPL)-related clinical manifestations include cardiac involvement. The heart can be involved through immune mediated and /or thrombotic mechanisms. Mortality due to cardiovascular problems is elevated in APS. However, the cardiovascular risk in patients with primary APS (PAPS) compared with lupus-related APS is yet to be established. Cardiac symptoms of APS include valve abnormalities (thickening and vegetations), coronary artery disease (CAD), myocardial dysfunction, pulmonary hypertension, and intracardiac thrombi. Heart valve lesions are the most common cardiac manifestation, observed in approximately one third of PAPS patients and usually do not cause hemodynamic significance. Deposits of immunoglobulins including anticardiolipin (aCL), and of complement components, are commonly observed in affected heart valves from these patients. This suggests that an inflammatory process is initiated by aPL deposition, eventually resulting in the formation of valvular lesion. aPL may have a direct role in the atherosclerotic process via induction of endothelial activation. Multiple traditional and autoimmune-inflammatory risk factors are involved in triggering an expedited atherosclerotic arterial disease evident in APS. It is imperative to increase the efforts in early diagnosis, control of risk factors and close follow-up, in the attempt to minimize cardiovascular risk in APS. Clinicians should bear in mind that a multidisciplinary therapeutic approach is of paramount importance in these patients. This article reviews the cardiac detriments of APS, including treatment recommendations for each cardiac complication.
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Affiliation(s)
- Tamara Kolitz
- Department of Medicine C, Wolfson Medical Center, Holon, Israel
| | - Shachaf Shiber
- Department of Rheumatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Sharabi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Wolfson Medical Center, Holon, Israel
| | - Asher Winder
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Wolfson Medical Center, Holon, Israel
| | - Gisele Zandman-Goddard
- Department of Medicine C, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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