Effect of glucocorticoids on the arteries in rheumatoid arthritis

Cardiovascular risk induced by low-dose corticosteroids in rheumatoid arthritis: a systematic literature review

OBJECTIVES

To assess the association between cardiovascular (CV) risk and low-dose corticosteroids (LD-CT, defined as a daily dose <10mg/day of prednisone) in rheumatoid arthritis (RA) patients.

METHODS

DATA SOURCE

A systematic review of the literature up to June 2009 was performed.

DATA EXTRACTION

(1) cardiovascular risk factors: high blood pressure, glycemia and lipid profile, carotid intima-media thickness, pulse-wave velocity, ventricular function; (2) "hard" outcomes: heart failure (HF), stroke, myocardial infarction (MI) or mortality.

DATA ANALYSIS

descriptive, comparing CV risk between LD-CT-treated RA patients and LD-CT-non-treated RA patients.

RESULTS

Of the 1138 screened reports, the literature search identified 37 assessing CV risk in LD-CT treated RA. The analysis showed a protective effect on serum lipid profile, an increase of insulin resistance or glycemia, probably no effect on blood pressure, no effect on atherosclerosis, discrepancies regarding arterial stiffness and no effect on ventricular function or heart rate variability. An association of LD-CT with major CV events was found in 4/6 studies. This included MI (HR=1.7 [1.2-2.3]), stroke (OR=4.36 [1.60-11.90] for LDC between 6 and 10mg/day), mortality (HR=2.03 [1.25-3.32]) and a composite index of CV events (in the group of rheumatoid factor positive RA, HR=2.21 [1.22-4.00]). Two studies did not find any significant association between LD-CT exposure and mortality (OR=2.25 [0.29-102.5]) or a composite index of CV events (OR=1.3 [0.8-2.0]).

CONCLUSION

Although the literature review showed poor association between LDC exposure and CV risk factors, a trend of increasing major CV events was identified.

The role of endothelial function and its assessment in rheumatoid arthritis

Patients with rheumatoid arthritis (RA) have a reduced life expectancy when compared with the general population, largely attributable to cardiovascular disease. Factors that contribute to this increased cardiovascular risk include traditional risk factors, which account for only part of the excess, along with manifestations of the disease itself. RA is characterized by inflammation, which also is a key component in the development of atherosclerosis. Inflammation leads to the activation of endothelial cells, which, through an increase in the expression of leukocyte adhesion molecules, promotes a pro-atherosclerotic environment. Endothelial dysfunction is an early preclinical marker of atherosclerosis, and is commonly found in patients with RA. Several methods are available for the assessment of endothelial function, such as flow-mediated dilatation and laser Doppler flowmetry combined with iontophoresis, each with its own advantages and limitations. Studies have shown that endothelial dysfunction in RA is closely associated with inflammation, and therapeutic reduction of inflammation leads to improvements in endothelial function. As such, assessments of endothelial function could prove to be useful tools in the identification and monitoring of cardiovascular risk in patients with RA. Given the increase in cardiovascular mortality associated with RA, effective management must involve prevention of cardiovascular risk, in addition to control of disease activity and inflammation.

25-hydroxyvitamin D and cardiovascular risk factors in women with systemic lupus erythematosus

OBJECTIVE

Low serum levels of 25-hydroxyvitamin D (25[OH]D; vitamin D) are associated with a higher frequency of cardiovascular disease and risk factors in the general population. Vitamin D deficiency has also been noted in systemic lupus erythematosus (SLE). The objective of this study was to evaluate the associations of serum 25(OH)D levels with cardiovascular risk factors in women with SLE.

METHODS

Data collected in 181 women with SLE included demographics, SLE activity and damage assessments, cardiovascular risk factors, medications, and laboratory assessments of inflammatory markers and 25(OH)D levels. Multiple linear and logistic regressions were used to estimate the association of 25(OH)D levels with cardiovascular risk factors.

RESULTS

The mean age and disease duration were 43.2 and 11.9 years, respectively. The mean 25(OH)D level was 27.1 ng/ml and 62.2% had 25(OH)D levels <30 ng/ml. In unadjusted analyses, lower 25(OH)D levels were significantly associated with higher diastolic blood pressure, low-density lipoprotein cholesterol, lipoprotein(a), body mass index (BMI), and fibrinogen levels, as well as self-reported hypertension and diabetes mellitus. Lower 25(OH)D levels were also significantly associated with higher SLE disease activity and damage scores. After adjustment for age, seasonal variation, and race/ethnicity, lower 25(OH)D levels were also significantly related to higher fasting serum glucose. With further adjustment for BMI, associations between 25(OH)D and cardiovascular risk factors were no longer significant.

CONCLUSION

This study demonstrates that vitamin D levels are low in women with SLE and significant associations exist with selected cardiovascular risk factors, although most of these associations can be explained by BMI.

A novel NADP(+)-dependent dehydrogenase activity for 7alpha/beta- and 11beta-hydroxysteroids in human liver nuclei: A third 11beta-hydroxysteroid dehydrogenase

Human tissue from uninvolved liver of cancer patients was fractionated using differential centrifugation and characterized for 11betaHSD enzyme activity against corticosterone, dehydrocorticosterone, 7alpha- and 7beta-hydroxy-dehydroepiandrosterone, and 7-oxo-dehydroepiandrosterone. An enzyme activity was observed in nuclear protein fractions that utilized either NADP(+) or NAD(+), but not NADPH and NADH, as pyridine nucleotide cofactor with K(m) values of 12+/-2 and 390+/-2microM, compared to the K(m) for microsomal 11betaHSD1 of 43+/-8 and 264+/-24microM, respectively. The K(m) for corticosterone in the NADP(+)-dependent nuclear oxidation reaction was 102+/-16nM, compared to 4.3+/-0.8microM for 11betaHSD1. The K(cat) values for nuclear activity with NADP(+) was 1687nmol/min/mg/micromol, compared to 755nmol/min/mg/micromol for microsomal 11betaHSD1 activity. Inhibitors of 11betaHSD1 decreased both nuclear and microsomal enzyme activities, suggesting that the nuclear activity may be due to an enzyme similar to 11betaHSD Type 1 and 2.

