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EXTENDED REPORT

Angiogenic biomarkers predict the occurrence of digital ulcers in systemic sclerosis

Jrme Avouac,1,2 Christophe Meune,3 Barbara Ruiz,2 Pierre Olivier Couraud,2 Georges Uzan,4 Catherine Boileau,5 Andr Kahan,1 Gilles Chiocchia,2,6 Yannick Allanore1,2
Additional data (supplementary gures and tables) are published online only. To view these les please visit the journal online (http://ard.bmj. com/content/71/3.toc)
1Rheumatology

A department, Paris Descartes University, Cochin Hospital, APHP, Sorbonne Paris Cit, Paris, France 2INSERM U1016 and CNRS UMR8104, Paris Descartes University, Cochin Institute, Sorbonne Paris Cit, Paris, France 3Cardiology department, Paris Descartes University, Cochin Hospital, APHP, Sorbonne Paris Cit, Paris, France 4INSERM U972, Paul Brousse Hospital, Villejuif, France 5Hormonology and Molecular Genetics Department, Biochemistry Department, U.V.S.Q University, Ambroise Par Hospital, APHP, Boulogne, France 6Rheumatology Department, Ambroise Par Hospital, U.V.S.Q University, APHP, Boulogne, France Correspondence to Professor Yannick Allanore, Hpital Cochin, Service de rhumatologie A, 27 rue du Faubourg Saint Jacques, 75014 Paris, France; yannick.allanore@cch.aphp.fr Received 10 May 2011 Accepted 9 October 2011 Published Online First 15 November 2011

ABSTRACT Objective To evaluate the possible merit of endothelial markers for the prediction of ischaemic digital ulcers in patients with systemic sclerosis (SSc). Methods Circulating endothelial progenitor cells (EPC), circulating endothelial cells and serum levels of placental growth factor (PlGF), soluble vascular adhesion molecule and vascular endothelial growth factor were measured in a prospective cohort of 100 SSc patients. The primary outcome was the occurrence of one or more new ischaemic digital ulcers during a planned 3-year follow-up. Results After the follow-up period, 17 patients developed new digital ulcers. By multivariate analysis focused on biomarkers, high PlGF serum levels and low EPC counts were identied as predictors of the occurrence of at least one new digital ulcer. In a secondary model including biomarkers together with clinical SSc characteristics all predictors of digital ulcers dened by p0.1 in univariate analysis, high PlGF serum levels (HR 7.26, 95% CI 1.92 to 27.41) and a history of digital ulcers (HR 9.32, 95% CI 1.51 to 59.83) were identied as independent predictors of a new digital ulcer. In an alternative model excluding patients with a history of digital ulcers at baseline, high PlGF serum levels (HR 13.46, 95% CI 1.58 to 114.73) and low EPC counts (HR 7.95, 95% CI 2.09 to 30.09) remained predictive of new digital ulcer occurrence during follow-up. Conclusion This study identied high PlGF serum levels and low circulating EPC counts as predictors of new digital ulcers in SSc. It highlights the critical role of angiogenesis in this vascular outcome. These markers may improve digital ulcer risk stratication and therefore allow earlier therapeutic intervention.

Systemic sclerosis (SSc) is a severe connective tissue disease characterised by vascular, immune and brotic changes in the skin and some internal organs.1 Peripheral microvascular and cardiovascular alterations are key features of SSc, with outcome depending on the extent and severity of vascular lesions. Microvascular lesions underlie many manifestations of SSc, including ischaemic digital ulcers, pulmonary hypertension, primary heart involvement and scleroderma renal crisis (SRC). Digital ulcers are frequent in SSc, averaging 30% prevalence according to the European League Against Rheumatism (EULAR) Scleroderma Trial and Research Group (EUSTAR) registry, and represent a heavy burden due to their major impact on quality of life.24 In addition, digital ulcers are thought to be a clinical parameter of severe vasculopathy that can be

