Myocardial fibrosis in systemic sclerosis assessed by cardiac magnetic resonance is associated with vascular endothelial growth factor expression

The hallmarks of systemic sclerosis (SSc) are endothelial dysfunction and fibrosis of the skin and the internal organs, including the heart. Primary cardiac involvement related to SSc is more related to fibrosis and its complications (1). Recurrent episodes of vasospasm with ischaemia and reperfusion cause abnormal myocardial perfusion with subsequent fibrosis (2). In SSc vascular damage and chronic tissue hypoxia promote angiogenesis with production of pro-angiogenic factors such as vascular endothelial growth factor (VEGF) (3). Endomyocardial biopsy is an invasive procedure used to diagnose myocardial fibrosis. To date, cardiac magnetic resonance (CMR) is employed in SSc to detect myocardial fibrosis showing patchy fibrosis distributed in both ventricules (4). As confirmed by a histopathological study, myocardial fibrosis can be detected through late gadolinium enhancement (LGE) on CRM with the same degree of reliability provided by myocardial biopsy (5).