Do carotid artery diameters manifest early evidence of atherosclerosis in women with rheumatoid arthritis?

OBJECTIVE

Given the high incidence of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA), we examined the associations between RA diagnosis and characteristics and evidence of carotid atherosclerosis. We take a unique approach by evaluating lumen and interadventitial diameters in addition to intima-media thickness and plaque.

METHODS

Ninety-three women with RA were matched with 93 healthy women by age, race, and menopause status. In cross-sectional analyses, we compared common carotid artery measures between groups and examined their relationships with measures of RA severity and activity.

RESULTS

Mean age was 53.3 years, and median RA duration was 14 years. Lumen diameter in patients was significantly greater than in healthy women (5.50 vs. 5.19 mm, p < 0.001), as was interadventitial diameter (6.92 vs. 6.61 mm, p < 0.001). Having RA also was independently associated with greater lumen (beta = 0.256, p < 0.01) and interadventitial (beta = 0.261, p < 0.01) diameters, after controlling for cardiovascular risk factors and intima-media thickness. Carotid intima-media thickness (0.70 vs. 0.71 mm) was similar, and the prevalence of carotid plaque in patients (21%) was higher but not statistically different from healthy women (15%). In patients with RA, we found positive associations between methotrexate dose and interadventitial diameter, between hypothyroidism and intima-media thickness, and between hypothyroidism and soluble endothelial adhesion molecule and plaque, independent of cardiovascular risk factors.

CONCLUSIONS

Women with RA have increased carotid artery diameters compared with healthy women. This may reflect premature vascular aging and may be an early indicator of increased cardiovascular risk.

Cardiometabolic risk in psoriasis: differential effects of biologic agents

Psoriasis is associated to an increased risk of cardiovascular (CV) complications. Overall, the pathogenic mechanisms involved in premature CV complications in psoriasis appear to be complex and multifactorial, with traditional and nontraditional risk factors possibly contributing to the increased risk. Based on what is known about the pathogenesis of psoriasis and extrapolating the current knowledge on CV complications in other inflammatory diseases, studies are needed to investigate if appropriate control of the inflammatory, immunologic and metabolic disturbances present in psoriasis can prevent the development of this potentially lethal complication. It is clear that there is a great need for heightened awareness of the increased risk for vascular damage in patients with psoriasis. It is also crucial to closely monitor patients with psoriasis for CV risk factors including obesity, hypertension, diabetes, and hyperlipidemia. Whether treatment regimens that effectively manage systemic inflammation will lead to prevention of CV complications in psoriasis needs to be investigated. Clearly, studies should focus on establishing the exact mechanisms that determine CV risk in psoriasis so that appropriate preventive strategies and treatment guidelines can be established.

The inextricable link between atherosclerosis and prototypical inflammatory diseases rheumatoid arthritis and systemic lupus erythematosus

The increased burden of cardiovascular disease in patients with rheumatoid arthritis and systemic lupus erythematosus has recently become the focus of intense investigation. Proatherogenic risk factors and dysregulated inflammation are the main culprits, leading to enhanced atherosclerosis in subgroups of patients with inflammatory diseases. Common molecular pathways shared by atherosclerosis and inflammatory disease may be involved. In this review we map the key determinants of the increased incidence of cardiovascular disease in patients with inflammatory diseases at each step of the atherogenesis.

Therapeutic manipulation of glucocorticoid metabolism in cardiovascular disease

The therapeutic potential for manipulation of glucocorticoid metabolism in cardiovascular disease was revolutionized by the recognition that access of glucocorticoids to their receptors is regulated in a tissue-specific manner by the isozymes of 11beta-hydroxysteroid dehydrogenase. Selective inhibitors of 11beta-hydroxysteroid dehydrogenase type 1 have been shown recently to ameliorate cardiovascular risk factors and inhibit the development of atherosclerosis. This article addresses the possibility that inhibition of 11beta-hydroxsteroid dehydrogenase type 1 activity in cells of the cardiovascular system contributes to this beneficial action. The link between glucocorticoids and cardiovascular disease is complex as glucocorticoid excess is linked with increased cardiovascular events but glucocorticoid administration can reduce atherogenesis and restenosis in animal models. There is considerable evidence that glucocorticoids can interact directly with cells of the cardiovascular system to alter their function and structure and the inflammatory response to injury. These actions may be regulated by glucocorticoid and/or mineralocorticoid receptors but are also dependent on the 11beta-hydroxysteroid dehydrogenases which may be expressed in cardiac, vascular (endothelial, smooth muscle) and inflammatory (macrophages, neutrophils) cells. The activity of 11beta-hydroxysteroid dehydrogenases in these cells is dependent upon differentiation state, the action of pro-inflammaotory cytokines and the influence of endogenous inhibitors (oxysterols, bile acids). Further investigations are required to clarify the link between glucocorticoid excess and cardiovascular events and to determine the mechanism through which glucocorticoid treatment inhibits atherosclerosis/restenosis. This will provide greater insights into the potential benefit of selective 11beta-hydroxysteroid dehydrogenase inhibitors in treatment of cardiovascular disease.

Cardiovascular, rheumatologic, and pharmacologic predictors of stroke in patients with rheumatoid arthritis: a nested, case-control study

OBJECTIVE

To determine the risk of stroke in patients with rheumatoid arthritis (RA) and risk factors associated with stroke.

METHODS

We performed nested case-control analyses within a longitudinal databank, matching up to 20 controls for age, sex, and time of cohort entry to each patient with stroke. Conditional logistic regression was performed as an estimate of the relative risk of stroke in RA patients compared with those with noninflammatory rheumatic disorders, and to examine severity and anti-tumor necrosis factor (anti-TNF) treatment effects in RA.

