Cardiac complications of systemic sclerosis and management: recent progress.

PURPOSE OF REVIEW: Cardiac complications in systemic sclerosis (SSc) continue to be a leading cause of death in this patient population. Early recognition and treatment of the cardiac diseases commonly associated with SSc is essential. RECENT FINDINGS: Recent studies have confirmed the significant increase in mortality in SSc patients with cardiac involvement. Electrocardiography and echocardiography (2DE) continue to play a major role in screening and diagnosing cardiac manifestations such as arrhythmias or biventricular dysfunction, respectively. Novel techniques such as myocardial strain imaging on 2DE and T1 mapping on cardiovascular magnetic resonance are useful for detecting subclinical cardiac abnormalities, but the clinical relevance of these findings is still not known. An expert consensus was recently published to help establish best practice guidelines on management of cardiac complications in SSc, but data supporting these recommendations remain limited. SUMMARY: Recent studies continue to enhance our understanding of SSc cardiac disease. Although the results of these studies help lessen the ambiguity of managing and treating these patients, there is still much more research to be done.

Left ventricular long axis function assessed during cine-cardiovascular magnetic resonance is an independent predictor of adverse cardiac events.

BACKGROUND: Left ventricular pump function requires a complex interplay involving myocardial fibers orientated in the longitudinal, oblique and circumferential directions. Long axis dysfunction appears to be an early marker for a number of pathological states. We hypothesized that mitral annular plane systolic excursion (MAPSE) measured during cine-cardiovascular magnetic resonance (CMR) reflects changes in long axis function and may be an early marker for adverse cardiovascular outcomes. The aims of this study were therefore: 1) To assess the feasibility and reproducibility of MAPSE measurements during routine cine-CMR; and 2) To assess whether MAPSE, as a surrogate for long axis function, is a predictor of major adverse cardiovascular events (MACE). METHODS: Four hundred consecutive patients undergoing CMR were prospectively enrolled. MAPSE was measured in the 4-chamber cine view. Patients were prospectively followed for major adverse cardiac events (MACE) - death, non-fatal myocardial infarction, hospitalization for heart failure or unstable angina, and late revascularization. Cox proportional hazards regression modeling was used to identify factors independently associated with MACE. Net reclassification improvement (NRI) was calculated to assess whether addition of MAPSE resulted in improved risk reclassification of MACE. RESULTS: Seventy-two MACE occurred during a median follow-up of 14.5 months. By Kaplan-Meier analysis, patients with lateral MAPSE <1.11 cm (median) experienced significantly higher incidence of MACE than patients with a MAPSE ≥1.11 cm (p = 0.027). After adjustment for established clinical risk factors which were univariate predictors (age, diabetes, hypertension, NYHA class, LV mass), lateral MAPSE remained a significant independent predictor of MACE (HR = 4.384 per cm decrease or 1.344 per 2 mm decrease; p = 0.020). Incorporation of lateral MAPSE into this risk model resulted in a net reclassification improvement (NRI) of 0.18 (p = 0.006). CONCLUSIONS: Reduced long axis function assessed with lateral MAPSE during cine-CMR is an independent predictor of MACE.

Downstream clinical consequences of stress cardiovascular magnetic resonance based on appropriate use criteria.

