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Efrimescu CI, Bonnet JF, Buggy DJ. Commentary: Diffuse Coronary Artery Vasospasm Following Aortic Valve Replacement in a Patient With Scleroderma. J Cardiothorac Vasc Anesth 2024; 38:2819-2822. [PMID: 39181761 DOI: 10.1053/j.jvca.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
| | | | - Donal J Buggy
- Mater Misericordiae University Hospital & Mater Private Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research, Cleveland Clinic, OH, USA; College of Anaesthesiologists of Ireland, Dublin, Ireland
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Chen IW, Wang WT, Lai YC, Lin CM, Liu PH, Wu SZ, Hung KC. Association between systemic sclerosis and risk of cerebrovascular and cardiovascular disease: a meta-analysis. Sci Rep 2024; 14:6445. [PMID: 38499699 PMCID: PMC10948904 DOI: 10.1038/s41598-024-57275-9] [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: 11/30/2023] [Accepted: 03/15/2024] [Indexed: 03/20/2024] Open
Abstract
We aimed to evaluate the association between systemic sclerosis (SSc) and major cerebrovascular/cardiovascular risks through a systematic approach. Databases were systematically searched from their inception to October 10, 2023 for studies comparing cerebrovascular/cardiovascular event rates between patients with SSc and controls. The primary outcome was the stroke risk in patients with SSc. Secondary outcomes included risk of myocardial infarction (MI), cardiovascular disease (CVD), peripheral vascular disease (PVD), and venous thromboembolism (VTE). Seventeen studies with 6,642,297 participants were included. SSc was associated with a significantly increased risk of stroke (HR, 1.64; 95% confidence interval [CI], 1.35-2.01), CVD (HR, 2.12; 95% CI, 1.36-3.3), MI (HR, 2.15; 95% CI, 1.23-3.77), VTE (HR, 2.75; 95% CI, 1.77-4.28), and PVD (HR, 5.23; 95% CI, 4.25-6.45). Subgroup analysis revealed a significantly increased stroke risk in the non-Asian group (HR, 1.55; 95% CI, 1.26-1.9), while the Asian group displayed a higher but not statistically significant risk (HR, 1.86; 95% CI, 0.97-3.55). The study found that SSc is associated with a significantly increased risk of cerebrovascular/cardiovascular events. These findings highlight the importance of vasculopathy in SSc and suggest the need for enhanced clinical monitoring and preventive measures in this high-risk population.
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Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Chen Lai
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, ChungHwa Road, YungKung Dist, Tainan, 71004, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, ChungHwa Road, YungKung Dist, Tainan, 71004, Taiwan
| | - Ping-Hsin Liu
- Department of Anesthesiology, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Su-Zhen Wu
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, ChungHwa Road, YungKung Dist, Tainan, 71004, Taiwan.
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Karakasis P, Patoulias D, Stachteas P, Lefkou E, Dimitroulas T, Fragakis N. Accelerated Atherosclerosis and Management of Cardiovascular Risk in Autoimmune Rheumatic Diseases: An Updated Review. Curr Probl Cardiol 2023; 48:101999. [PMID: 37506959 DOI: 10.1016/j.cpcardiol.2023.101999] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
Even though diagnosis and management pathways have been substantially improved over the last years, autoimmune rheumatic diseases (AIRDs) such as rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren's syndrome, and systemic vasculitides have been linked to elevated rates of cardiovascular morbidity and mortality, primarily secondary to accelerated atherosclerosis. This phenomenon can be partially attributed to the presence of established cardiovascular risk factors but may also be a result of other inflammatory and autoimmune mechanisms that are enhanced in AIRDs. According to the current guidelines, the recommendations regarding cardiovascular disease prevention in patients with AIRDs are not significantly different from those applied to the general population. Herein, we present a review of the current literature on the risk of accelerated atherosclerosis in AIRDs and provide a summary of available recommendations for the management of cardiovascular risk in rheumatic diseases.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece.
| | - Dimitrios Patoulias
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Second Department of Internal Medicine, European Interbalkan Medical Center, Thessaloniki, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece
| | - Eleftheria Lefkou
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Perigenesis, Institute of Obstetric Haematology, Thessaloniki, Greece
| | - Theodoros Dimitroulas
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece; Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration," Thessaloniki, Greece
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Rotondo C, Sciacca S, Rella V, Busto G, Colia R, Cantatore FP, Corrado A. Subclinical coronary atherosclerosis, detected by computer tomography with coronary calcium score, and the occurrence of major cardiovascular events at 5 years of follow-up in a cohort of patients with systemic sclerosis. Eur J Intern Med 2023; 115:62-69. [PMID: 37316356 DOI: 10.1016/j.ejim.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/21/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Spreading data describe cardiovascular disease (CVD) as a growing cause of hospitalization in systemic sclerosis (SSc) patients. Although interstitial lung disease and pulmonary arterial hypertension (PAH) remain the principal causes of mortality, the presence of CVD has been shown to further increase mortality in SSc patients. Few and contrasting data are available on cardiovascular impairment, particularly of subclinical coronary arteries disease, in SSc patients. The aims of this study were: 1) to determine the demographic, clinical, and cardiovascular differences between the groups of SSc patients with and without subclinical coronary atherosclerosis (SCA) assessed by coronary calcium score; 2) to verify the performance of cardiovascular risk scores in SSc for detection of SCA major cardiovascular events (MCVE); 3) to evaluate the risk factors associated to MCVE in 5 years of follow-up in this study group of patients. METHODS Sixty-seven SSc patients were enrolled in this study. SCA was assessed using quantification of coronary calcium score by computerized tomography, reported as Agatson. Evaluation of common cardiovascular risk scores, carotid plaques by Doppler ultrasonography, the history of peripheral artery disease (PAD), lipid profiles, and clinical and laboratiristic characteristics of SSc were assessed at baseline visits for each patient. Factors associated with the presence of SCA were assessed by multivariate logistic analysis. A five years prospective study was performed for the evaluation of MCVE occurrence and its possible predictors. RESULTS The prevalence of SCA was 42% (Agatston scores of 266.04 ± 455.9 units) in our group of SSc patients. Patients with SCA were principally older (p = 0.0001) and had higher rates of CENP-B antibodies (57% vs 26%; p = 0.009), pulmonary arterial hypertension (PAH) (25% vs 3%; p = 0.008), dysphagia (86% vs 61%; p = 0.027), and users of statins (36% vs 8%; p = 0.004), carotid plaque (82% vs 13%; p = 0.0001), PAD (79% vs 18%; p = 0.0001), and metabolic syndrome (25% vs 0%; p = 0.002) than patients without SCA. Metabolic syndrome (OR: 8.2, p = 0.0001), presence of a PAD (OR: 5.98, p = 0.031), and carotid plaque (OR: 5.49, p = 0.010) were the main factors associated with SCA in SSc patients, by multivariate regression analysis. MCVE occurred in 7 patients. By multivariate COX regression analysis unique predictor of MCVE in 5 years of follow-up in our SSc patients was the presence of PAH (HR: 10.33, p = 0.009). Of note, the contemporary presence of PAH and SCA (defined as "not pure" pattern of PAH) was observed in 71% of patients with the occurrence of MCVE CONCLUSION: This study evidenced the high presence of the new "not pure" pattern of PAH, which could worsen the outcome in SSc in a medium-term (5 years) observation period. Furthermore, our data confirmed a higher cardiovascular impairment in SSc due to the presence of both SCA, mainly associated with typical cardiovascular risk factors, and PAH, life-threatening complications of SSc, that is the principal cause of the occurrence of MCVE in our SSc patients. A careful assessment of cardiovascular involvement in SSc and a more aggressive therapeutic strategy for preventing CAD and treating PAH should be highly suggested to reduce MCVE in SSc patients.