RESULTS

We identified 269 patients with first-ever all-category strokes and 67 with ischemic stroke, including 41 in RA patients. The odds ratio (OR) for the risk of all-category stroke in RA was 1.64 (95% confidence interval [95% CI] 1.16-2.30, P = 0.005), and for ischemic stroke was 2.66 (95% CI 1.24-5.70, P = 0.012). Ischemic stroke was predicted by hypertension, myocardial infarction, low-dose aspirin, comorbidity score, Health Assessment Questionnaire score, and presence of total joint replacement, but not by diabetes, smoking, exercise, or body mass index. Adjusted for cardiovascular and RA risk factors, ischemic stroke was associated with rofecoxib (P = 0.060, OR 2.27 [95% CI 0.97-5.28]), and possibly with corticosteroid use. Anti-TNF therapy was not associated with ischemic stroke (P = 0.584, OR 0.80 [95% CI 0.34-1.82]).

CONCLUSION

RA is associated with increased risk of stroke, particularly ischemic stroke. Stroke is predicted by RA severity, certain cardiovascular risk factors, and comorbidity. Except for rofecoxib, RA treatment does not appear to be associated with stroke, although the effect of corticosteroids remains uncertain.

Critical role of macrophages in glucocorticoid driven vascular calcification in a mouse-model of atherosclerosis

OBJECTIVE

Macrophage-derived products are known to play a crucial role during atherogenesis and vascular calcification. Glucocorticoids (GC) are important modulators of immune cell functions, but their specific effects on macrophages behavior during plaque formation are not defined. The present study was therefore designed to investigate the effects of macrophage-specific deletion of the glucocorticoid receptor (GR(LysMCre)) on atherogenesis and vascular calcification in a hyperlipidemic mouse-model.

METHODS AND RESULTS

Bone marrow was isolated from GR(LysMCre) mice and wild-type controls (GR(flox)) and subsequently transplanted into lethally irradiated LDL-receptor-deficient mice. Animals were fed a Western-type diet for 15 or 24 weeks, and atherosclerotic lesions within the aortic sinus were evaluated. At both time points, no significant difference in serum lipid and corticosterone concentrations, atherosclerotic lesion size and macrophage-content within the lesions could be observed. However, GR(LysMCre) mice showed less calcification as well as a significant reduction of RANKL, BMP2, and Msx2 expression within the vasculature. In vitro studies using conditioned media from macrophages which had been stimulated with dexamethasone demonstrated a dose-dependent increase in calcium deposition by vascular smooth muscle cells.

CONCLUSIONS

This study demonstrates that macrophage-specific glucocorticoid receptor inactivation reduces vascular calcification without affecting atherosclerotic lesion size in LDL receptor-deficient mice.

Cardiovascular disease in rheumatoid arthritis

PURPOSE OF REVIEW

Individuals with rheumatoid arthritis are at increased risk for morbidity and mortality from cardiovascular disease (CVD). The purpose of this review is to discuss recent advances in our understanding of the pathogenesis, prevalence, treatment, and prevention of accelerated atherosclerotic disease in rheumatoid arthritis.

RECENT FINDINGS

Recent reports have highlighted the increased risk for silent myocardial infarction and sudden death in rheumatoid arthritis, and the potential roles of traditional and nontraditional risk factors for CVD, including abnormal revascularization of damaged peripheral blood vessels and genetic polymorphisms. Several studies have also added important information on the possible role of anti-tumor necrosis factor-alpha therapy, other disease modifying antirheumatic drugs, and nonsteroidal anti-inflammatory drugs in decreasing CVD risk.

SUMMARY

The pathogenic mechanisms involved in accelerated cardiovascular complications in rheumatoid arthritis appear to be complex and multifactorial. Both traditional and nontraditional risk factors potentially contribute to the increased cardiovascular risk. Good control of the inflammation, immunologic disturbances, and metabolic changes seen in rheumatoid arthritis are crucial in the prevention of this potentially lethal complication. There is a need for heightened awareness of the increased risk for silent ischemia, early myocardial infarction, and sudden death. Further exploration of the mechanisms of vascular repair and their potential role in premature atherosclerosis is needed.

Early treatment reduces the cardiovascular risk factors in newly diagnosed rheumatoid arthritis patients

OBJECTIVE

To investigate subclinical atherosclerosis and the effect of treatment in patients with early rheumatoid arthritis (RA).

PATIENTS AND METHODS

Forty patients with early RA who met the revised American College of Rheumatology (ACR) criteria and disease duration of <1 year were included in the study. Smokers and patients with classical risk factors for atherosclerosis were excluded. The serum levels of total cholesterol (TC), triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol were determined in all patients before and after 1 year of therapy. Carotid artery intima-media thickness (IMT) and carotid plaque were measured before and after treatment. RA disease activity was measured using the 28 joint indices score (DAS-28) and clinical improvement was determined by the ACR response criteria. Forty-five age- and sex-matched nonsmoking volunteers were used as controls. All patients were treated with methotrexate and prednisone.

RESULTS

RA patients had a baseline mild dyslipidemia characterized by a decrease in serum HDL-C levels and a high TC/HDL-C atherogenic ratio compared with controls. Both lipid parameters were significantly improved after treatment (P<0.01). Common carotid artery IMTs at baseline were higher in RA patients compared with controls (P<0.05). After 1 year of therapy there was a significant decrease in the IMTs (P<0.001). Thirty-five patients (88%) achieved the ACR 20%, while 30 (75%) reached the ACR 50% response criteria. A significant decrease of DAS-28 was observed after treatment (P<0.03).

CONCLUSIONS

The atherogenic lipid profile and subclinical atherosclerosis are features of early RA, which improved after therapy. Early intervention and control of the disease activity may reduce the risk of atherosclerosis and cardiovascular events in patients with RA.