associated with or predict other vascular lesions.57 Treatment of digital ulcers remains challenging and the identication of reliable predictors of digital ulcers is still an unmet clinical need in SSc.3 4 Endothelial injury and insufcient endothelial repair are strong contributors to the genesis of the vasculopathy underlying digital ulcers. Circulating endothelial cell (CEC) levels in peripheral blood is a direct reection of vascular damage and more specically endothelial injury.8 Vascular damage in SSc is insufciently compensated by endothelial repair processes that relate to angiogenesis and vasculogenesis. Angiogenesis is insufcient in SSc, resulting from defective vascularisation and tissue hypoxia, despite elevated levels of proangiogenic factors in the serum or the skin of SSc patients such as vascular endothelial growth factor (VEGF), placental growth factor (PlGF) or soluble vascular cell adhesion molecule (sVCAM).912 Previous data have also emphasised quantitative perturbations of vasculogenesis.1315 In particular, we reported high circulating endothelial progenitor cell (EPC) levels in SSc, supporting their general mobilisation. However, low EPC numbers in the peripheral blood of SSc patients were associated with the presence of past and/or current digital ulcers, suggesting increased homing during active vascular disease and overall insufcient vasculogenesis to counterbalance vascular damage.14 16 Subsequent to this rst approach, the objective of this study was to determine the possible merit of different endothelial markers reecting endothelial injury, disturbed angiogenesis and vasculogenesis to predict the occurrence of digital ulcers.10 1215 1721 These biomarkers were also secondarily evaluated for the prediction of other cardiac/vascular events that rely on microvascular complications.

PATIENTS AND METHODS

Extended details of the methodology are shown in the supplementary data (available online only).

Study population
We prospectively evaluated 100 consecutive SSc patients who were hospitalised in the Rheumatology A Department, Cochin Hospital, Paris, France, for routine follow-up of the disease from 1 September 2006 to 1 November 2007. SSc was classied as limited cutaneous or diffuse cutaneous subset according to the criteria reported by LeRoy et al.22 Inclusion and exclusion criteria are detailed in the supplementary data (available online only).

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Follow-up
Once included in the study cohort, patients were seen by his/ her usual physician on a regular basis of 36 month intervals, as indicated by their disease severity, and were hospitalised at least annually for clinical evaluation, including echocardiography and pulmonary function tests. The nal study observation was planned as the last observation of the last trimester of the year 2010 (or the last available observation) or the last observation at the time of death from any cause, with analyses and completion of the database performed during the rst trimester of the year 2011.

RESULTS Baseline characteristics

The meanSD age of the 100 patients (89 women) was 5613 years and the meanSD disease duration was 98 years. Forty patients had the diffuse cutaneous subset, and 60 the limited. Their baseline characteristics are shown in table 1.

Baseline values and correlation between vascular markers

The median (IQR) number of EPC and CEC in peripheral blood of SSc patients was 99 (64164) and 215 (12708)/106 Linmononuclear cells, respectively. The median (IQR) serum levels of VEGF, PlGF and sVCAM were 352 (183474) pg/ml, 61 (3387) pg/ml and 614 (4869819) ng/ml, respectively. Among these vascular markers, only baseline values of EPC and CEC were correlated (r=0.52, p<0.0001).

Outcome measures
The primary outcome was the occurrence of at least one or more ischaemic digital ulcers, dened by a painful area of 2 mm or greater in diameter with visible depth and loss of dermis, amenable to healing and localised by ngertip. Digital ulcers caused by conditions other than SSc and non-ischaemic digital ulcers were not taken into consideration. The secondary outcome was the occurrence of at least one new cardiac or vascular event, as a consequence of the generalised vasculopathy. Cardiac/vascular events were assessed by an exploratory index, dened as the occurrence of at least one of the following events: (1) one or more new ischaemic digital ulcers; (2) pre-capillary pulmonary hypertension conrmed by resting mean pulmonary artery pressure of 25 mm Hg or greater together with a pulmonary capillary wedge pressure of 15 mm Hg or less; (3) left ventricular dysfunction, dened by a left ventricular ejection fraction less than 50%, as determined using the Simpson method; (4) SRC, dened by a sudden and marked increase in systemic blood pressure and acute renal failure, with or without signicant microangiopathic haemolytic anaemia or thrombocytopenia.6 23 We also considered as a secondary outcome the occurrence of death from any cause during the followup period.

