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Enthesitis-related arthritis — SCE Rheumatology MCQ

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HardPaediatric rheumatologyEnthesitis-related arthritisSCE Rheumatology

A patient with diffuse systemic sclerosis has new ventricular ectopy, a low-grade troponin rise and exertional presyncope. Coronary disease has been excluded and echocardiography is non-diagnostic. Which investigation should define possible primary myocardial involvement?

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Correct answer: D — Cardiac MRI with myocardial tissue characterisation

Explanation lettering: E = shown as A · A = shown as B · B = shown as C · C = shown as E

D is correct. When primary systemic-sclerosis heart involvement is suspected, BSR recommends cardiovascular magnetic resonance because it can characterise myocardial inflammation, fibrosis, ventricular function and perfusion more sensitively than a non-diagnostic echo. Holter monitoring should also quantify arrhythmia burden. Endomyocardial biopsy is reserved for selected cases after coronary disease is excluded, not used routinely. Repeating an insensitive test a year later risks progression, while pulmonary angiography and calcium scoring do not answer the myocardial question.

Reference: BSR 2024 guideline for management of systemic sclerosis: https://academic.oup.com/rheumatology/article/63/11/2956/7750184