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Affiliation(s)
- C Rotondo
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - S Sciacca
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - V Rella
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy
| | - G Busto
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - R Colia
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy
| | - F P Cantatore
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
| | - A Corrado
- Department of medical and surgical sciences - Rheumatology Unit, University of Foggia, Policlinico di Foggia viale Luigi Pinto 1, Foggia 71122, Italy.
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The role of asymmetric dimethylarginine in endothelial dysfunction and abnormal nitric oxide metabolism in systemic sclerosis: results from a pilot study. Clin Rheumatol 2023; 42:1077-1085. [PMID: 36534350 DOI: 10.1007/s10067-022-06472-w] [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: 08/18/2022] [Revised: 11/17/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION/OBJECTIVES Systemic sclerosis (SSc) is characterized by generalized vasculopathy affecting mainly small vessels while macrovascular involvement is less investigated. The aim of this study was to examine associations between asymmetric dimethylarginine (ADMA) - a biomarker of atherosclerosis - and assessments of macrovascular endothelial function in patients with SSc. METHODS This was a cross-sectional study including consecutive SSc patients attending the Scleroderma Outpatient Clinic. ADMA measurement in serum samples was based on an enzyme immunoassay technique. Participants underwent blood pressure measurement according to 2018 ESC/ESH Guidelines, applanation tonometry for the evaluation of arterial stiffness, and carotid ultrasound for the measurement of the intima-media thickness (cIMT). RESULTS Eighty-one Caucasians (82.3% female) SSc individuals with mean age 55.44 ± 13.4 years were included in this analysis. The correlation analysis of ADMA levels (unadjusted and adjusted values) with functional and morphological parameters of atherosclerosis revealed no statistically significant associations. Subgroup analysis based on disease duration (≤ 4 years), immunologic profile (SCL-70 and ACA antibodies), disease type (limited, diffuse), and inflammatory status (erythrocyte sedimentation rate [ESR] > 25 mm/h and C-reactive protein [CRP] > 5 mg/L) showed no associations, except from a significant positive correlation between ADMA levels and cΙΜΤmean (r = 0.370, p = 0.044) in individuals with early SSc. CONCLUSIONS The results of the study suggest that ADMA may be related with accelerated atherosclerosis in early stages of the disease. However, the lack of association between other morphological and functional parameters of endothelial dysfunction may suggest that other regulators of nitric oxide metabolism may contribute to macrovascular injury in SSc in various phases of the disease. Key Points • ADMA is a biomarker of atherosclerosis and has been linked with microvascular complications of SSc. •ADMA was not correlated with morphological and functional parameters of atherosclerosis in the population of the study. •The demonstrated association between ADMA and cIMT in patients with early SSc may suggest a role of NO/ADMA pathway in the initiation of macrovascular injury in SSc.
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Tessier S, Longo S, Numeir M, Ido F. Non-hereditary arterial tortuosity syndrome in systemic sclerosis. Am J Med Sci 2023:S0002-9629(23)01066-2. [PMID: 36925065 DOI: 10.1016/j.amjms.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/23/2022] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Malek Numeir
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA.
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Moysidou GS, Dara A, Arvanitaki A, Skalkou A, Pagkopoulou E, Daoussis D, Kitas GD, Dimitroulas T. Understanding and managing cardiac involvement in systemic sclerosis. Expert Rev Clin Immunol 2023; 19:293-304. [PMID: 36690592 DOI: 10.1080/1744666x.2023.2171988] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory. AREAS COVERED This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed. EXPERT OPINION Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.
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Affiliation(s)
- Georgia-Savina Moysidou
- 4th Department of Internal Medicine, Attikon, University Hospital, National and Kapodistrian University of Athens, Chaidari, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Skalkou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Daoussis
- Department of Rheumatology, University of Patras Medical School, Patras, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Theodoros Dimitroulas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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Fathi HM, Fawzy MW, Aboul-Eyon II, Eldesouky ATH, Eesa NN. Value of nail fold video capillaroscopy and carotid intima media thickness in assessment of micro and macro-vascular disease in systemic sclerosis patients. THE EGYPTIAN RHEUMATOLOGIST 2021. [DOI: 10.1016/j.ejr.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Martinez SC, Mohamed M, Potts J, Abhishek A, Roddy E, Savage M, Bharadwaj A, Kwok CS, Bagur R, Mamas MA. Percutaneous coronary intervention outcomes in patients with rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis. Rheumatology (Oxford) 2020; 59:2512-2522. [DOI: 10.1093/rheumatology/kez639] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Objective
Patients with autoimmune rheumatic disease (AIRD) are at an increased risk of coronary artery disease. The present study sought to examine the prevalence and outcomes of AIRD patients undergoing percutaneous coronary intervention (PCI) from a national perspective.
Methods
All PCI-related hospitalizations recorded in the US National Inpatient Sample (2004–2014) were included, stratified into four groups: no AIRD, RA, SLE and SSc. We examined the prevalence of AIRD subtypes and assessed their association with in-hospital adverse events using multivariable logistic regression [odds ratios (OR) (95% CI)].
Results
Patients with AIRD represented 1.4% (n = 90 469) of PCI hospitalizations. The prevalence of RA increased from 0.8% in 2004 to 1.4% in 2014, but other AIRD subtypes remained stable. In multivariable analysis, the adjusted odds ratio (aOR) of in-hospital complications [aOR any complication 1.13 (95% CI 1.01, 1.26), all-cause mortality 1.32 (1.03, 1.71), bleeding 1.50 (1.30, 1.74), stroke 1.36 (1.14, 1.62)] were significantly higher in patients with SSc compared with those without AIRD. There was no difference in complications between the SLE and RA groups and those without AIRD, except higher odds of bleeding in SLE patients [aOR 1.19 (95% CI 1.09, 1.29)] and reduced odds of all-cause mortality in RA patients [aOR 0.79 (95% CI 0.70, 0.88)].
