Prognostic impact of coronary microcirculation abnormalities in systemic sclerosis: a prospective study to evaluate the role of non-invasive tests

Abstract

Introduction: Microcirculation dysfunction is a typical feature of systemic sclerosis (SSc) and represents the earliest abnormality of primary myocardial involvement. We assessed coronary microcirculation status by combining two functional tests in SSc patients and estimating its impact on disease outcome.

Methods: Forty-one SSc patients, asymptomatic for coronary artery disease, were tested for coronary flow velocity reserve (CFR) by transthoracic-echo-Doppler with adenosine infusion (A-TTE) and for left ventricular wall motion abnormalities (WMA) by dobutamine stress echocardiography (DSE). Myocardial multi-detector computed tomography (MDCT) enabled the presence of epicardial stenosis, which could interfere with the accuracy of the tests, to be excluded. Patient survival rate was assessed over a 6.7-±3.5-year follow-up.

Results: Nineteen out of 41 (46%) SSc patients had a reduced CFR (≤2.5) and in 16/41 (39%) a WMA was observed during DSE. Furthermore, 13/41 (32%) patients showed pathological CFR and WMA. An inverse correlation between wall motion score index (WMSI) during DSE and CFR value (r=-0.57, P<0.0001) was observed; in addition, CFR was significantly reduced (2.21±0.38) in patients with WMA as compared to those without (2.94±0.60) (P<0.0001). In 12 patients with abnormal DSE, MDCT was used to exclude macrovasculopathy. During a 6.7-±3.5-year follow-up seven patients with abnormal coronary functional tests died of disease-related causes, compared to only one patient with normal tests.

Conclusions: A-TTE and DSE tests are useful tools to detect non-invasively pre-clinical microcirculation abnormalities in SSc patients; moreover, abnormal CFR and WMA might be related to a worse disease outcome suggesting a prognostic value of these tests, similar to other myocardial diseases.

Figure 1

Doppler echocardiography image of a SSc patient with WMA and impaired CFR. Doppler echocardiography image of a patient with wall motion abnormalities (hypokinesia of apical segments) during Dobutamine Stress Echocardiography (upper panel) and abnormal Coronary Flow Reserve (lower pannel).

Figure 2

Inverse correlation between CFR and WMSI in examined SSc patients. Relationship between coronary flow reserve (CFR) and wall motion score index (WMSI) in systemic sclerosis patients. WMSI = difference between rest and peak WMSI (0 to 1 minute after the end of peak dose).

Figure 3

Kaplan-Meier survival curves in patients stratified according to normal CFR/no WMA and abnormal CFR/WMA. Kaplan-Meier survival curves in patients stratified according to normal coronary flow reserve (CFR >2.5) and no wall motion abnormalities (WMA) versus abnormal CFR (CFR ≤2.5) and WMA at Doppler echocardiography. The worst survival is observed in patients with abnormal CFR.