The heart and cardiovascular manifestations in rheumatoid arthritis

Cardiovascular features in rheumatoid arthritis (RA) are common. Among those are the classical extra-articular features that not only include pericarditis, cardiomyopathy/myocarditis, cardiac amyloidosis, coronary vasculitis, arrhythmia and valve diseases, but also congestive heart failure and ischaemic heart disease which are found more frequently and are associated with an increased mortality compared with the general population. This overview discusses the epidemiological aspects of these cardiovascular diseases and their relevance for diagnosis and treatment of RA.

Glucocorticoids and cardiovascular disease

Chronic excessive activation of glucocorticoid receptors induces obesity, insulin resistance, glucose intolerance, dyslipidaemia and hypertension. Subtle abnormalities of the hypothalamic-pituitary-adrenal axis and/or of tissue sensitivity to glucocorticoids are also associated with these cardiovascular risk factors in patients with the metabolic syndrome. Furthermore, glucocorticoids have direct effects on the heart and blood vessels, mediated by both glucocorticoid and mineralocorticoid receptors and modified by local metabolism of glucocorticoids by the 11beta-hydroxysteroid dehydrogenase enzymes. These effects influence vascular function, atherogenesis and vascular remodelling following intra-vascular injury or ischaemia. This article reviews the systemic and cardiovascular effects of glucocorticoids, and the evidence that glucocorticoids not only promote the incidence and progression of atherogenesis but also modify the recovery from occlusive vascular events and intravascular injury. The conclusion is that manipulation of glucocorticoid action within metabolic and cardiovascular tissues may provide novel therapeutic avenues to combat cardiovascular disease.

Premature cardiovascular disease after allogeneic hematopoietic stem-cell transplantation

We assessed incidence and risk factors of cardiovascular events in 265 patients undergoing allogeneic hematopoietic stem-cell transplantation (HSCT) between 1980 and 2000 and who survived at least 2 years. Results were compared with a cohort of 145 patients treated during the same period with autologous HSCT. The median age of patients with allogeneic HSCT at last follow-up was 39 years, and median follow-up was 9 years. Eighteen (6.8%) patients after allogeneic and 3 (2.1%) patients after autologous HSCT experienced an arterial event. The cumulative incidence of first arterial event after allogeneic HSCT was 22.1% (95% CI, 12.0-40.9) at 25 years. The cumulative incidence 15 years after allogeneic HSCT was 7.5% as compared with 2.3% after autologous HSCT. Adjusting for age, risk of an arterial event was significantly higher after allogeneic HSCT (RR 6.92; P =.009). In multivariate analysis, allogeneic HSCT (RR: 14.5; P =.003), and at least 2 of 4 cardiovascular risk factors (hypertension, dyslipidemia, diabetes, obesity) (RR: 12.4; P =.02) were associated with a higher incidence of arterial events after HSCT. Thus, long-term survivors after allogeneic HSCT are at high risk for premature arterial vascular disease. HSCT might favor the emergence of established risk factors, such as hypertension, diabetes, and dyslipidemia.

Effects of keishibukuryogan on vascular function in adjuvant-induced arthritis rats

It is known that rheumatoid arthritis (RA) accelerates atherosclerosis. Further, the soluble form of vascular adhesion molecule-1 (VCAM-1) is known as a predictive marker of atherosclerosis in RA patients. We reported that keishibukuryogan, one of the Kampo formulas, improved articular symptoms and decreased soluble VCAM-1 in patients with RA. In adjuvant-induced arthritis (AIA) rats, an animal model of RA, it is known that endothelial function is injured by inflammation. So, we investigated the effect of keishibukuryogan on endothelial function in AIA rats. Lewis rats were divided into control, AIA control, and AIA with keishibukuryogan groups. The AIA with keishibukuryogan group was fed 3% keishibukuryogan contained in normal chow. On day 25 after injection of Mycobacterium butyricum, endothelium-dependent relaxation by acetylcholine in the AIA control group was suppressed, but it was improved in the AIA with keishibukuryogan group. The contractions by xanthine/xanthine oxidase in both AIA rats increased, but that in keishibukuryogan decreased compared to the AIA control group. Plasma levels of lipid peroxide increased in the AIA control group, but keishibukuryogan decreased these levels. Plasma levels of nitric oxide (NO) increased in both AIA groups. The expressions of endothelial NO synthase, inducible NO synthase and VCAM-1 of thoracic aorta were investigated by western blotting. These expressions increased in the AIA control group, but were restricted in the AIA with keishibukuryogan group. We considered that keishibukuryogan protected the endothelial function of AIA rats mainly by its anti-oxidative effect.

Enhanced Immune System Activation and Arterial Inflammation Accelerates Atherosclerosis in Lupus-Prone Mice

OBJECTIVE

Premature atherosclerosis is a characteristic feature of systemic lupus erythematosus, a prototypic autoimmune disease. The principle cellular and molecular mechanisms which underlie such accelerated atherosclerosis are indeterminate.

METHODS AND RESULTS

The pathophysiology of lupus-mediated atherogenesis was evaluated in a novel animal model involving transplantation of bone marrow cells from the lupus prone strain gld into Ldl-r(-/-) mice. Diet-induced atherogenesis in lethally-irradiated Ldl-r(-/-) mice transplanted with gld bone marrow cells resulted in accelerated atherosclerosis (+65%) as compared with control mice transplanted with wild-type marrow cells. Enhanced atherogenesis was associated with enhanced activation of both B and T lymphocytes and with arterial inflammation involving endothelial cell activation, monocyte recruitment, and accumulation of apoptotic debris, macrophages, and CD4 T cells, but was independent of plasma lipid levels and renal function.

CONCLUSIONS

Our data support the contention that despite the absence of both disturbed cholesterol homeostasis and renal dysfunction in autoimmune gld-->Ldl-r(-/-) mice, lupus disease induces enhanced activation of the immune system and acts locally on the vasculature to induce inflammation, together with accumulation of apoptotic debris, macrophages, and CD4 T cells, thereby accelerating plaque progression.