Conclusion
In a nationwide cohort of US hospitalizations, we demonstrate increased rates of all adverse clinical outcomes following PCI in people with SSc and increased bleeding in SLE. Management of such patients should involve a multiteam approach with rheumatologists.
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Affiliation(s)
- Sara C Martinez
- Division of Cardiology, Providence St. Peter Hospital, Olympia, WA, USA
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Jessica Potts
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
| | | | - Edward Roddy
- School of Primary, Community and Social Care, Keele University, UK
- Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, Haywood Hospital, Burslem, UK
| | - Michael Savage
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
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Martínez-López-de-Castro N, Álvarez-Payero M, Samartín-Ucha M, Martín-Vila A, Piñeiro-Corrales G, Rodríguez-Rodríguez M, Maceiras-Pan FJ, Melero-González RB, Pego-Reigosa JM. Biological therapy safety in chronic inflammatory arthropathy patients. Eur J Rheumatol 2020:1-7. [PMID: 31922476 DOI: 10.5152/eurjrheum.2019.19074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 05/27/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The marketing of biological therapies transformed the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. But there is still concern about patient safety and management in daily clinical practice. The aim of this study was to estimate risk factors of the adverse effects in a cohort of Spanish patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. METHODS A single institution, descriptive, retrospective, cohort study was developed from January 2009 to December 2016. Patients diagnosed with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis on biological therapies were included. Undesirable events affecting patients during biological therapy, their clinical implications and the use of health resources related to adverse effects were collected. RESULTS Three hundred and sixty-two patients corresponding to 478 biological therapy lines were analysed. It implied 1192 years of monitoring. There were 57 adverse effects per 100 biological patient- years and 4.8 serious adverse effects per 100 biological patient-years. The only significant factor for a likely serious adverse effect was having a Charlson Index ≥10, OR of 6.2 (CI 95%: 3.4-11.1, p<0.001). Around 15 % of patients with adverse effects were admitted to hospital and 25% received attention at the Emergency Department. CONCLUSION Over half of the patients with arthropathies on biological therapy can suffer adverse effect during treatment but only 8.5% of these effects are serious. Special vigilance must be paid to patients with a higher number of comorbidities because they are more likely to experience serious adverse effects.
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Affiliation(s)
- Noemi Martínez-López-de-Castro
- Department of Pharmacy, University Hospital Complex of Vigo, Pontevedra, Spain
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
| | - Miriam Álvarez-Payero
- Department of Pharmacy, University Hospital Complex of Vigo, Pontevedra, Spain
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
| | - Marisol Samartín-Ucha
- Department of Pharmacy, University Hospital Complex of Vigo, Pontevedra, Spain
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
| | | | | | - María Rodríguez-Rodríguez
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
| | - Francisco José Maceiras-Pan
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
- Department of Rheumatology, University Hospital Complex of Vigo, Pontevedra, Spain
| | - Rafael Benito Melero-González
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
- Department of Rheumatology, University Hospital Complex of Vigo, Pontevedra, Spain
| | - Jose María Pego-Reigosa
- Galicia Sur Biomedical Foundation, University Hospital Complex of Vigo Estrada Clara Campoamor, Pontevedra, Spain
- Department of Rheumatology, University Hospital Complex of Vigo, Pontevedra, Spain
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11
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[Systemic sclerosis and macrovascular involvement: Status of the issue in 2019]. JOURNAL DE MÉDECINE VASCULAIRE 2019; 44:400-421. [PMID: 31761307 DOI: 10.1016/j.jdmv.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/08/2019] [Indexed: 01/12/2023]
Abstract
Systemic sclerosis (SSc) is a rare immune disease leading to fibrosis of the skin and internal organs. Microvasculopathy is a hallmark of SSc. However, some patients have severe macrovascular complications as affecting cerebral, cardiac or peripheral vessels. To date, macrovascular involvement in SSc remains a matter of debate. Many studies have shown an increased prevalence of macrovascular involvement in SSc in comparison with controlled subjects with similar cardiovascular risk factors. Various methods were used: ankle brachial pressure index, intima media thickness, imagery, coronary calcium score, pulse wave velocity, or flow mediated dilation. The pathophysiology of macrovascular involvement remains unknown and is probably multifactorial: accelerated atherosclerosis, endothelial dysfunction, or reflected wave of microvessel obliteration. The aim of this study was to perform a comprehensible review of the literature, through the study of different types of involved vessels. Results of the main studies are summarized in tables according to the method of investigation used.
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12
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Pagkopoulou E, Arvanitaki A, Daoussis D, Garyfallos A, Kitas G, Dimitroulas T. Comorbidity burden in systemic sclerosis: beyond disease-specific complications. Rheumatol Int 2019; 39:1507-1517. [PMID: 31300848 DOI: 10.1007/s00296-019-04371-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/04/2019] [Indexed: 01/10/2023]
Abstract
Systemic sclerosis (SSc) is a chronic, systemic disease characterized by fibrosis of the skin and internal organs, vasculopathy, and auto-immune activation. On the top of severe organ involvement such as interstitial lung and myocardial fibrosis, pulmonary hypertension, and renal crisis, individuals diagnosed with SSc may suffer from a number of comorbidities. This is a narrative review according to published recommendations and we searched the online databases MEDLINE and EMBASE using as key words the following terms: systemic sclerosis, scleroderma, myocardial fibrosis in combination with micro- and macro-vascular disease, cardiac involvement, atherosclerosis, cardiovascular disease and coronary arteries, infections, cancer, depression, osteoporosis, and dyslipidemia. Although data are usually inconclusive it appears that comorbidities with significant impact on life expectancy, namely cardiovascular disease, infections, and cancer as well as phycological disorders affecting emotional and mental health are highly prevalent in SSc population. Thereafter, the aim of this review is to summarize the occurrence and the clinical significance of such comorbidities in SSc population and to discuss how rheumatologists can incorporate the management of these conditions in daily clinical practice.
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Affiliation(s)
- Eleni Pagkopoulou
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, 54642, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Daoussis
- Department of Rheumatology, Faculty of Medicine, Patras University Hospital, University of Patras Medical School, Patras, Greece
| | - Alexandros Garyfallos
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, 54642, Thessaloniki, Greece
| | - George Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK.,Arthritis Research UK, Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, 54642, Thessaloniki, Greece.
