Arthritis Care & Research Vol. 66, No. 10, October 2014, pp 1591–1596 © 2014, American College of Rheumatology
LETTERS DOI 10.1002/acr.22338
Value of tricuspid annular peak systolic velocity (sⴕ) measurement in scleroderma-associated pulmonary arterial hypertension: comment on the article by Gopal et al To the Editor: We read with interest the article by Gopal et al published recently in Arthritis Care & Research (1). This is an excellent article describing the need for a detailed investigation of right ventricular (RV) function, including the tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (s⬘), in a population with systemic sclerosis (SSc; scleroderma)–associated pulmonary arterial hypertension (PAH) (1). The authors evaluated the relationship between echocardiographic measurements of RV function and the gold standard rightsided heart catheterization (RHC) measurements in scleroderma patients and found that the RHC data strongly correlated with noninvasive measurements of RV function (1). In 2006, Forﬁa et al ﬁrst described the excellent sensitivity, reproducibility, and clinical utility of the M-mode– derived parameter TAPSE in various forms of PAH (2). Recently, Mathai et al (3) proposed that TAPSE strongly predicted survival in patients with SSc-associated PAH. The s⬘, a newer tissue Doppler imaging– derived echocardiographic measurement, has been demonstrated to be a relevant measurement of RV systolic function regardless of the pulmonary artery pressure (4). Tedford et al (5) showed that RV dysfunction was worse in SSc-associated PAH compared to patients with idiopathic PAH. For the convenience of the audience of Arthritis Care & Research and especially the centers performing detailed echocardiographic investigations of the RV, we want to add that we have recently published similar data on impaired s⬘ values in adolescents and young adults with PAH secondary to congenital heart diseases (PAH-CHD) (6). In our opinion, s⬘ proved to be a valuable parameter of systolic RV function in various forms of PAH, such as SSc-associated PAH, idiopathic PAH, and PAHCHD (4 – 6). We want to thank the authors for addressing the need for a systematic evaluation of the RV in SSc-associated PAH patients and want to highlight that Gopal et al (1) correlated the echocardiographic parameters TAPSE and s⬘ to RHC measurements, which signiﬁcantly strengthened the results. In our opinion, systolic RV function should be carefully investigated in patients with systemic diseases
leading to secondary PAH, such as rheumatologic disorders. We hope that TAPSE and s⬘ will be used in the future as parameters that provide information about the extent of RV dysfunction in patients with SSc-associated PAH, regardless of the disease stage. Jasmin Pansy, MD Martin Koestenberger, MD Medical University Graz Graz, Austria William Ravekes, MD Johns Hopkins University School of Medicine Baltimore, MD 1. Gopal DM, Doldt B, Finch K, Simms RW, Farber HW, Gokce N. Relation of novel echocardiographic measures to invasive hemodynamic assessment in scleroderma-associated pulmonary arterial hypertension. Arthritis Care Res (Hoboken) 2014;66: 1386 –94. 2. Forﬁa PR, Fisher MR, Mathai SC, Housten-Harris T, Hemnes AR, Borlaug BA, et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med 2006;174:1034 – 41. 3. Mathai SC, Sibley CT, Forﬁa PR, Mudd JO, Fisher MR, Tedford RJ, et al. Tricuspid annular plane systolic excursion is a robust outcome measure in systemic sclerosis-associated pulmonary arterial hypertension. J Rheumatol 2011;38:2410 – 8. 4. Saxena N, Rajagopalan N, Edelman K, Lopez-Candales A. Tricuspid annular systolic velocity: a useful measurement in determining right ventricular systolic function regardless of pulmonary artery pressures. Echocardiography 2006;23: 750 –5. 5. Tedford RJ, Mudd JO, Girgis RE, Mathai SC, Zaiman AL, Housten-Harris T, et al. Right ventricular dysfunction in systemic sclerosis-associated pulmonary arterial hypertension. Circ Heart Fail 2013;6:953– 63. 6. Koestenberger M, Nagel B, Ravekes W, Avian A, Heinzl B, Fandl A, et al. Tricuspid annular peak systolic velocity (S⬘) in children and young adults with pulmonary artery hypertension secondary to congenital heart diseases, and in those with repaired tetralogy of Fallot: echocardiography and MRI data. J Am Soc Echocardiogr 2012;25:1041–9.
Choosing the right rituximab dose for the right patient: comment on the article by Bredemeier et al To the Editor: In a recent issue of Arthritis Care & Research, Bredemeier et al reviewed rituximab (RTX) clinical trials and reached the strong conclusion that a lower dose of 1591