Imaging

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.