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Primary percutaneous coronary intervention in ST-elevation myocardial infarction with an ectatic infarct-related artery. Coron Artery Dis 2019; 30:277-284. [PMID: 30789360 DOI: 10.1097/mca.0000000000000720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to describe the procedural characteristics, myocardial perfusion, and long-term outcomes in ST-elevation myocardial infarction patients with an ectatic infarct-related artery (IRA). PATIENTS AND METHODS The retrospective analysis included 1270 consecutive ST-elevation myocardial infarction patients treated by primary percutaneous coronary intervention who were categorized according to the coronary anatomy of the IRA as follows: ectatic group (n=91) and control group (n=1179). RESULTS Compared with the control group, patients in the ectatic group experienced lower Thombolysis in myocardial infarction grade 3 flow rate after percutaneous coronary intervention (64.8 vs. 88.2%: ectatic group vs. nonectatic group, P<0.001) and more frequent distal embolization (44.4 vs. 11.1%, P<0.001). ECG ST resolution was significantly lower in the ectatic group (P<0.001). Paradoxically, the left ventricular ejection fraction values at discharge were significantly higher in the ectatic group (P=0.032) and the infarct size assessed within 6-12 months after discharge tended to be smaller (P=0.06). The 30-day mortality rate was not significantly different between the two groups (3.3 vs. 5.0%, P=0.378) as well as Kaplan-Meier analysis for long-term overall survival in both groups (P=0.8). CONCLUSION Patients with ectatic IRA were characterized by discrepancies between high angiographic thrombus burden in a larger vessel and impact on left ventricular function that may influence their long-term survival.
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Elsayed AM, Elhefny AM, Abogabal MM, Mobasher SA, Abdelzaher A, Alhassanein KF, Sayed S, Haroon MM, Soliman HM. Progressive systemic sclerosis in Egyptian patients: Clinical characteristics and nail fold capillaroscopy. THE EGYPTIAN RHEUMATOLOGIST 2019. [DOI: 10.1016/j.ejr.2018.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Panopoulos S, Tektonidou M, Drosos AA, Liossis SN, Dimitroulas T, Garyfallos A, Sakkas L, Boumpas D, Voulgari PV, Daoussis D, Thomas K, Georgiopoulos G, Vosvotekas G, Vassilopoulos D, Sfikakis PP. Prevalence of comorbidities in systemic sclerosis versus rheumatoid arthritis: a comparative, multicenter, matched-cohort study. Arthritis Res Ther 2018; 20:267. [PMID: 30514359 PMCID: PMC6280404 DOI: 10.1186/s13075-018-1771-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Comorbidities are common in chronic systemic connective tissue diseases and are associated with adverse outcomes, increased morbidity and mortality. Although the prevalence of comorbidities has been well-studied in isolated diseases, comparative studies between different autoimmune diseases are limited. In this study, we compared the prevalence of common comorbidities between patients with systemic sclerosis (SSc) and patients with rheumatoid arthritis (RA). METHODS Between 2016 and 2017, 408 consecutive patients with SSc, aged 59 ± 13 years (87% women), were matched 1:1 for age and gender with 408 patients with RA; mean disease duration was 10 ± 8 and 9 ± 8 years, respectively. Rates of cardiovascular risk factors, coronary artery disease, stroke, chronic obstructive pulmonary disease (COPD), osteoporosis, neoplasms and depression were compared between the two cohorts. RESULTS The prevalence of dyslipidemia (18.4% vs 30.1%, p = 0.001) and diabetes mellitus (5.6% vs 11.8%, p = 0.007) and body mass index (p = 0.001) were lower in SSc compared to RA, while there was no difference in arterial hypertension or smoking. While there was a trend for lower prevalence of ischemic stroke in SSc than in RA (1.1% vs 3.2%, p = 0.085), coronary artery disease was comparable (2.7% vs 3.7%). No differences were found between patients with SSc and patients with RA in the prevalence of COPD (5.2% vs 3.7%), osteoporosis (24% vs 22%) or neoplasms overall (1.1% vs 1.7%); however lung cancer was the most prevalent cancer in SSc (7/17, 41%), whereas hematologic malignancies (7/19, 36%) and breast cancer (7/19, 36%) predominated in RA. Depression was more prevalent in SSc (22% vs 12%, p = 0.001), especially in diffuse SSc. CONCLUSIONS Despite the prevalence of dyslipidemia and diabetes mellitus in SSc being almost half that in RA, the cardiovascular comorbidity burden appears to be similar in both. The overall prevalence of neoplasms is no higher in SSc than in RA, but SSc has a more negative impact on quality of life, as clearly, more SSc patients develop depression compared to patients with RA.
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Affiliation(s)
- Stylianos Panopoulos
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Maria Tektonidou
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
| | - Alexandros A. Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School University of Ioannina, Ioannina, Greece
| | - Stamatis-Nick Liossis
- Division of Rheumatology, University of Patras Medical School, Patras University Hospital, Patras, Greece
| | | | | | - Lazaros Sakkas
- Department of Rheumatology and Clinical Immunology, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Boumpas
- Joint Rheumatology Program, 4th Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Paraskevi V. Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School University of Ioannina, Ioannina, Greece
| | - Dimitrios Daoussis
- Division of Rheumatology, University of Patras Medical School, Patras University Hospital, Patras, Greece
| | - Konstantinos Thomas
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Ave, 115 27 Athens, Greece
| | - Georgios Georgiopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Ave, 115 27 Athens, Greece
| | - Georgios Vosvotekas
- 1st Department of Medicine, Aristotle University of Thessaloniki, School of Medicine, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Ave, 115 27 Athens, Greece
| | - Petros P. Sfikakis
- Joint Rheumatology Program, 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Laikon General Hospital, Athens, Greece
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Hatemi AC, Tongut A, Özyedek Z, Çerezci İ, Özgöl İ, Perk Gürün H. Association between ascending aortic diameter and coronary artery dilation: a demographic data analysis. J Int Med Res 2016; 44:1349-1358. [PMID: 28322097 PMCID: PMC5536746 DOI: 10.1177/0300060516666623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective Coronary artery dilations (CDs), a subgroup of coronary artery anomalies (CAAs), are relatively rare but important cardiac pathologies. They are considered to be linked to coronary atherosclerosis in most cases. Methods The demographic data, multi-slice computed tomographic coronary angiography data, coronary calcium score, and ascending aortic diameter (AAD) of 1538 patients were reviewed. In total, 197 (12.8%) patients (166 men, 31 women; age 15 – 84 years; mean 55.78 ± 12.32 years) with CAAs were identified, and 81 (5.3%) patients (70 men, 11 women; age 27 – 80 years; mean 56.63 ± 12.06 years) had CDs. Multiple regression and correlation analyses were performed in all 1538 patients to predict the association between the AAD and the presence of CD and thus their correlation with atherosclerosis. Results The AAD was significantly larger in patients with than without CAAs and CDs. Male sex was significantly more prevalent in patients with CAAs and CDs. According to the multiple logistic regression model, male sex increased the risk of CD by 2.650 and the risk of CAA by 2.017, while hyperlipidaemia decreased the risk of CAA by 0.681. While a moderately weak correlation between the AAD and age was observed in patients with CDs, no correlation was found between the AAD and coronary calcium score. Conclusion Although the natural history and physiopathology of CDs is not yet fully understood, the present study shows an association between the AAD and the presence of CDs but a lack of association between atherosclerosis and CDs.