Primary outcome, occurrence of ischaemic digital ulcers

During a follow up period of 2913 months (median 36 months), new ischaemic digital ulcers occurred in 17 SSc patients (10 patients with a history of previous digital ulcers and seven patients with no previous digital ulcers). The mean time to the development of new digital ulcers after study inclusion was 18 months (median 17 months). By univariate analysis, low EPC numbers (HR 3.94, 95% CI 1.41 to 11.03, p=0.009), high PlGF (HR 8.25, 95% CI 1.78 to 38.26, p=0.007) and sVCAM (HR 3.14, 95% CI 1.01 to 9.83, p=0.04) serum levels were identied as predictive biomarkers of the occurrence of at least one new digital ulcer (table 2). KaplanMeyer analyses of freedom from the occurrence of new digital ulcers for these three markers are shown in gures 1AC. Multivariate Cox analysis conrmed PlGF levels (HR 7.95, 95% CI 2.09 to 30.10, p=0.002) and EPC levels (HR 2.33, 95% CI 1.44 to 12.22, p=0.03) as independent predictors of the development of digital ulcers (table 2). In a second multivariate Cox model including these two biomarkers and all other predictors of digital ulcers dened by a p value of 0.1 or less in univariate analysis, high PlGF serum levels (HR 7.26, 95% CI 1.92 to 27.41) and a history of digital ulcers (HR 9.32, 95% CI 1.51 to 59.83) were identied in multivariate analysis as independent predictors of new digital ulcers (table 2).

EPC and CEC sorting and ow cytometry quantication

We used a method previously described and validated to enrich mononuclear cells and quantify EPC and CEC by ow cytometry.14 24 This method is described in detail in the supplementary data (available online only).

VEGF, PlGF and sVCAM ELISA

Serum levels of VEGF, PlGF and sVCAM were measured using the quantitative sandwich ELISA technique (Quantikine kits; R&D Systems, Minneapolis, MN).

Table 1

Baseline characteristics of patients with SSc

SSc (n=100) 5613 98 60/40 29 42 22 17 803 89 41 30 27 31 39 100 26 27

Statistical analysis
To estimate the cut-off of each endothelial marker, we compared levels of EPC, CEC, VEGF, PlGF and sVCAM between SSc patients and a group of 20 healthy controls (15 women, 5516 years old), assessed during the same study period. These results revealed that the median value of all the markers for SSc patients were above the 95th percentile of the levels observed in the controls; therefore, to evaluate their predictive value on clinical outcomes, levels of EPC, CEC, VEGF, PlGF and sVCAM were considered as categorical variables, and associations were assessed according to the median value of each endothelial marker. Predictors of digital ulcers and cardiac/vascular outcomes were evaluated by univariate and multivariate Cox proportional hazards models and summarised as HR and 95% CI. Survival was evaluated using the KaplanMeier method.
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Age (years), mean SD Disease duration (years), mean SD Limited/diffuse cutaneous subset, n History of digital ulcers, n Pulmonary brosis on CT scan, n ESR >28 mm H1, n CRP >10 mg/l, n Serum creatinine, moles/l, mean SD Positive antinuclear antibodies (>1/160), n Positive antitopoisomerase 1 antibodies, n Positive anticentromere antibodies, n (%) FVC <75% predicted, n DLCO/AV <75% predicted, n Medsger severity scale >2, n Calcium antagonists, n ACE inhibitors, n Low dose oral prednisone, n

DLCO/AV, diffusing capacity for carbon monoxide/alveolar volume; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FVC, forced vital capacity; SSC, systemic sclerosis.

