Contractile reserve in systemic sclerosis patients as a major predictor of global cardiac impairment and exercise tolerance

Abstract

Several studies have evidenced high prevalence of myocardial systolic and diastolic dysfunction among patients with systemic sclerosis (SSc). Exercise echocardiography has shown a diagnostic and prognostic role in identifying early left ventricular (LV) dysfunction in several myocardial pathological settings. The aim of our study was to evaluate early signs of LV impairment under exercise and their correlation to patient's exercise tolerance. Forty-five patients (age 60.4 ± 10.3 years) with SSc and 20 age and sex comparable controls were enrolled in the study. All patients underwent clinical evaluation, 2D echocardiography associated with Tissue Doppler and speckle tracking to evaluate LV deformation indexes, and an exercise echocardiography to evaluate left ventricle contractile reserve (LVCR) and exercise pulmonary pressures. Finally, a 6-minute walking test (6MWT) to evaluate exercise tolerance was also performed. Compared to controls, SSc patients showed an impaired diastolic function (E/E' 10.9 ± 3.7 vs 8.36 ± 2.01; p < 0.01) associated with larger left atrial dimensions (LAVI 28.4 ± 8.7 vs 19.3 ± 4.6 mL/m(2); p < 0.01). During exercise echocardiography, a reduced global longitudinal strain at peak exercise (S-GLS) was highlighted compared to controls (15.7 ± 3.6 vs 18.2 ± 2.2; p = 0.001). A S-GLS cutoff <18%, identified by ROC analysis, identified SSc patients with a reduced diastolic function, exercise tolerance at the 6MWT and higher pulmonary pressures. Our data show that in SSc patients a reduced LVCR characterizes the patients with a more extensive cardiovascular impairment in terms of LV diastolic function, pulmonary pressures and exercise tolerance. These data underline the importance of exercise echocardiography for the preclinical screening of the LV impairment in this population.

Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis

“…The present study showed that SSc patients exhibited reduced LVGLS, LVGCS and LVGRS compared with healthy controls, although some studies have had different conclusions. Cadeddu et al 20 have reported reduced LVGLS compared with controls only during exercise. Durmus et al 21 have found that LVGLS, LVGCS and LVGRS were similar between the two groups.…”

Lung Diffusion Capacity Affects Stroke Volume in Systemic Sclerosis

“…That is, impaired lung perfusion capacity reduced exercise tolerance, which affected the stroke volume without pathological heart involvement. In addition, it must be noted that diastolic dysfunction according to the E/E' ratio was reported to reduce cardiopulmonary exercise tolerance in patients with normal EF [11,18,24,25]. Therefore, the exercise tolerance is regulated by multiple factors.…”

“…In healthy subjects, the left ventricular end-diastolic volume was reported to be directly related to the change in stroke volume during exercise [17]. Cadeddu et al [18] demonstrated that bicycle exercise affected left ventricular diastolic function through global longitudinal strain using speckle tracking echocardiography, although the dysfunction was not observed at rest in systemic sclerosis. Thus, the assessment of hemodynamic function during exercise may increase heart involvement compared with at rest.…”

Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management

“…Structurally, LV hypertrophy appears more common in SSc than controls ( 52 ). Patients with SSc also have higher E/e’ ratios ( 53 ) (representing higher LV filling pressures) and increased isovolumetric relaxation times compared to controls ( 48 ). Interestingly, abnormal E/e’ ratio [defined as transmitral to mitral annular early diastolic velocity ratio ( 54 )] was also associated with duration of recognized SSc disease in months, as well as mean duration of Raynaud’s phenomenon, suggesting temporal relation in SSc-related fibrotic disease of different organs ( 49 ).…”