Терапевтический архив (Dec 2014)
Поражение сердца при системных васкулитах: патогенетические звенья, значение факторов риска развития сердечно-сосудистых осложнений и диагностика
Abstract
AIM. To study the rate and types of cardiac involvement, the patterns of cardiovascular events (CVE) and to determine the importance of risk factors for atherosclerosis and the role of noninvasive methods in the diagnosis of cardiovascular diseases in patients with systemic vasculitides (SV). MATERIALS AND METHODS. Three hundred and twenty-one patients with SV, including 138 (42.8%) with granulomatosis and polyangiitis (Wegener's granulomatosis) (GPA), 79 (24.7%) with Takayasu's arteritis (TA), 55 (17.2%) with polyarteritis nodosa (PAN), and 49 (15.3%) with eosinophilic granulomasis and polyangiitis (EGPA) (Churg-Strauss syndrome), were examined in 1989 to 2011. The clinical manifestations of the disease were studied retrospectively in 153 (47.6%) patients examined in 1989 to 2004 and prospectively in 168 (52.4%) patients examined in 2005 to 2011. The investigators performed EchoCG in the examinees prospectively, myocardial perfusion scintigraphy (PSG) in 92 patients, and multislice spiral computed tomography (MSCT) of coronary vessels in 32. The SCORE scale was employed to study risk factors for CVE. The data of cardiac and vascular morphological examinations were analyzed in 55 patients. RESULTS. Heart damage as a major visceral injury in SV was detected in 63.3% of the cases with TA, in 70.9% of those with PAN, in 67.3% of those with EGPA, and in 48.5% of those with GPA. CVEs were diagnosed in 51 (15.9%) of the 321 patients. The rate of CVEs turned out to be higher in the patients with EGPA (22.3%) and PAN (18.2%) and slightly below in those with GPA (14.5%) and TA (12.6%). Echocardiography revealed aortic regurgitation in 28.5% of the patients with TA, left ventricular hypertrophy in 47% and diastolic dysfunction in 55% of those with PAN, pericarditis in 16 and 8% of those with EGPA and GPA, respectively; the signs of myocardial dilatation were diagnosed more frequently in EGPA (18.3%) than in other SVs. PSG diagnosed various myocardial perfusion disorders in 59% of the patients with SV; at the same time, focal changes prevailed over diffuse ones in the patients with PAN (45.8%) and EGPA (50%), diffuse ones in those with GPA (42.3%); these disorders being approximately equally frequently found in TA. MSCT revealed coronary calcification in 66% of the patients with GPA, 62.5% of those with EGPA, in 50% of those with PAN, and in 14.3% of those with TA. Postmortem examination displayed atherosclerotic changes in one or more great arteries in 28 (50.9%) of 55 dead patients. Deaths from cardiovascular causes were noted in 18 (30.9%) patients with SV. The causes of death were stated to be an acute cerebrovascular accident in 14.5% of the patients, myocardial infarction in 9.1%, and chronic heart failure in 7.3%. CONCLUSION. The cardiac manifestations of SV are associated with immune inflammation and concomitant hypertension and atherosclerosis. The combination of traditional RFs for atherosclerosis and SV in the same patient allows the latter to be assigned to a very high CVE risk group. Early heart damage diagnosis using non-invasive methods provides a way of optimizing the further management tactics in patients with SV.