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Table 2 Primary outcome: results of univariate and multivariate analyses of candidate predictors of digital ulcers, by model analysed
Univariate analysis Baseline characteristics p Value HR (95% CI) Multivariate analysis p Value HR (95% CI)

Main model: evaluation of different biomarkers for the occurrence of new ischaemic digital ulcers Low EPC (<99 EPC/106 Lin-mononuclear cells) 0.009* High CEC (215 CEC/106 Lin-mononuclear cells) 0.4 High serum VEGF (352 pg/ml) 0.7 High serum PlGF (61 pg/ml) 0.007* High serum sVCAM (614 ng/ml) 0.04* Alternative model: inclusion of biomarkers and other SSc disease characteristics with a p value 0.1 Low EPC (<99 EPC/106 Lin-mononuclear cells) 0.009* High serum PlGF (61 pg/ml) 0.007* History of digital ulcers 0.0004* ESR >28 mm H1 0.1* Alternate model: exclusion of patients with a history of digital ulcers Low EPC (<99 EPC /106 Lin-mononuclear cells) 0.009* High serum PlGF (61 pg/ml) ESR >28 mm H1 0.007* ESR >28 mm H1 0.1*

3.94 (1.41 to 11.03) 1.47 (0.56 to 3.84) 1.19 (0.44 to 3.07) 8.25 (1.78 to 38.26) 3.14 (1.01 to 9.83) 3.94 (1.41 to 11.03) 8.25 (1.78 to 38.26) 9.96 (2.79 to 35.59) 2.18 (0.8 to 5.61) 3.94 (1.41 to 11.03) 8.25 (1.78 to 38.26) 2.18 (0.89 to 5.61)

0.03 NA NA 0.002 0.1 0.07 0.02 0.01 0.1 0.04 0.03 0.8

2.33 (1.44 to 12.22) 7.95 (2.09 to 30.10) 2.01 (0.43 to 9.42) 2.21 (0.89 to 11.78) 7.26 (1.92 to 27.41) 9.32 (1.51 to 59.83) 4.00 (0.689 to 23.59) 7.95 (2.09 to 30.09) 13.46 (1.58 to 114.73) 1.81 (0.099 to 6.68)

*Variables included in the multivariate Cox regression analysis. CEC, circulating endothelial cells; DLCO/AV, diffusing capacity for carbon monoxide/alveolar volume; EPC, endothelial progenitor cells; ESR, erythrocyte sedimentation rate; NA, not applicable, PlGF, placental growth factor; sVCAM: soluble vascular cell adhesion molecule; VEGF, vascular endothelial growth factor.

In a third model excluding patients with a history digital ulcers at baseline, high PlGF serum levels (HR 13.46, 95% CI 1.58 to 114.73) and low EPC counts (HR 7.95, 95% CI 2.09 to 30.09) were found to be predictors of new digital ulcers (table 2).

Secondary outcomes
During the follow up period, 27 of the 100 patients developed at least one cardiac or vascular event: new ischaemic digital ulcers in 17, precapillary pulmonary hypertension in ve, left ventricular dysfunction in four and SRC in a single patient. The mean time to the development of a cardiac/vascular event was 19 months (median 20 months). Seven patients died during the follow-up period. Causes of death were precapillary pulmonary hypertension in four patients (three patients with pulmonary arterial hypertension and one with pulmonary hypertension secondary to interstitial lung disease), right heart failure secondary to myocardial brosis in one patient, serious infection in one patient and severe inammatory myositis associated with SSc in one patient. According to our exploratory index, low circulating EPC numbers, high PlGF and high sVCAM serum levels were identied in univariate and multivariate Cox analyses as predictors of cardiac and vascular events in SSc (table 3). In a second model including these three biomarkers and other predictors of cardiac/vascular events dened by a p value of 0.1 or less in univariate analysis, low EPC counts (HR 5.14, 95% CI 1.21 to 21.80) and high PlGF serum levels (HR 5.32, 95% CI 1.24 to 22.91) were identied in multivariate analysis as independent predictors of the occurrence of cardiac and vascular events in SSc patients (table 3). In addition, low EPC counts, high PlGF and sVCAM serum levels were predictive in univariate Cox analysis of the occurrence of death during the study period, but this was not conrmed by multivariate analysis.