Insulin resistance is an independent risk factor for atherosclerosis in rheumatoid arthritis

The objective of this study was to investigate the relationship between insulin resistance (IR) and subclinical atherosclerosis in patients with rheumatoid arthritis (RA). Carotid artery intima media thickness (IMT), using ultrasound evaluation, and other clinical and laboratory variables were investigated in 45 RA outpatients and in 48 controls with soft tissue disorders. IR was assayed by homeostasis model assessment (HOMA2) and metabolic syndrome by National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) criteria. Insulin resistance, as defined by HOMA2-IR>1, was seen in 40 (88.9%) RA patients and in three (6.2%) controls (p<0.001). No significant difference was detected in the prevalence of metabolic syndrome. The median IMT was greater in RA patients (0.76 mm; interquartile range [IQR] 0.65, 0.85) than in the controls (0.66 mm; IQR 0.60, 0.72) (p<0.001). Dividing the RA patients according to the cut-off IMT value (0.72 mm), a difference was detected in both systolic (p=0.04) and diastolic blood pressure (p=0.02), disease activity score (DAS28) (p=0.008), HOMA2-IR (p<0.001) and cumulative oral steroid dose (p=0.001). Moreover, the frequency of cases with increased IMT was higher in glucocorticoid users than in non-users (21/23 vs. 9/22, respectively) (p<0.001). Spearman's rho correlation showed a significant positive relationship between IMT and HOMA2-IR (p<0.001). Multivariate stepwise analysis selected HOMA2-IR plus diastolic BP plus glucocorticoid exposure as the best predictive model for subclinical atherosclerosis (R2c=0.577, F=21, p<0.001). In conclusion, this study showed a significantly higher prevalence of IR in RA patients and pointed out a significant association between IR and subclinical atherosclerosis. This relationship may be driven primarily by exposure to steroid therapy.

Glucocorticoids and cardiovascular and cerebrovascular events in polymyalgia rheumatica

OBJECTIVE

To examine the effect of glucocorticoid use on the risk of various cardiovascular diseases in patients with polymyalgia rheumatica (PMR).

METHODS

We assembled a population-based incidence cohort of 364 patients with PMR first diagnosed between January 1, 1970 and December 31, 1999. Inclusion criteria were age > or = 50 years, bilateral aching and morning stiffness involving at least 2 areas (neck, shoulders, hips, or proximal aspects of the thighs), and erythrocyte sedimentation rate (ESR) > or = 40 mm/hour. In patients who fulfilled the first 2 criteria but had a normal ESR, a rapid response to low-dose glucocorticoids served as the third criterion. Patients were followed up until death or December 31, 2004. Cox models with time-dependent covariates were used to examine the association between glucocorticoid exposure and risk of myocardial infarction, heart failure, peripheral vascular disease, and cerebrovascular disease.

RESULTS

A total of 364 PMR patients (mean age 73 years, 67% women) were followed for a median of 7.6 years. During the disease course, 310 (85%) patients received glucocorticoids. After adjusting for age, calendar year, and ESR, patients who received glucocorticoids did not have a significantly higher risk for myocardial infarction, heart failure, peripheral vascular disease, or cerebrovascular disease (hazard ratio [95% confidence interval] 0.58 [0.29-1.18], 0.85 [0.45-1.54], 0.58 [0.24-1.40], and 0.65 [0.33-1.26], respectively) compared with those who did not receive glucocorticoids. In fact, a trend for a protective effect was seen. No significant association was observed between cumulative glucocorticoid dose and any of the outcomes (P = 0.39).

CONCLUSION

In patients with PMR, treatment with glucocorticoids is not associated with an increased risk of cardiovascular diseases.

Glucocorticoids and cardiovascular events in rheumatoid arthritis: a population-based cohort study

OBJECTIVE

To determine the relationship between glucocorticoid exposure and cardiovascular (CV) events in patients with rheumatoid arthritis (RA).

METHODS

A total of 603 adult residents of Rochester, Minnesota with incident RA between 1955 and 1995 were followed up through their medical records for a median of 13 years (total of 9,066 person-years). Glucocorticoid exposure was defined 3 ways: tertiles of cumulative exposure; recent use (< or =3 months) versus past use (>3 months); and average daily dosage (< or =7.5 mg/day or >7.5 mg/day). CV events, including myocardial infarction, heart failure, and death from CV causes, were defined according to validated criteria. Cox regression models were adjusted for demographic features, CV risk factors, and RA characteristics.

RESULTS

Rheumatoid factor (RF)-negative patients with exposure to glucocorticoids were not at increased risk of CV events, irrespective of the glucocorticoid dosage or timing of use, as compared with the reference group of RF-negative patients who had never been exposed to glucocorticoids. In contrast, RF-positive patients were at increased risk of CV events, particularly with higher cumulative exposure, higher average daily dosage, and recent use of glucocorticoids. RF-positive patients with high cumulative exposure to glucocorticoids had a 3-fold increased risk of CV events (hazard ratio 3.06 [95% confidence interval 1.81-5.18]), whereas RF-negative patients with high cumulative exposure were not at increased risk (hazard ratio 0.85 [95% confidence interval 0.39-1.87]).

CONCLUSION

RF-positive but not RF-negative patients were at increased risk of CV events following exposure to glucocorticoids. These findings suggest that glucocorticoids interact with RF status to modulate the occurrence of CV events in patients with RA. The mechanisms underlying this interaction are unknown and should be the subject of further research.