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Affiliation(s)
- Ali Can Hatemi
- 1 Istanbul University, Institute for Cardiology, Department of Cardiovascular Surgery, Istanbul, Turkey.,2 Kartal Koşuyolu Heart Center, Pediatric Cardiovascular Surgery Clinic, Istanbul
| | - Aybala Tongut
- 2 Kartal Koşuyolu Heart Center, Pediatric Cardiovascular Surgery Clinic, Istanbul
| | - Zeki Özyedek
- 3 Macka Emar Advanced Medical Imaging Center, Istanbul, Turkey
| | - İsmail Çerezci
- 3 Macka Emar Advanced Medical Imaging Center, Istanbul, Turkey
| | - İlhan Özgöl
- 1 Istanbul University, Institute for Cardiology, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Hande Perk Gürün
- 4 Marmara University, Marmara Faculty of Medicine, Department of Public Health, Istanbul, Turkey
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A critical view on cardiovascular risk in systemic sclerosis. Rheumatol Int 2016; 37:85-95. [PMID: 27405985 DOI: 10.1007/s00296-016-3530-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
Systemic Sclerosis (SSc) is an autoimmune disorder characterized by microvascular injury and diffuse fibrosis of the skin and internal organs. While macrovascular disease and higher risk for cardiovascular events are well documented in other systemic rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, the presence and extent of atherosclerosis among patients with SSc is yet to be established. Primary cardiac involvement, due to impairment of coronary microvascular circulation and myocardial fibrosis, considerably affects prognosis and life expectancy of individuals with SSc, representing one of the leading causes of death in this population. On the other hand the existence and prevalence of atherosclerotic coronary disease remains an issue of debate as studies comparing structural and morphological markers of atherosclerosis and cardiovascular events between SSc patients and the general population have yielded controversial results. The aim of this review is to summarize recent literature about the prevalence of cardiovascular disease in SSc, review the surrogate markers of CVD that have been evaluated and examine whether common pathogenic mechanisms exist between SSc and macrovascular disease.
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18
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Determinants of atherosclerosis in an Egyptian cohort of systemic sclerosis: Relation to disease activity and severity. THE EGYPTIAN RHEUMATOLOGIST 2016. [DOI: 10.1016/j.ejr.2015.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fibroblast growth factor-23 in patients with systemic sclerosis: A case–control study. EGYPTIAN RHEUMATOLOGIST 2016. [DOI: 10.1016/j.ejr.2014.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Heshmat TS, Khalil NM, Elhamid HA, Labib S, Mahfouz M. Assessment of premature coronary atherosclerosis in patients with systemic lupus erythematosus disease. THE EGYPTIAN RHEUMATOLOGIST 2015. [DOI: 10.1016/j.ejr.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ali H, Ng KR, Low AHL. A qualitative systematic review of the prevalence of coronary artery disease in systemic sclerosis. Int J Rheum Dis 2015; 18:276-86. [PMID: 25884668 DOI: 10.1111/1756-185x.12566] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIMS To review existing literature on the prevalence/incidence of coronary artery disease (CAD), and secondarily highlight risk factors for CAD in systemic sclerosis (SSc). METHODS A PubMed and Cochrane Central Register of Controlled Trials search of studies (till 30 November 2013) relating to SSc and CAD was performed, retrieving 180 titles. INCLUSION CRITERIA studies reporting CAD prevalence/incidence in SSc based on autopsy findings, coronary artery calcium scores, coronary angiographic findings and physician/patient-reported CAD. EXCLUSION CRITERIA (i) not written in English; (ii) not concerned with human subjects; (iii) single case reports or review articles; (iv) genetic studies; and 95) other surrogate outcome measures of atherosclerosis. Quality assessment was done using the Newcastle-Ottawa score (range 0-9). RESULTS Thirteen studies (Newcastle-Ottawa score 5-8) were selected. Of eight studies with controls, seven reported increased CAD prevalence (10-56%) or incidence (2.3%) compared to controls (prevalence 2-44%; incidence 1.5%). Of five studies without controls, CAD prevalence was 8-32%. Five of six studies reported that traditional cardiovascular risk factors were similar/reduced in SSc compared to controls. SSc was an independent risk factor for CAD, in addition to age (n = 2), hypercholesterolaemia (n = 3), male gender (n = 1), hypertension and diabetes (n = 1). Disease duration, renal involvement and pulmonary arterial hypertension were associated with CAD. CONCLUSIONS Systemic sclerosis is associated with an increased prevalence/incidence of CAD. SSc is an independent risk factor for CAD. The association of CAD with SSc-related factors requires further research. Meanwhile, patients with SSc should be screened and treated for identified traditional cardiovascular risk factors.
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Affiliation(s)
- Hassan Ali
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore City, Singapore
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Cannarile F, Valentini V, Mirabelli G, Alunno A, Terenzi R, Luccioli F, Gerli R, Bartoloni E. Cardiovascular disease in systemic sclerosis. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:8. [PMID: 25705640 DOI: 10.3978/j.issn.2305-5839.2014.12.12] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/16/2014] [Indexed: 12/19/2022]
Abstract
Cardiovascular (CV) system involvement is a frequent complication of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). It still remains unclear if a premature atherosclerosis (ATS) occurs even in systemic sclerosis (SSc). Although microvascular disease is a hallmark of SSc, in the last few years a number of studies highlighted a higher prevalence of macrovascular disease in SSc patients in comparison to healthy individuals and these data have been correlated with a poorer prognosis. The mechanisms promoting ATS in SSc are not fully understood, but it is believed to be secondary to multi-system organ inflammation, endothelial wall damage and vasculopathy. Both traditional risk factors and endothelial dysfunction have been proposed to participate to the onset and progression of ATS in such patients. In particular, endothelial cell injury induced by anti-endothelial antibodies, ischemia/reperfusion damage, immune-mediated cytotoxicity represent the main causes of vascular injury together with an impaired vascular repair mechanism that determine a defective vasculogenesis. Aim of this review is to analyse both causes and clinical manifestations of macrovascular involvement and ATS in SSc.