DISCUSSION
This is the rst prospective study to demonstrate that increased serum PlGF levels and circulating EPC levels predict the subsequent development of digital ulcers in patients with SSc. The identication of relevant predictive biomarkers may allow the detection of a subset of patients who might be candidates for preventive therapeutic strategies.3 4
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Digital ulcers are a frequent complication in patients with SSc. The origin of ulcers is multifactorial. Ischaemia due to vascular disease, sclerodactily, calcinosis and local trauma may all contribute to ulcer initiation.25 Then, the development of digital ulcers results from poor blood ow and tissue hypoxia. Whatever its origin, digital ulcers are often extremely painful, cause signicant impairment of hand function and activities of daily living, infection, digital resorption, and as a consequence markedly alter quality of life.3 Scarce data are available regarding the incidence of new ischaemic digital ulcers in SSc. The number of patients who developed new digital ulcers was less important in our cohort than in the placebo group of the RAPIDS-1 study (17 of 100 patients with at least one new digital ulcers vs 26 of 43 patients in the RAPIDS-1 study), a study that assessed the preventive effect of bosentan for ischaemic digital ulcers.3 Based on the high number of patients with active digital ulcers (24/43 patients from the placebo group of the RAPIDS-1 study had active digital ulcers at baseline), we assume that the exclusion of patients with active digital ulcers in our study accounts for this difference. Our results have identied high serum PlGF levels as a predictor of the development of digital ulcers in SSc patients with or without a history of digital ulcers. PlGF, a secreted dimeric glycoprotein very similar to VEGF, has been shown to be chemotactic and mitogenic for endothelial cells in vitro and proangiogenic in vivo.18 19 PlGF has been reported to be dysregulated in preeclampsia, a severe vascular complication of pregnancy. Two recent cross-sectional studies have reported elevated serum PlGF levels in SSc patients compared with healthy controls.12 20 Together with our results, these ndings suggest a possible contribution of this proangiogenic protein in SSc vascular disturbances. Increased levels of PlGF, reecting increased angiogenesis, were predictive of the development of digital ulcers, in which there is a loss of vessels. Digital ulcers are associated with a destructive vasculopathy, which is a source of tissue hypoxia, one of the major stimuli of angiogenesis.17 25 Therefore, elevated angiogenic markers, including PlGF, may appear as an attempt at a compensatory response to maintain vascular function with the formation of new vessels, which might lead to enhanced capillary formation. Increased serum levels of angiostatic markers,