Atherogenesis takes place in cholesterol-fed rabbits when circulating concentrations of endogenous cortisol are increased and inflammation suppressed

Atherosclerosis is an inflammatory disease, but the response of the endogenous anti-inflammatory system during this process has not been evaluated previously. Cortisol is the end product of this anti-inflammatory system, but is also able to activate cellular processes that induce atherogenesis; however, it is unknown whether atherogenesis occurs when circulating concentrations of endogenous cortisol are increased or when they are decreased. We have evaluated the counter-regulatory responses of cortisol and interleukin-1beta (IL-1beta) during the short- and long-term responses to vascular injury in rabbits fed a 2% cholesterol diet. In the short-term group (n=18), serum cortisol and IL-1beta concentrations were measured after 10, 20 and 30 days. Rabbits developed hypercholesterolemia and hypercortisolemia, with only modest increases in IL-1beta. Although inflammation was low-grade, atherogenesis took place, with subintimal lipid accumulation evident on day 30. In the second group (n=18), we evaluated variables after 40, 60 and 90 days. This group developed hypercholesterolemia, but serum cortisol concentrations were inappropriately normal, while IL-1beta concentrations were elevated 8.6-fold; advanced atherosclerotic plaques were evident on days 60 and 90. These results show that atherogenesis occurs when high endogenous cortisol levels are suppressing inflammation, and are consistent with a promotion of early atherogenesis by high cortisol concentrations.

Mineralocorticoid Receptor Activation Promotes Vascular Cell Calcification

OBJECTIVE

Clinical studies demonstrate that mineralocorticoid receptor (MR) antagonism improves outcomes in cardiovascular patients and that vascular calcification correlates with adverse cardiac events. We have recently demonstrated that human vascular smooth muscle cells (VSMCs) express functional MRs that, in response to aldosterone, modulate expression of osteogenic genes including alkaline phosphatase (ALP) and bone morphogenetic protein-2 (BMP2). This study examines the effects of MR activation by aldosterone on the process of in vitro vascular calcification.

METHODS AND RESULTS

Using immunoblotting and adenoviral promoter-reporter assays, we demonstrated that calcifying vascular cells (CVCs), an in vitro model of vascular calcification, express MRs that mediate both aldosterone- and cortisol-stimulated gene transcription. In this model, aldosterone stimulated ALP activity, an early marker of osteoblastic differentiation, as well as mineralization. Aldosterone antagonism with spironolactone abolished both effects implicating CVC MRs in the mechanism of aldosterone-stimulated vascular calcification. Inhibition of BMP2 signaling by overexpression of dominant negative BMP2 receptor did not attenuate aldosterone-induced osteoblastic differentiation.

CONCLUSIONS

Aldosterone activation of MR promotes osteoblastic differentiation and mineralization of VSMCs independent of BMP2 signaling. These data provide a mechanistic link between hormone-mediated VSMC MR activation and vascular calcification, two processes associated with increased risk of cardiovascular ischemic events in humans.

Is steroid resistance related to multidrug resistance-I (MDR-I) in rheumatoid arthritis?

Both healthy ageing and rheumatoid arthritis (RA) are frequently associated with acquired steroid resistance. Here, we investigated the potential involvement of steroid resistance with multidrug resistance (MDR) and explored the impact of pathological ageing on lymphocyte sensitivity to glucocorticoids. Seventy-four RA patients and 26 healthy controls took part in this study. Peripheral blood mononuclear cells were isolated and T-cell sensitivity to glucocorticoids was measured in vitro. The functional activity of P-glycoprotein was analyzed by flow cytometry and ABCB1/MDR-1 gene polymorphisms were assessed in peripheral lymphocytes. Patients and controls had similar sensitivities to glucocorticoids. Only controls presented age-related immunological changes, including reduced T-cell proliferation and relative resistance to corticosterone. Patients had a higher percentage (72%) of lymphocytes actively extruding rhodamine 123 (Rh123(dim)) than controls (60%) in spite of similar P-glycoprotein activity. A higher percentage of Rh123(dim)+ lymphocytes was observed in patients who were more resistant to dexamethasone in vitro. The distribution of ABCB1 genotypes in RA patients did not differ significantly from that in controls and were not associated to steroid sensitiveness or disease activity. These data suggest that peripheral lymphocytes of arthritic patients are fully responsive to GCs in vitro in spite of displaying higher MDR activity.

Atherosclerosis and inflammation: insights from rheumatoid arthritis

Cardiovascular disease is a major health care problem and the most common cause of death among individuals from developed nations. Our understanding of atherosclerosis has evolved from a passive process resulting in narrowing of the lumen and consequent myocardial ischemia to a dynamic process that involves inflammation. The study of atherosclerosis in patients with chronic inflammation, such as rheumatoid arthritis (RA), will provide insights into the relationship between inflammation and atherosclerosis. We review the relationship between atherosclerosis and inflammation within the context of RA, providing evidence that patients with RA have increased cardiovascular morbidity and mortality and accelerated coronary and extra-coronary atherosclerosis. In addition, traditional and novel cardiovascular risk factors are discussed. Finally, actions that a rheumatologist can take to better control this cardiovascular morbidity are suggested. These can be summarized as follows: (1) careful assessment and treatment of cardiovascular risk, (2) better control of inflammation, and (3) individual risk-benefit evaluation of need for cyclo-oxygenase-2 inhibitors, nonsteroidal anti-inflammatory drugs, and high doses of corticosteroids.

Essential polyunsaturated fatty acids, inflammation, atherosclerosis and cardiovascular diseases

Atherosclerosis is the primary cause of coronary and cardiovascular diseases (CVD). Epidemiological studies have revealed several important environmental (especially nutritional) factors associated with atherosclerosis. However, progress in defining the cellular and molecular interactions involved has been hindered by the etiological complexity of the disease. Nevertheless, our understanding of CVD has improved significantly over the past decade owing to the availability of new randomized trial data. In particular, the failure of antioxidant and anti-inflammatory treatments to consistently reduce the rate of CVD complications suggests that theories of atherosclerosis may have considerably exaggerated the importance of oxidized lipoprotein and vascular inflammation. In that context, one new and basic question is whether the biology of essential dietary lipids may help us understand the role of the inflammatory process in CVD. Essential dietary lipids of the omega-6 and omega-3 families are the precursors of major mediators of inflammation such as eicosanoids that regulate the production of inflammatory cytokines and the expression of some major inflammation genes. On the other hand, non-essential lipids (omega-9 and saturated fatty acids) interfere with biological activities of essential lipids. Finally, essential omega-3 and omega-6 fatty acids have different, often antagonistic, effects on inflammation, and their effects can vary according to the type of cells and target organs involved, as well as their respective amounts in the diet. Because of the extreme complexity in the etiology of CVD, the best strategy may be to monitor the main features of dietary patterns, such as the Mediterranean diet, that are known to be associated with a low prevalence of both CVD and chronic inflammatory diseases.

