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Review
The enigmatic immunoglobulin G4-related disease and its varied cardiovascular manifestations
  1. Aamina Shakir1,
  2. Yurong Wheeler2,
  3. Guha Krishnaswamy3,4
  1. 1Internal Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
  2. 2Pathology, Ballad Health, Johnson City, Tennessee, USA
  3. 3Wake Forest University Department of Internal Medicine, Winston-Salem, North Carolina, USA
  4. 4Allergy, Asthma and Clinical Immunology, Bill Hefner VA Medical Center and affiliated institutions, Salisbury, North Carolina, USA
  1. Correspondence to Dr Guha Krishnaswamy, Wake Forest University Department of Internal Medicine, Winston-Salem, North Carolina, USA; gkrishna{at}wakehealth.edu

Abstract

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterised by multiorgan lymphoplasmacytic infiltration, obliterative phlebitis and storiform fibrosis. It can be associated with cardiovascular pathology. The objective of this narrative review is to summarise the published literature on cardiovascular manifestations of IgG4-RD and to provide a basis for diagnosis and management of the condition by the practising cardiologist.

We propose the following categorisations of cardiovascular IgG4-RD: aortitis, medium-vessel arteritis, pulmonary vascular disease, phlebitis, valvulopathy, pericarditis, myocardial disease and antineutrophilic cytoplasmic antibody-associated vasculitis. We also review herein developments in radiological diagnosis and reported medical and surgical therapies. Cardiovascular lesions frequently require procedural and/or surgical interventions, such as aortic aneurysm repair and valve replacement. IgG4-RD of the cardiovascular system results in serious complications that can be missed if not evaluated aggressively. These are likely underdiagnosed, as clinical presentations frequently mimic cardiovascular disease due to more common aetiologies (myocardial infarction, abdominal aortic aneurysm and so on). While systemic corticosteroids are the mainstay of IgG4-RD treatment, biological and disease-modifying agents are becoming more widely used. Cardiologists should be aware of cardiovascular IgG4-RD as a differential diagnosis, and understand the roles of corticosteroids, disease-modifying agents and biologicals, as well as their integration with surgical approaches. There are several knowledge gaps, including diagnosis, risk factors, pathogenesis and appropriate management in Ig4-RD of the cardiovascular system. Areas lacking well-conducted randomized trials include safety of steroids in the setting of vascular aneurysms and the role of disease-modifying drugs and biological agents in patients with established cardiovascular complications of this multifaceted enigmatic disease.

  • valvular heart disease
  • pulmonary vascular disease
  • pericardial disease
  • systemic inflammatory diseases
  • aortitis

https://doi.org/10.1136/heartjnl-2020-318041

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    Footnotes

    • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

    • Contributors AS wrote the majority of the manuscript. YW edited the manuscript and provided pathology images. GK wrote several sections of the manuscript, edited it and created the figures.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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