Title : Subclinical left ventricular dysfunction in patients with active systemic lupus erythematosus – a speckle tracking echocardiography study with follow-up
Abstract:
Background: Cardiovascular disease is a major cause of morbidity and mortality in systemic lupus erythematosus (SLE) patients. The detection of myocardial involvement in patients with SLE is difficult since clinical symptoms and signs are nonspecific, and myocardial involvement may be present in patients with preserved left ventricular (LV) ejection fraction (EF). In this regard, standard methods for evaluating cardiac function used in clinical practice often lack the sensitivity to detect myocardial abnormalities in SLE. The use of speckle tracking echocardiography (STE) is currently proposed as a more sensitive and reproducible approach to detect subtle myocardial systolic dysfunction compared to conventional LV EF.
Aim of the study: We sought to investigate myocardial deformation parameters by STE in patients with active SLE disease compared to controls, with follow-up 3-6 months later when disease activity is controlled.
Subjects and Methods: This prospective observational case-control study included 113 subjects divided into 63 matched healthy -and gender-50% and 50 age ≥ EF LV andactive SLE with patients individuals. Disease activity was defined as SELENA-SLEDAI score > 4. Active SLE patients were divided into two groups: mild-moderate disease activity (n=40, 37 females) and severe activity (n=23, 19 females), defined as SELENA-SLEDAI ≤ 12 and > 12, respectively. Fifty survived SLE patients were followed up after 3-6 months following activity remission.
All subjects underwent comprehensive echocardiographic examination with pulsed wave Doppler measurement of the mitral inflow, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) including strain parameters (global longitudinal strain [GLS] and global circumferential strain [GCS]), rotation, twist and torsion
Results: Our study included 63 patients with active SLE (89% females, median age (IQR) 26 years (21, 31) and 50 age- and gender-matched healthy individuals. Although the majority of active SLE cases (87%) did not fulfill conventional criteria for diastolic dysfunction, there were significant differences in several diastolic function parameters compared to controls, with SLE patients having lower lateral e’, septal e’ and higher average E/e’ (p-value for all <0.001). Active SLE patients showed significantly worse strain parameters compared to controls (respective values for mean GLS and GCS -19.9 % ± 2.1 in patients versus -22.7% ± 1.3 in controls and -21.2 ± 2.5 % versus -25.1 ± 1.7%; p-value < 0.001 for each). LV basal and apical rotation, twist and torsion were significantly reduced in active SLE cases compared to controls (p-value < 0.001 for all). Diastolic function and deformation parameters were not significantly different between patients with mild-moderate and severe activity. Deformation parameters, but not diastolic function ones, improved during follow-up.
Conclusion: Despite normal LV systolic function by conventional EF, patients with active SLE demonstrated subtle myocardial affection by STE, evidenced by worse GLS and GCS, as well as lower twist and torsion, compared to healthy controls. These abnormalities improved after control of disease activity. STE is a simple, non-invasive tool useful for early identification of cardiac dysfunction in patients with active SLE and follow-up of disease activity and could be incorporated into SLE activity scores.
Key words: systemic lupus erythematosus, echocardiography, speckle tracking, torsion, and twist