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Figure 1 (A, B): KaplanMeier analyses of freedom from ischaemic digital ulcers in 100 patients with systemic sclerosis (SSc). Curves are shown for SSc patients who had circulating endothelial progenitor cell (EPC) levels less than 99 and 99/106 or greater Lin-mononuclear cells at study entry (p<0.0001) (A), or in those who had placental growth factor (PlGF) serum levels 61 or greater and less than 61 pg/ml at study entry (p<0.0001) (B), or in those who had vascular cell adhesion molecule (sVCAM) serum levels less than 614 and 614 ng/ml or greater at study entry (C). Table 3 Results of univariate and multivariate analyses of candidate predictors of predened secondary outcomes
Baseline characteristics Cardiac/vascular events (N=27) Evaluation of different biomarkers for the occurrence of cardiac/vascular events Low EPC (<99 EPC/106 Lin-mononuclear cells) High CEC (215 CEC/106 Lin-mononuclear cells) High serum VEGF (352 pg/ml) High serum PlGF (61 pg/ml) High serum sVCAM (614 ng/ml) Inclusion of biomarkers and other SSc disease characteristics with a p value 0.1 Low EPC (<99 EPC/106 Lin-mononuclear cells) High serum PlGF (61 pg/ml) High serum sVCAM (614 ng/ml) History of digital ulcers DLCO/AV <70% ESR >28 mm H1 Evaluation of different biomarkers for the occurrence of death Low EPC (<99 EPC/106 Lin-mononuclear cells) High CEC (215 CEC/106 Lin-mononuclear cells) High serum VEGF (352 pg/ml) High serum PlGF (61 pg/ml) High serum sVCAM (614 ng/ml) Univariate analysis p Value* HR (95% CI) 0.0004* 0.8 0.9 0.0004* 0.02* 0.0004* 0.0004* 0.02* 0.02* 0.07* 0.1* 0.0004* 0.8 0.9 0.0004* 0.02* 4.72 (2.02 to 11.04) 1.09 (0.51 to 2.31) 0.99 (0.47 to 2.11) 10.12 (3.36 to 30.50) 2.81 (1.17 to 6.75) 4.72 (2.02 to 11.04) 10.12 (3.36 to 30.50) 2.81 (1.17 to 6.75) 2.69 (1.21 to 5.97) 1.93 (0.939 to 4.01) 1.80 (0.849 to 3.86) 4.72 (2.02 to 11.04) 1.09 (0.519 to 2.31) 0.99 (0.479 to 2.11) 9.34 (2.70 to 32.26) 2.81 (1.179 to 6.75 Multivariate analysis p Value HR (95% CI) 0.03 NA NA 0.02 0.02 0.03 0.02 0.06 0.8 0.2 0.09 0.1 NA NA 0.9 0.07 3.18 (1.19 to 12.80) 5.01 (1.229 to 20.41) 3.27 (1.19 to 8.97) 5.14 (1.21 to 21.80) 5.32 (1.24 to 22.91) 3.02 (0.98 to 9.27) 1.25 (0.369 to 4.41) 1.46 (0.89 to 3.26) 2.90 (0.84 to 10.03) 9.05 (0.64 to 127.10) 1.09 (0.11 to 10.85) 8.45 (0.82 to 87.12)