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Affiliation(s)
- Francesca Cannarile
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Valentina Valentini
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Giulia Mirabelli
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Alessia Alunno
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Riccardo Terenzi
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Filippo Luccioli
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Roberto Gerli
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
| | - Elena Bartoloni
- Department of Medicine, Rheumatology Unit, University of Perugia, Via dal Pozzo 06132, Perugia, Italy
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Farag NA, El Serougy EM, Metawee SA, El Azizi HS. Subclinical atherosclerosis and peripheral vascular disease in systemic sclerosis patients: Relation to potential risk factors. EGYPTIAN RHEUMATOLOGIST 2015. [DOI: 10.1016/j.ejr.2014.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. Contribution of cardiovascular magnetic resonance in the evaluation of coronary arteries. World J Cardiol 2014; 6:1060-1066. [PMID: 25349650 PMCID: PMC4209432 DOI: 10.4330/wjc.v6.i10.1060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 08/11/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular magnetic resonance (CMR) allows the nonradiating assessment of coronary arteries; to achieve better image quality cardiorespiratory artefacts should be corrected. Coronary MRA (CMRA) at the moment is indicated only for the detection of abnormal coronary origin, coronary artery ectasia and/or aneurysms (class I indication) and coronary bypass grafts (class II indication). CMRA utilisation for coronary artery disease is not yet part of clinical routine. However, the lack of radiation is of special value for the coronary artery evaluation in children and women. CMRA can assess the proximal part of coronary arteries in almost all cases. The best results have been observed in the evaluation of the left anterior descending and the right coronary artery, while the left circumflex, which is located far away from the coil elements, is frequently imaged with reduced quality, compared to the other two. Different studies detected an increase in wall thickness of the coronaries in patients with type I diabetes and abnormal renal function. Additionally, the non-contrast enhanced T1-weighed images detected the presence of thrombus in acute myocardial infarction. New techniques using delayed gadolinium enhanced imaging promise the direct visualization of inflamed plaques in the coronary arteries. The major advantage of CMR is the potential of an integrated protocol offering assessment of coronary artery anatomy, cardiac function, inflammation and stress perfusion-fibrosis in the same study, providing an individualized clinical profile of patients with heart disease.
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Amaya-Amaya J, Montoya-Sánchez L, Rojas-Villarraga A. Cardiovascular involvement in autoimmune diseases. BIOMED RESEARCH INTERNATIONAL 2014; 2014:367359. [PMID: 25177690 PMCID: PMC4142566 DOI: 10.1155/2014/367359] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 12/15/2022]
Abstract
Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.
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Affiliation(s)
- Jenny Amaya-Amaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63C-69, 11001000 Bogotá, Colombia
- Mederi, Hospital Universitario Mayor, Calle 24 No. 29-45, 11001000 Bogotá, Colombia
| | - Laura Montoya-Sánchez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63C-69, 11001000 Bogotá, Colombia
- Mederi, Hospital Universitario Mayor, Calle 24 No. 29-45, 11001000 Bogotá, Colombia
| | - Adriana Rojas-Villarraga
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Carrera 24 No. 63C-69, 11001000 Bogotá, Colombia
- Mederi, Hospital Universitario Mayor, Calle 24 No. 29-45, 11001000 Bogotá, Colombia
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Schiopu E, Au KM, McMahon MA, Kaplan MJ, Divekar A, Singh RR, Furst DE, Clements PJ, Ragvendra N, Zhao W, Maranian P, Khanna D. Prevalence of subclinical atherosclerosis is increased in systemic sclerosis and is associated with serum proteins: a cross-sectional, controlled study of carotid ultrasound. Rheumatology (Oxford) 2013; 53:704-13. [PMID: 24357811 DOI: 10.1093/rheumatology/ket411] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES SSc is associated with an increased prevalence of atherosclerosis (ATS). This study assessed the prevalence of subclinical ATS as measured by carotid US and explored serum proteins to identify potential biomarkers of SSc-ATS. METHODS Forty-six SSc female patients and 46 age- and ethnicity-matched controls underwent carotid US to assess the presence of plaque and carotid intima media thickness (CIMT). Abstracted data included demographics, ATS risk factors and serum measurements [cholesterol, proinflammatory high-density lipoprotein (piHDL), CRP, lipoproteins]. Serum cytokines/proteins analyses included circulating type I IFN activity by quantifying IFN-inducible genes, soluble junctional adhesion molecule A (sJAM-A) and 100 serum proteins by using a microplate-based multiplex platform. Proteins significant at P < 0.05 on bivariate analyses for the presence of plaque were used to develop a composite measure. RESULTS Patients with SSc had more plaque (45.6% vs 19.5%, P = 0.01) but similar CIMT compared with controls. Multiplex analysis detected significant associations between serum proteins of inflammation, vasculopathy and fibrosis with ATS in SSc, including IL-2, IL-6, CRP, keratinocyte growth factor, intercellular adhesion molecule 1, endoglin, plasminogen activator inhibitor 1 and insulin-like growth factor binding protein 3 associated with carotid plaque. Myeloid progenitor inhibitory factor 1, serum amyloid A, thrombomodulin, N-terminal pro-brain natriuretic peptide (BNP), and Clara cell secretory protein 16 kD correlated with CIMT. The median composite score for the plaque group was 6 and for the no plaque group it was 2 (P < 0.0001). CONCLUSION Patients with SSc have a higher prevalence of carotid plaque than matched controls, and patients with SSc-plaque vs patients without plaque have elevated serum proteins implicated in both vasculopathy and fibrosis. Further studies are needed to evaluate the role of these proteins in SSc compared with healthy controls.
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Affiliation(s)
- Elena Schiopu
- Division of Rheumatology/Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SPC 5422, Ann Arbor, MI 48109, USA.
