Review Article
Speckle tracking echocardiography as a new diagnostic tool for an assessment of cardiovascular disease in rheumatic patients.

https://doi.org/10.1016/j.pcad.2020.03.005Get rights and content

Highlights

  • The actual prevalence of cardiovascular (CV) involvement in rheumatic disorders is currently underestimated.

  • Rheumatic disorders are burdened by premature mortality mainly due to CV disease (CVD) events and early atherosclerosis occurrence.

  • Speckle tracking echocardiography allows detection of cardiac involvement very precociously.

  • A proper and early detection of subclinical myocardial dysfunction improves patient CV risk stratification.

  • Early assessment of CV involvement may allow tailoring therapy for each patient and rheumatic disorder.

Abstract

Chronic inflammation represents the cornerstone of the raised cardiovascular (CV) risk in patients with inflammatory rheumatic diseases (IRD). Standardized mortality ratios are increased in these patients compared to the general population, which can be explained by premature mortality associated with early atherosclerotic events. Thus, IRD patients need appropriate CV risk management in view of this CV disease (CVD) burden. Currently, optimal CV risk management is still lacking in usual care, and early diagnosis of silent and subclinical CVD involvement is mandatory to improve the long-term prognosis of those patients. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. CV imaging provides valuable information as a reliable diagnostic tool. Currently, different techniques are employed to evaluate CV risk, including transthoracic or trans-esophageal echocardiography, magnetic resonance imaging, or computed tomography, to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. All the above methods are reliable in investigating CV involvement, but more recently, Speckle Tracking Echocardiography (STE) has been suggested to be diagnostically more accurate.

In recent years, the role of left ventricular ejection fraction (LVEF) as the gold standard parameter for the evaluation of systolic function has been debated, and many efforts have been focused on the clinical validation of new non-invasive tools for the study of myocardial contractility as well as to characterize the subclinical alterations of the myocardial function. Improvement in the accuracy of STE has resulted in a large amount of research showing the ability of STE to overcome LVEF limitations in the majority of primary and secondary heart diseases.

This review summarizes the additional value that STE measurement can provide in the setting of IRD, with a focus in the different clinical stages.

Introduction

The actual prevalence of cardiovascular (CV) involvement in inflammatory rheumatic diseases (IRD) has been underestimated for a long time. However, the availability of advanced and improved therapeutic tools, together with increased patients' life expectancy and better clinical responses to treatments, has led to a closer look to the “behind-the-scene” complications of rheumatic diseases. CV manifestations of rheumatic diseases are increasingly recognized and, in some patients, might also be the initial presentation of the rheumatic disorder.1 The spectrum of CV disease (CVD) manifestations associated with IRD is considerably broad, since rheumatic disorders can directly affect the myocardium, the cardiac valves, the pericardium, the conduction system, and the vasculature. Fatal CVD outcomes are preceded by a subclinical CVD involvement, which is largely prevalent in patients with systemic conditions and mostly attributed to early development and accelerated progression of atherosclerosis and vascular repair failure. This subclinical stage allows early detection, risk stratification and management in these patients2 if properly identified. However, in the absence of an appropriate management, accumulating damage culminates in life-threatening complications in the long term. Therefore, assessing and managing the risk of CV manifestations is essential in IRD, and early diagnosis through non-invasive diagnostic tools is highly warranted to prevent accumulating damage. In this review, we aim to thoroughly and comprehensively review the literature focused on the early detection of the cardiac involvement in a wide spectrum of IRD by Speckle Tracking Echocardiography (STE).

Section snippets

Cardiac imaging biomarkers: an unmet need for the clinical setting

Traditional CV risk factors cannot fully account for the actual CVD occurrence in IRD and hence, they cannot be used as predictive tools for the clinical setting. As a consequence, new biomarkers are needed in this scenario. Serum and laboratory biomarkers are still of uncertain value, and imaging biomarkers have been proposed to stratify the risk. Although atherosclerosis measurement, including carotid intimal-medial thickness (cIMT) and vascular function surrogate markers, such as Pulse Wave

STE: a potential new tool

The human left ventricle (LV) consists of two muscular helixes that surround the mid-ventricular circumferential layer of muscle fibers. The contraction of these endocardial and epicardial helixes results in a twisting motion that is thought to minimize the transmural stress of the LV muscle. In the healthy myocardium, the LV twist response to stimuli that alter preload, afterload, or contractility has been described and it is deemed to be relatively consistent and predictable.4

The value of

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting about 1% of the global population. It is characterized by chronic joint and systemic inflammation and enhanced atherosclerosis. In particular, CVD represents the leading cause of morbidity and mortality, accounting for 40–50% of all deaths. The excess of CV mortality and morbidity could be explained by chronic inflammation, disease duration and activity, immunosuppressive therapy, in addition to traditional CV risk factors.2

Conclusion

IRD are definitely burdened by increased CV risk, and there is a compelling body of evidence supporting a notable, early impairment of myocardial function in these conditions, mostly linked to the inflammatory burden and independently of traditional CV risk factors. As a result, there is an unmet need in estimating and reporting the cardiac involvement in a standardized and uniform manner so far.

The STE is able to detect and measure the subclinical myocardial dysfunction, and growing evidence

Statement of conflict of interest

The authors declared no conflicts of interest. Funders have no role in study conception and design, data analysis and interpretation or decision to publish.

Acknowledgements

JR-C is supported by the “Juan de la Cierva” program (IJCI-2017-32070; Ministry of Science, Innovation and Universities, Spain), “Fondo de Investigación Sanitaria” (PI16/00113; Instituto de Salud Carlos III, Spain), and "PCTI-Plan de Ciencia, Tecnologíae Innovación 2018–2022" (IDI/2018/00152; FICYT, Spain). This research did not receive any specific grant from funding agencies in the commercial or not-for-profit sectors.

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      Improvement in the accuracy of STE shows an ability to overcome left ventricular (LV) ejection fraction (EF) limitations in the majority of heart diseases. Additional value that STE measurement is provided in the setting of inflammatory rheumatic diseases [15]. The aim of this work was to study the left atrium modulating the left ventricular filling and to investigate its relation with disease activity in a trial to find a noninvasive method to detect subclinical early cardiac affection in RA patients.

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