Death from any cause (N=7)

*Variables included in the multivariate Cox regression analysis. AV, alveolar volume; CEC, circulating endothelial cells; DLCO, diffusing capacity for carbon monoxide; EPC, endothelial progenitor cells; ESR, erythrocyte sedimentation rate; PlGF, placental growth factor; SSc, systemic sclerosis; sVCAM, soluble vascular cell adhesion molecule; VEGF, vascular endothelial growth factor.

such as thrombospondin 1, endoglin or endostatin, have been reported in SSc and might also contribute to the lack of angiogenesis despite increased levels of angiogenic biomarkers. Our results also show that decreased EPC levels independently predict the occurrence of digital ulcers in SSc patients without any sign of previous digital ulcers. This is in accordance with our previous results, which showed a higher likelihood of digital ulcers in patients with low EPC levels. In contrast to the measurement of a single serum marker for the prediction of risk,
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the use of a cellular marker of risk, such as the level of EPC, unies the complex interactions of multiple negative factors and may yield a better picture of in-vivo mechanisms. While we hypothesise that an accurate identication of highrisk patients using PlGF and EPC levels will hasten the detection of digital ulcers and the introduction of adequate treatment at a time period when they may be of greater efcacy, this remains to be conrmed in dedicated studies. Further explorations are therefore now needed to assess PlGF and EPC as biomarkers of
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digital ulcers in terms of screening, diagnostic evaluation and response to therapy. SSc is the most life threatening of the connective tissue disorders, although survival rates have improved in recent years.26 27 Heart involvement and pulmonary brosis are the main causes of morbidity and mortality.7 2830 Consistent with these observations, ve of seven deaths that occurred in our cohort were related to primary heart involvement and precapillary pulmonary hypertension. The development of new cardiac/vascular events was frequent in our cohort after a mean follow-up of 29 months, with 27 new events. EPC and PlGF levels were also predictive of cardiac/vascular involvement dened as an exploratory composite index. This latter included digital ulcers, pulmonary hypertension, left ventricular dysfunction and SRC, as these complications all rely on the generalised vasculopathy. This observation is sustained by the well-established association between digital ulcers and pulmonary hypertension, as well as the most recent data showing an association between left ventricular dysfunction and digital ulcers.57 31 However, such a composite index, including both cardiac and vascular manifestations, will require further validation. CEC levels have been correlated with endothelial dysfunction and were found to be elevated in patients with atherosclerosis, cancer or SSc.13 15 24 32 Elevated serum VEGF and sVCAM levels, such as elevated skin VEGF levels,10 17 have also been reported in SSc. However, none of these three biomarkers was predictive of the development of digital ulcers in SSc patients. This study should be interpreted within its limitations. We cannot comment on patients with known renal or cardiac failure as they were excluded from the study. Despite the recent elaboration of dedicated recommendations, the detection of EPC by ow cytometry in peripheral blood remains challenging. No consensual technique of cell enrichment before uorescenceactivated cell sorter analysis or a combination of surface markers has yet been validated.33 Therefore, further studies are necessary regarding EPC quantication before being used routinely. Conversely, serum PlGF measurement by quantitative sandwich ELISA is easier to handle and more standardised, which suggests an easier application in routine care. The number of patients who developed precapillary pulmonary hypertension, left ventricular dysfunction and SRC was too low to allow the rm identication of predictors. Further studies with a greater sample size and larger population are thus warranted to assess the predictive value of endothelial biomarkers for the development of these cardiac and vascular complications. This would also allow subgroup analyses according to the different causes of pulmonary hypertension and left ventricular dysfunction. We did not perform a systematic capillaroscopic evaluation at inclusion, which prevented us from determining the value of this examination for the development of ischaemic digital ulcers. However, the merit of capillaroscopy for digital ulcer prediction is now under investigation in a European observational study (CAP study, protocol number AC-052-521). In conclusion, our results suggest that circulating EPC counts and serum PlGF levels can be used to identify SSc patients who are at risk of the development of digital ulcers during a median 36-month follow-up period. This may have important clinical implications, in that non-invasive tests may be used to identify high-risk patients who should undergo more careful evaluation. Further studies assessing the use of these markers in therapeutic strategies aimed at the selection of patients for early treatment or preventive therapy are indicated.
398 Contributors Study design: JA, YA. Acquisition of data: JA, CM, BR. Analysis and interpretation of data: JA, CM, BR, YA. Manuscript preparation: JA, CM, POC, GU, CB, AK, GC, YA. Statistical analysis: JA, CM, YA. Funding This study received nancial support from the Socit Franaise de Rhumatologie, Association des Sclrodermiques de France, Groupe Franais de Recherche sur la Sclrodermie (bourse AMPLI), INSERM, Agence Nationale pour la Recherche (grant no R07094KS) and Fond dEtude et de Recherche du Corps Mdical des Hpitaux de Paris. It was also supported by an investigator-initiated research grant from Pzer Ltd. Competing interests None. Ethics approval Ethics approval was received from CPP Ile de France 3. Provenance and peer review Not commissioned; externally peer reviewed.

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Angiogenic biomarkers predict the occurrence of digital ulcers in systemic sclerosis

Jrme Avouac, Christophe Meune, Barbara Ruiz, et al. Ann Rheum Dis 2012 71: 394-399 originally published online November 15, 2011

doi: 10.1136/annrheumdis-2011-200143

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