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Tissue Doppler assessment of right ventricular function in female patients with limited form of systemic sclerosis. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2013.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Komócsi A, Vorobcsuk A, Faludi R, Pintér T, Lenkey Z, Költő G, Czirják L. The impact of cardiopulmonary manifestations on the mortality of SSc: a systematic review and meta-analysis of observational studies. Rheumatology (Oxford) 2012; 51:1027-36. [DOI: 10.1093/rheumatology/ker357] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Ngian GS, Sahhar J, Wicks IP, Van Doornum S. Cardiovascular disease in systemic sclerosis--an emerging association? Arthritis Res Ther 2011; 13:237. [PMID: 21888685 PMCID: PMC3239376 DOI: 10.1186/ar3445] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Microvascular disease is a prominent feature of systemic sclerosis (SSc) and leads to Raynaud's phenomenon, pulmonary arterial hypertension, and scleroderma renal crisis. The presence of macrovascular disease is less well established, and, in particular, it is not known whether the prevalence of coronary heart disease in SSc is increased. Furthermore, in terms of cardiac involvement in SSc, there remains conjecture about the relative contributions of atherosclerotic macrovascular disease and myocardial microvascular disease. In this review, we summarize the literature describing cardiovascular disease in SSc, discuss the pathophysiological mechanisms common to SSc and atherosclerosis, and review the surrogate markers of cardiovascular disease which have been examined in SSc. Proposed mediators of the vasculopathy of SSc which have also been implicated in atherosclerosis include endothelial dysfunction, a reduced number of circulating endothelial progenitor cells, and an increased number of microparticles. Excess cardiovascular risk in SSc is suggested by increased arterial stiffness and carotid intima thickening and reduced flow-mediated dilatation. Cohort studies of adequate size are required to resolve whether this translates into an increased incidence of cardiovascular events in patients with SSc.
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Affiliation(s)
- Gene-Siew Ngian
- The University of Melbourne, Department of Medicine (Royal Melbourne Hospital/Western Hospital), 4th Floor, Clinical Sciences Building, Royal Melbourne Hospital, Royal Parade, Parkville, Victoria 3050, Australia.
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Mok MY, Lau CS, Chiu SSH, Tso AWK, Lo Y, Law LSC, Mak KF, Wong WS, Khong PL, Lam KSL. Systemic sclerosis is an independent risk factor for increased coronary artery calcium deposition. ACTA ACUST UNITED AC 2011; 63:1387-95. [DOI: 10.1002/art.30283] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
BACKGROUND The mechanisms involved in the pathogenesis of coronary artery ectasia (CAE) have not been elucidated. Circulating antiendothelial cell antibodies (AECA) are often detectable in systemic vasculitis and have been implicated in the pathogenesis of endothelial injury. Their prevalence in CAE is not known. METHODS AND RESULTS Out of 475 consecutive patients subjected to coronary angiography, 27 patients were diagnosed with CAE. Thirty patients matched for age, body mass index, sex, and coronary artery disease prevalence, served as controls. Serum AECA of IgG, IgM, and IgA isotypes were detected using a cell-based enzyme-linked immunosorbent assay (ELISA). Antinuclear antibodies (ANA) and antineutrophil cytoplasmic antibodies (ANCA) were detected using indirect immunofluorescence. IgG and IgM anticardiolipin antibodies (aCL) were detected using commercial ELISA. The prevalence of ANA and ANCA was similar in CAE patients and controls (33.3 vs. 43.3%, and 3.3 vs. 7.4%, respectively). There was no significant difference in IgG or IgM aCL reactivity between patients and controls. Both CAE patients and controls were negative for IgG AECA. The frequency of IgM AECA positivity was similar in CAE patients and controls. The prevalence of AECA of the IgA isotype was significantly higher in CAE patients (37.0 vs. 10%, P<0.05). CONCLUSION There is increased prevalence of circulating AECA of the IgA isotype in patients with CAE. This provides evidence for a role of autoimmunity in the pathogenesis of certain cases of CAE.
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Pinter T, Faludi R, Magyari B, Vorobcsuk A, Kumanovics G, Minier T, Czirjak L, Komocsi A. Mechanism of coronary flow reserve reduction in systemic sclerosis: insight from intracoronary pressure wire studies. Rheumatology (Oxford) 2010; 50:781-8. [DOI: 10.1093/rheumatology/keq402] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
Systemic sclerosis (SSc) is a chronic disease of unknown etiology, characterized by enhanced fibrosis, and microvascular abnormalities. During the past several decades, the death rates due to cardiovascular disease or cerebrovascular disease in SSc patients substantially increased and are currently responsible for 20-30% of mortality. Various autoimmune rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus accelerate atherosclerosis. Although microvascular disease is a hallmark of SSc, an ongoing debate exists regarding the presence and extent of macrovascular diseases and the presence of accelerated atherosclerosis in SSc patients. Despite conflicting results as to intima-media thickness (IMT) in SSc patients, the most recent and largest study has found no difference in either plaque occurrence or IMT. Additionally, abnormal coronary flow reserve in SSc patients appears to be due to microvascular involvement rather than atherosclerosis of the epicardial coronary arteries. Angiographic findings as well as computed tomography studies have generated conflicting reports as to coronary atherosclerosis in SSc. Herein, we review the current knowledge of macrovascular involvement and atherosclerosis in SSc. The differences between SSc and other autoimmune rheumatic diseases in the presence and extent of atherosclerosis need to be further investigated.
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Wiesent F, Weinerth J. [Digital ulcers in systemic sclerosis--an interdisciplinary challenge]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 2010; 105:578-581. [PMID: 20824416 DOI: 10.1007/s00063-010-1096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 05/26/2010] [Indexed: 05/29/2023]
Abstract
Digital ulcers in systemic sclerosis are painful ischemic necrotic lesions of the acra. Optimal treatment consists of conventional wound management and medication: iloprost infusions promote primary healing of the ulcers, while the dual endothelin receptor antagonist bosentan is used for secondary prophylaxis of new ulcers. The described case illustrates the essential interdisciplinary collaboration for optimal management of these patients.
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Affiliation(s)
- Franziska Wiesent
- III. Medizinische Klinik, Funktionsbereich Rheumatologie/Osteologie, Zentralklinikum Augsburg, Augsburg, Germany.