BACKGROUND: Appropriate use criteria (AUC) have been developed by professional organizations as a response to the rising costs of imaging, with the goal of optimizing test-patient selection. Consequently, the AUC are now increasingly used by third-party-payers to assess reimbursement. However, these criteria were created by expert consensus and have not been systematically assessed for CMR. The aim of this study was to determine the rates of abnormal stress-CMR and subsequent downstream utilization of angiography and revascularization procedures based on the most recent AUC. METHODS: 300 consecutive patients referred for CMR-stress testing were prospectively enrolled. Two cardiologists reviewed all clinical information before the CMR-stress test and classified the test as "appropriate', "maybe appropriate" or "rarely appropriate" according to the 2013 AUC. Patients were followed for 2 months for the primary outcomes of coronary angiography and/or revascularization. RESULTS: 49.7% of stress CMRs were appropriate, 36.7% maybe appropriate, and 13.6% rarely appropriate. Ischemia was significantly more likely to be seen in the appropriate (18.8%) or maybe appropriate groups (21.8%) than the rarely appropriate group (4.8%) (p = 0.030 and p = 0.014 respectively). Referral for cardiac catheterization was not significantly different in the appropriate (10.1%) and maybe appropriate groups (10.0%) compared to the rarely appropriate group (2.4%) (p = 0.119 and p = 0.127 respectively). No patients undergoing catheterization in the rarely appropriate group went on to require revascularization, in contrast to 53.3% of the appropriate vs 36.4% of the maybe appropriate patients (p = 0.391). Presence of ischemia led to referral for cardiac catheterization in 50.0% of the appropriate group vs 33.3% of the maybe appropriate group (p = 0.225); in contrast to none of the rarely appropriate group. CONCLUSIONS: The great majority of tests were classified as appropriate or maybe appropriate. Downstream cardiac catheterization rates were similar in all 3 groups. However, rarely appropriate studies never required revascularization, suggesting suboptimal resource utilization. Studies classified as maybe appropriate had similar rates of abnormal findings and led to similar rates of downstream catheterization and revascularization as those that were deemed appropriate. This suggests that consideration could be given to upgrading some of the common maybe appropriate indications to the appropriate category.

Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission.

BACKGROUND: The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission. METHODS: There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization. RESULTS: In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, ß1 = -0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS. CONCLUSIONS: The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Subcostal View-Based Longitudinal Strain in Patients With Breast Cancer Is an Alternative to Conventional Apical View-Based Longitudinal Strain.

BACKGROUND: Strain imaging is a robust clinical tool in cardiac surveillance of patients with breast cancer. However, image quality and therefore ability to accurately measure strain are often limited in this patient group because of tissue expanders, implants, and/or flap reconstruction. The aim of the present study was to evaluate the feasibility of measuring left ventricular longitudinal strain (LVLS) in the echocardiographic subcostal view in female patients with breast cancer. METHODS: A total of 110 studies from 68 female patients with breast cancer were included. The feasibility of LVLS speckle-tracking measurements in the apical three-chamber (3C) and four-chamber (4C) views and in the subcostal 3C and 4C views was evaluated. The LVLS speckle-tracking measurements obtained in these two echocardiographic views were compared using intraclass correlation coefficients and Bland-Altman analyses. RESULTS: The feasibility of LVLS in the apical 3C and 4C views was 98.1% and 98.1%, respectively. In comparison, the feasibility of LVLS in the subcostal 3C and 4C views was 93.6% and 96.3%, respectively. A high degree of reliability was found between apical and subcostal LVLS 3C and 4C measurements. For the 3C view, the average measure intraclass correlation coefficient was 0.81 (95% CI, 0.72-0.88). For the 4C view, the average measure intraclass correlation coefficient was 0.80 (95% CI, 0.70-0.87). Bland-Altman analysis showed good agreement between apical and subcostal measurements in both the 3C and 4C views. CONCLUSIONS: Subcostal 3C and 4C LVLS can be reliably measured, with good agreement with conventional LVLS from the apical views, in female patients with breast cancer. Importantly, the subcostal view may provide a novel alternative for trending LVLS in patients with breast cancer who have technically limited apical windows.

17HSD 2 may be higher in African-American breast cancer and is associated with estrogen receptor-negative tumors.

BACKGROUND: African-American women develop more aggressive breast cancers and at an earlier age compared with Caucasian women. MATERIALS AND METHODS: We compared gene expression profiles of breast cancer cell lines that were developed from African-American and Caucasian patients to identify biological differences in breast cancers that develop in these groups. Real-time PCR was used to evaluate mRNA expression in cell lines and in a series of breast cancer cases. Gene microarray signal intensities were also analyzed in the International Genomics Consortium Expression Project for Oncology (expO) dataset. RESULTS: 17,-Hydroxysteroid dehydrogenase type 2 (17HSD 2) gene and mRNA expression were significantly higher in the African-American cell lines (p<0.05). However, 17HSD 2 expression did not differ significantly between the two cohorts in either our clinical series or the expO dataset. 17HSD 2 expression was found to be predictive of younger age at diagnosis and estrogen receptor status. CONCLUSION: Overexpression of 17HSD 2 in African-American breast cancer may contribute to the increased proportion of estrogen receptor-negative breast cancers and worse clinical outcome among African-American patients.