First Pilot Study of an Implantable Loop Recorder (ILR) in Systemic Sclerosis Detects Significant Cardiac Arrhythmias with CMR Abnormalities

Lesley-Anne Bissell¹, Bianca Dumitru¹, Giuseppina Abignano¹, Bara Erhayiem², Graham Fent², Peter Swoboda², Adam McDiarmid², John Greenwood², Francesco Del Galdo¹, Jacqueline Andrews¹, Sven Plein², Lee Graham² and Maya Buch¹, ¹Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, ²Multidisciplinary Cardiovascular Research Centre & The Division of Cardiovascular and Diabetes Research, LIGHT, University of Leeds, Leeds, United Kingdom

Meeting: 2016 ACR/ARHP Annual Meeting

Date of first publication: September 28, 2016

Keywords: Cardiovascular disease and systemic sclerosis, MRI

Session Information

Date: Monday, November 14, 2016

Title: Systemic Sclerosis, Fibrosing Syndromes, and Raynaud's – Clinical Aspects and Therapeutics - Poster II

Session Type: ACR Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: SSc-cardiomyopathy associated conduction abnormalities carry a poor prognosis, but their pathogenesis is unclear. Early detection to prevent complications is essential. ILRs are well-established in cardiology practice. In patients (pts) with SSc and no known cardiac disease, we aimed to test feasibility of the REVEAL® ILR, the spectrum of cardiac conduction abnormalities (CCA) detected & association with CMR abnormality.

Methods: 20 pts with (ACR/EULAR criteria) SSc, with no diabetes &/or more than 1 cardiovascular (CV) risk factor, were assessed for SSc/CV profile & comprehensive CV assessment performed, inc. 3T delayed enhancement-CMR (reported by CMR-cardiologists) & ILR insertion. ILR data was downloaded 3 monthly +/- at pt request if symptomatic. Baseline CMR compared to 30 healthy controls (HC) and 1-year ILR data is reported with CMR. CK/troponin data available by time of ACR.

Results: ILR data was available for 19 pts; 63% female, 84% Caucasian; mean (SD) age 53 (12)years, median (IQR) time from 1^st non-RP symptom 7.5(1.8, 19.5)years; 32% dcSSc, 32% ACA+ve, 21% Scl70+ve, 47% palpitations hx, 42% known ILD, 11% DU hx, 0% pulmonary hypertension. CMR data was available for 15 SSc pts (DE in 14; 1 pt claustrophobic, no IV access in 2, 1 CMR abandoned due to PPM insertion for CHB). Extracellular volume (ECV) was higher in SSc pts vs. HC; mean difference (diff.) 4.9 (3.2, 6.6)% p<0.001 R²0.568, adj. for age/sex; with greater late gadolinium enhancement detection in SSc (36% vs. 3% in HC, p=0.009) (both markers of fibrosis), with lower LVmass/EDV (p=0.006) & trend for lower LV mass in SSc. Eleven (58%) patients had ILR findings: 7 (37%) supraventricular ectopics (SVE), 2 (11%) ventricular ectopics (VE), 3 (16%) bigeminy, 1 (5%) couplet, 1 (5%) salvo, & 5 (26%) arrhythmias of which 1 atrial flutter, 1 atrial flutter leading to atrial fibrillation, 1 SVT and 2 serious arrhythmias of 1 VT & 1 complete heart block (CHB). Of the 5 pts with arrhythmias, 4 were asymptomatic at time of arrhythmia (pt with VT had palpitations), 3 had dcSSc (inc. both serious arrhythmias), 2 ACA+ve, 1 Scl70, 2 known ILD, 2 DU hx. Trend towards greater ECV & distensibility (ie lower arterial stiffness) seen in pts with arrhythmias. Trend for higher ECV in those with SVE [unadj. mean diff. (95%CI) 1.1 (-2.5, 4.7)% p0.513], VE [0.7 (-4.9, 6.3)% p0.789] & arrhythmias [1.8 (-3.7, 7.3)%]. Table 1: CMR measures in SSc pts with/without arrhythmias (values=mean(SD) *n(%))

CMR variable	No arrhythmia N (%)=12 (80)	Arrhythmia N (%)=3 (20)	Unadjusted mean difference (95% CI), p value	Mean difference (95% CI), p value adjusted for age & sex
LVEF, %	60.11 (4.97)	60.12 (2.16)	0.01 (-6.48, 6.50), 0.997	0.30 (-5.52, 6.12), 0.912
LVmass/BSA, g/m²	44.90 (11.66)	44.33 (5.80)	-0.57 (-15.86, 14.71), 0.937	-0.12 (-13.43, 13.18), 0.984
LV mass/EDV, g/ml	0.54 (0.08)	0.52 (0.05)	-0.03 (-0.13, 0.08), 0.592	-0.03 (-0.15, 0.09), 0.612
RVEF, %	57.30 (19.18)	59.23 (5.35)	1.94 (-22.84, 26.71), 0.869	0.18 (-18.28, 18.65), 0.983
Torsion, degrees	12.57 (5.78) (n=10)	14.36 (0.98)	1.79 (-2.45, 6.03), 0.615	1.64 (-6.31, 9.58), 0.652
ECV, %	29.55 (3.31) (n=11)	32.32 (2.0)	2.77 (-1.67, 7.20), 0.199	2.82 (-1.99, 7.63), 0.220
Presence of LGE	5 (41.7)*	0 (0.0)*	p=0.258	–
Distensibility, 10^-3mmHg^-1	3.69 (2.25) (n=11)	5.73 (4.46)	2.04 (-8.17, 12.24), 0.277	1.96 (-1.84, 5.75), 0.277

Conclusion: This first ILR in SSc study demonstrates its feasibility and utility in the incidental detection of CCA, including serious cardiac arrhythmias & suggests associated CMR abnormalities. These data support the need for identification of pts at risk that would benefit from ILR & provide insights into the pathogenesis of SSc-cardiomyopathy.

Disclosure: L. A. Bissell, None; B. Dumitru, None; G. Abignano, None; B. Erhayiem, None; G. Fent, None; P. Swoboda, None; A. McDiarmid, None; J. Greenwood, None; F. Del Galdo, None; J. Andrews, None; S. Plein, None; L. Graham, None; M. Buch, None.

To cite this abstract in AMA style:

Bissell LA, Dumitru B, Abignano G, Erhayiem B, Fent G, Swoboda P, McDiarmid A, Greenwood J, Del Galdo F, Andrews J, Plein S, Graham L, Buch M. First Pilot Study of an Implantable Loop Recorder (ILR) in Systemic Sclerosis Detects Significant Cardiac Arrhythmias with CMR Abnormalities [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/first-pilot-study-of-an-implantable-loop-recorder-ilr-in-systemic-sclerosis-detects-significant-cardiac-arrhythmias-with-cmr-abnormalities/. Accessed .

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