Decreased levels of circulating alpha2-Heremans-Schmid glycoprotein/Fetuin-A (AHSG) in patients with rheumatoid arthritis

OBJECTIVE

Alpha2-Heremans Schmid glycoprotein/Fetuin-A (AHSG) is a circulating negative acute-phase protein, which inhibits bimineralization. It is often considered as a potential mediator between chronic inflammation and cardiovascular diseases. The metabolism of AHSG in patients with rheumatoid arthritis (RA) is unknown.

METHODS

Serum AHSG concentrations were measured in 102 patients with RA using a newly developed indirect enzyme-linked immunosorbent assay (ELISA).

RESULTS

The serum AHSG levels in the RA patients were significantly lower than that in healthy volunteers (249.8 +/- 84.1 vs 425.0 +/- 93.0 microg/ml, P<0.0001). Serum C-reactive protein concentration and erythrocyte sedimentation rate were inversely correlated, while albumin, hemoglobin and total cholesterol were positively correlated with AHSG. Current serum AHSG levels did not affect the presence of aortic calcification, whereas cumulative glucocorticoid dosage was significantly related to aortic calcification (P=0.005).

CONCLUSION

Serum AHSG levels were significantly decreased in patients with RA. The levels reflected inflammatory and malnutritional conditions. Its role in the development of cardiovascular diseases or inflammatory bone resorption remain uncertain in RA patients.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Acceleration of atherosclerosis during the course of rheumatoid arthritis

Patients with rheumatoid arthritis (RA) are predisposed to atherosclerosis and cardiovascular disease. This is thought to be caused in part, by exposure to chronic systemic inflammation during the course of the disease. We hypothesized that RA disease duration augments the effect of age on atherosclerosis. We measured the carotid artery intima-media thickness (IMT) in 631 consecutive RA patients. We ascertained age, sex and disease duration, established CV risk factors, RA clinical manifestations and markers of inflammation. We used multivariable regression to model IMT, with age as the independent variable. We then added RA duration quartile x age interaction terms to estimate the IMT-age relationship within RA duration strata. We found that the rate at which the IMT increased per unit of age steepened in proportion to the RA duration, from 0.154 mm/10 years among patients with RA for 7 years or less, to 0.295 mm/10 years among patients with RA for 20 years or more (P<or=0.001). None of the covariates effaced the significance of the age x RA duration product terms. Thus, patients with prolonged RA have more atherosclerosis than patients of the same age with more recent disease onset. This suggests that atherogenesis accelerates after the onset of RA. Systemic inflammation may amplify the age-related risk of CV disease.

[Rheumatoid arthritis and cardiovascular complications]

Rheumatoid arthritis is associated with increased morbidity and mortality due to cardiovascular events. Elevated concentrations of acute-phase proteins and cytokines and endothelial dysfunction, demonstrated also by lack of traditional risk factors, play an important role in these complications. Antirheumatic drug treatment can modify the frequency and severity of cardiovascular events.

Antirheumatic drug use and the risk of acute myocardial infarction

OBJECTIVE

To assess the risk of acute myocardial infarction (AMI) associated with the use of disease-modifying antirheumatic drugs (DMARDs) and other medications commonly used in rheumatoid arthritis (RA).

METHODS

We conducted a nested case-control analysis within a cohort of subjects with RA, observed between 1999 and 2003, identified from the PharMetrics claims database. For each first AMI hospitalization identified during followup, 10 controls matched on sex, age, and time of study entry were randomly selected from the cohort. Conditional logistic regression was used to estimate the rate ratio (RR) of AMI associated with the current use of anti-RA therapy, as measured from dispensed prescriptions, after adjustment for AMI risk factors.

RESULTS

The cohort included 107,908 subjects (average age 54 years at cohort entry). During followup, 558 AMI cases occurred (3.4 per 1,000 per year). AMI rate was significantly decreased with the current use of any DMARD (adjusted RR 0.80, 95% confidence interval [95% CI] 0.65-0.98). This effect was consistent across all DMARDs, including methotrexate (RR 0.81, 95% CI 0.60-1.08), leflunomide (RR 0.28, 95% CI 0.12-0.65), and other traditional DMARDs (RR 0.67, 95% CI 0.46-0.97), but not biologic agents (RR 1.30, 95% CI 0.92-1.83). AMI rate increased with the use of glucocorticoids (RR 1.32, 95% CI 1.02-1.72) but not with nonselective nonsteroidal antiinflammatory drugs (RR 1.05, 95% CI 0.81-1.36) or cyclooxygenase 2 (COX-2) inhibitors (RR 1.11, 95% CI 0.87-1.43).

CONCLUSION

DMARD use is associated with a reduction in AMI risk in patients with RA. No risk increase was found with the COX-2 inhibitors in this population.

Prevention of cardiovascular disease in patients with rheumatic diseases

Cardiovascular disease (CVD), the leading cause of death in the USA, has emerged as an important comorbidity in the rheumatic diseases. As disease-modifying therapies have resulted in better disease control and decreases in disease-associated mortality, it is now apparent that the prevalence of CVD and cardiovascular (CV) events is significantly increased in a number of rheumatic disorders when compared with age and gender-matched subjects from the general population. Investigations into the mechanisms of CVD in the general population have provided insights into potential mechanisms in rheumatic disease patients and possible aetiologies for their increased risk. Although there are no evidence-based guidelines for CV risk factor screening and interventions specific to patients with rheumatic disease, the best current approach utilizes evidence-based recommendations for the general population (and higher-risk subgroups) modified by what is known of CV risk factor and event prevalence in these patients.