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Mok MY, Chiu SSH, Lo Y, Mak HKF, Wong WS, Khong PL, Lau CS. Coronary atherosclerosis using computed tomography coronary angiography in patients with systemic sclerosis. Scand J Rheumatol 2010; 38:381-5. [PMID: 19585378 DOI: 10.1080/03009740902992979] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Impaired coronary artery reserve has previously been demonstrated in patients with systemic sclerosis (SSc). Both micro- and macrovascular factors are probably contributory to the underlying pathogenesis. OBJECTIVES To examine the frequency of coronary atherosclerosis in a series of SSc patients by computed tomography coronary angiography (CTCA), a less invasive method than conventional coronary angiography, the current gold standard in the detection of coronary atherosclerosis, and to explore its clinical associations. METHODS Nineteen consecutive SSc patients [six with diffuse (dSSc) and 13 with limited disease (lSSc)] with disease duration of >or= 3 years were recruited. Coronary calcium score and contrast angiography were examined by CT scan. Conventional cardiovascular factors and inflammatory markers were measured and correlated with CT findings. RESULTS The mean+/-SD age of these patients was 52.5+/-12.5 years with median disease duration of 12.5 years. Six (31.6%) patients were found to have coronary artery calcification (calcium score 13-2008). Coronary calcium was detected in one dSSc patient but contrast angiography was not performed because of interference from an in situ implantable cardiac device. Some parts of the coronary arteries were not assessable in two patients who had ectopic cardiac rhythm. Five lSSc patients had calcified plaques causing variable coronary luminal stenosis. All patients were asymptomatic. Patients with abnormal CTCA findings were more likely to be older (p < 0.001) and were less likely to have serum anti-Scl70 antibodies (p = 0.003) than those without, after Bonferroni correction. CONCLUSIONS Coronary atherosclerosis is not uncommon in asymptomatic SSc patients. CTCA is a convenient and non-invasive method for studying coronary atherosclerosis.
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Affiliation(s)
- M Y Mok
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, PR China.
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Komócsi A, Pintér T, Faludi R, Magyari B, Bozó J, Kumánovics G, Minier T, Radics J, Czirják L. Overlap of coronary disease and pulmonary arterial hypertension in systemic sclerosis. Ann Rheum Dis 2010; 69:202-5. [PMID: 19158116 DOI: 10.1136/ard.2008.096255] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a common complication of systemic sclerosis (SSc). Symptoms of coronary artery disease (CAD) and PAH are closely related and cardiac catheterisation is needed to confirm their diagnosis. The aim of the present work was to investigate of the extent of overlap between CAD and PAH in patients with SSc. METHODS Based on non-invasive investigations, 20 patients out of 120 were suspected to have PAH ("suspected PAH" group). Another 10 patients showed signs of coronary disease ("suspected CAD" Group). In these 30 patients, right heart catheterisation and coronary angiography were performed, and the coronary flow reserve (CFR) was assessed by thermodilution technique. RESULTS In the "suspected PAH" and the "suspected CAD" groups, PAH was found in 12/20 and 2/10 cases, and coronary artery stenosis in 9/20 and 6/10 cases, respectively. Severely reduced CFR was revealed in 7/20 and 3/10 cases, respectively. CONCLUSIONS PAH, CAD and reduced CFR all show a considerable overlap in symptomatic patients with SSc. The current non-invasive investigations are neither sensitive nor specific enough to make an appropriate distinction between these different disease manifestations. A more invasive approach, such as coronary angiography at the initial catheterisation, is required to properly characterise and treat the different forms of cardiac involvement in SSc.
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Affiliation(s)
- A Komócsi
- University of Pécs, Heart Institute, H-7624 Pécs, Ifjúság u. 13, Hungary.
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Kobayashi H, Yokoe I, Hirano M, Nakamura T, Nakajima Y, Fontaine KR, Giles JT, Kobayashi Y. Cardiac magnetic resonance imaging with pharmacological stress perfusion and delayed enhancement in asymptomatic patients with systemic sclerosis. J Rheumatol 2009; 36:106-12. [PMID: 19040307 DOI: 10.3899/jrheum.080377] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess cardiac involvement in asymptomatic patients with systemic sclerosis (SSc) by cardiac magnetic resonance imaging (MRI). METHODS Ten asymptomatic patients with SSc (all female; mean age 59.5+/-9.4 yrs) underwent contrast enhanced cardiac MRI on a 1.5 T MRI device. Adenosine triphosphate was used for stress and rest perfusion to assess perfusion defects due to microvascular impairment or ischemia, and delayed enhanced (DE) imaging was obtained for the assessment of myocardial necrosis and fibrosis. We evaluated the pathophysiological associations of stress perfusion combined with DE imaging with SSc disease severity measures. RESULTS Stress perfusion defects were seen in 5 out of 9 patients (56%): 4 had nonsegmental subendocardial perfusion defects and one had a segmental subendocardial perfusion defect. Three patients were found to have DE. DE was not observed in any patient without perfusion defect; and among the 5 patients with perfusion defects, 3 (60%) had DE. Two of the 3 had DE in segments not matching the region of nonsegmental perfusion defects. The remaining one had a segmental subendocardial DE matching the region of a segmental perfusion defect. Perfusion defects were seen in 75% of patients with a history of digital ulceration compared to only 20% of those without history of ulceration. CONCLUSION Subclinical myocardial involvement, as detected by cardiac MRI, was frequent in asymptomatic patients with SSc. Cardiac MRI may aid in understanding the pathophysiological mechanism of SSc.
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Affiliation(s)
- Hitomi Kobayashi
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4100, Baltimore, MD 21224, USA.
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Khurma V, Meyer C, Park GS, McMahon M, Lin J, Singh RR, Khanna D. A pilot study of subclinical coronary atherosclerosis in systemic sclerosis: coronary artery calcification in cases and controls. ACTA ACUST UNITED AC 2008; 59:591-7. [PMID: 18383403 DOI: 10.1002/art.23540] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is associated with vasculopathy and endothelial cell injury, which could potentially increase the risk of coronary atherosclerosis. Multidetector computed tomography, a noninvasive procedure, generates a coronary calcium score (CCS) as a marker for coronary atherosclerosis. Serum proinflammatory high-density lipoprotein (piHDL) is a potential novel marker of atherosclerotic risk. The objective of the pilot study was to determine 1) the prevalence of subclinical coronary atherosclerosis in SSc and 2) serum piHDL levels as a potential novel marker of atherosclerotic risk in SSc. METHODS A cross-sectional study of 17 patients with SSc and 17 age-, sex-, and race-matched healthy controls in Cincinnati, Ohio, was conducted. Measurements included CCS; body mass index; lipid profile; and serum levels of high-sensitivity C-reactive protein, homocysteine, and piHDL. RESULTS Patients with SSc were slightly older (mean 52.8 years) than control subjects (mean 50.6 years; P = 0.01). Coronary calcium was found in 12 participants (9 with SSc, 3 controls; P = 0.03). The mean +/- SD CCS in patients with SSc was significantly greater than the controls (126.6 +/- 251.0 versus 14.7 +/- 52.2; P = 0.003). Five patients with SSc (29%), but no controls, had detectable levels of piHDL (P = 0.06). CONCLUSION Prevalence of subclinical coronary atherosclerosis is greater in patients with SSc compared with healthy controls. These findings should be confirmed in a larger study.
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Bibliography. Current world literature. Myositis and myopathies. Curr Opin Rheumatol 2007; 19:651-3. [PMID: 17917548 DOI: 10.1097/bor.0b013e3282f20347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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