Recommendations of the French Society for Rheumatology. TNFalpha antagonist therapy in rheumatoid arthritis

OBJECTIVES

To develop recommendations for TNFalpha-antagonist therapy in patients with rheumatoid arthritis (RA) seen in everyday practice, under the aegis of the French Society for Rheumatology.

METHOD

We used the methods recommended by the French Agency for Healthcare Accreditation and Evaluation, the AGREE collaboration, and the European League against Rheumatism (EULAR). The recommendations focus on patient selection, monitoring, and treatment adjustments.

RESULTS

Criteria for selecting patients eligible for TNFalpha-antagonist treatment of RA include: 1) a definitive diagnosis of RA; 2) disease activity for longer than 1 month, including presence of objective signs of inflammation; or radiographic progression; 3) previous failure of methotrexate in the highest tolerated dosage or of another disease-modifying antirheumatic drug in patients with contraindications to methotrexate; 4) absence of contraindications to TNFalpha-antagonist therapy. When starting TNFalpha-antagonist therapy 1) a thorough baseline evaluation should be conducted; 2) any of the three available agents can be used, as no differences in efficacy have been identified in patient populations; 3) concomitant methotrexate therapy is recommended regardless of the TNFalpha antagonist used; and 4) patients should receive standardized follow-up at regular intervals. Treatment adjustments should be based on the following: 1) the treatment objective is achievement of a EULAR response; 2) when such a response is not achieved, the dosage or dosing interval can be changed, or the patient can be switched to another TNFalpha antagonist; 3) in patients who experience intolerance to a TNFalpha antagonist, another TNFalpha antagonist may be tried, depending on the nature of the adverse event; 4) occurrence of a remission should lead to a reduction in symptomatic medications, most notably glucocorticoids where used; in the event of a prolonged remission, either the TNFalpha antagonist or the concomitant disease-modifying antirheumatic drug may be reduced.

CONCLUSION

These recommendations are intended to help physicians use TNFalpha antagonists in their everyday practice with RA patients. They do not constitute regulations.

Macrophage migration inhibitory factor and glucocorticoid sensitivity

Glucocorticoids (GCs) are widely used in the treatment of inflammatory diseases including rheumatoid arthritis (RA). Treatment with GC is associated with significant dose-dependent side-effects. The pro-inflammatory cytokine macrophage migration inhibitory factor (MIF) has emerged in recent years as a candidate factor which could regulate GC sensitivity. MIF is induced by GC, and is able to override anti-inflammatory actions of GCs. In this review, we summarize the pro-inflammatory actions of MIF with respect to RA, describe the interactions between MIF and GC and examine new evidence, which identifies MIF as a specific target for steroid sparing.

Cardiovascular involvement in rheumatoid arthritis

Cardiovascular (CV) disease morbidity and mortality are increased in patients with rheumatoid arthritis (RA) and much of the excess CV disease morbidity appears to be due to atherosclerosis. The pathogenesis of atherosclerosis (ATS) in RA is complex and there is increasing evidence that many factors including novel and traditional cardiovascular risk factors, RA treatments and the RA inflammatory disease process are involved in the development of CV disease in these patients. Of particular interest are the effects of chronic inflammation and immune dysregulation associated with RA. These have been shown to be associated with endothelial dysfunction, which is an early, potentially reversible, functional abnormality of the arterial wall. However, as several CV disease risk factors and drug prescribing are also influenced by RA disease severity it is very difficult to separate out the effects of the inflammatory disease burden on the cardiovascular system in RA.

Statins in rheumatology

Statins were developed for the treatment of lipid disorders and have been proved to reduce cardiovascular morbidity and mortality when used for primary or secondary prevention. Beneficial effects in patients with osteoporotic fractures or rheumatoid arthritis (RA) have been suggested but remain unproven. Cardiovascular morbidity and mortality are increased in patients with RA or systemic lupus erythematosus, who should undergo serum lipid assays. When these show dyslipidemia, statin therapy should be started according to current recommendations.

Update of tnf-alpha antagonists and cardiovascular disease in rheumatoid arthritis

Tumor necrosis factor-alpha (TNF-alpha) antagonists were unexpectedly found to have no beneficial effects in moderate-to-severe heart failure in two large randomized clinical trials. In certain doses, the agents were found to be harmful. These results have important implications for rheumatoid arthritis (RA). Patients with the disease have an increased risk for developing cardiovascular co-morbidity, including heart failure. Because of the beneficial effect of the TNF-alpha antagonists in the management of RA, these agents have gained widespread use. Rheumatologists and other physicians who provide care for RA are thus likely to encounter candidates for anti-TNF-alpha therapy who have overt or subclinical heart failure. Although data are currently not sufficient to support evidence-based recommendations, it is possible to make reasonable suggestions to guide clinical practice.

Disease modification and cardiovascular risk reduction: two sides of the same coin?

Inflammatory rheumatic diseases are associated with a substantial increase in accelerated atherosclerosis, with complex interactions between traditional and disease-related risk factors. Therefore, cardiovascular risk reduction should be considered as integral to the control of disease activity in the care plans of patients with RA, SLE and, arguably any chronic inflammatory disease. Shared care structures, already established for the monitoring of DMARDs, could be adapted to communicate and monitor cardiovascular risk reduction objectives. We review the evidence for the efficacy of a range of therapeutic strategies, the majority of which impact on both disease activity and cardiovascular risk. The algorithm proposed here attempts to distil the latest advice from specialist panels at the National Cholesterol Education Program and the British Hypertension Society, as well as incorporating the existing data on SLE and RA patients. The algorithm is structured to minimize clinic time and resources necessary to stratify patients into groups for ROUTINE, SUBSTANTIAL or INTENSIVE risk management; the associated table summarizes optimal therapeutic objectives in each of these groups. The implication of this algorithm is that management of cardiovascular risk should be much more aggressive than is currently the norm in patients with chronic inflammatory diseases, such as RA and SLE. Long-term studies of such interventions are needed to further clarify the benefits of intensive cardiovascular risk management in these patients.