Cardiovascular disease in rheumatoid arthritis

Effects of biologics on vascular function and atherosclerosis associated with rheumatoid arthritis

Endothelial dysfunction and accelerated atherosclerosis lead to increased cardiovascular morbidity and mortality in rheumatoid arthritis (RA). Sustained inflammation is a major risk factor. Apart from traditional vasculoprotective agents, biologics may also exert favorable effects on the vasculature. Indeed, tumor necrosis factor-alpha (TNF-alpha) inhibitors agents may transiently improve endothelial function. There are conflicting data regarding the effects of biologics on atherosclerosis and arterial stiffness. Infliximab stimulates the number and differentiation of endothelial progenitor cells that lead to vascular repair. There may be differences in the effects of TNF blockers on dyslipidemia, as long-term infliximab therapy may be proatherogenic, while some studies suggest that etanercept and adalimumab may exert beneficial effects on lipids. TNF blockers may decrease the incidence of cardiovascular events in RA. Preliminary data suggest that rituximab may also improve endothelial function and dyslipidemia. Further studies are needed to determine the net effects of biologics on the vasculature.

The vasculature in rheumatoid arthritis: cause or consequence?

The expansion of the synovial lining of joints in rheumatoid arthritis (RA) necessitates an increase in the vascular supply to the synovium, to cope with the increased requirement for oxygen and nutrients. New blood vessel formation -'angiogenesis'- is recognized as a key event in the formation and maintenance of the pannus in RA, suggesting that targeting blood vessels in RA may be an effective future therapeutic strategy. Although many pro-angiogenic factors have been demonstrated to be expressed in RA synovium, vascular endothelial growth factor (VEGF) has been demonstrated to a have a central involvement in the angiogenic process in RA. Nevertheless, it is unclear whether angiogenesis - whether driven by VEGF and/or other factors - should be considered as a 'cause' or 'consequence' of disease. This ongoing 'chicken vs. egg' debate is difficult, as even the success of angiogenesis inhibition in models of RA does not provide a direct answer to the question. This review will focus on the role of the vasculature in RA, and the contribution of different angiogenic factors in promoting disease. Although no data regarding the effectiveness of anti-angiogenic therapy in RA have been reported to date, the blockade of angiogenesis nevertheless looks to be a promising therapeutic avenue.

Non-invasive assessment of coronary flow reserve and ADMA levels: a case-control study of early rheumatoid arthritis patients

OBJECTIVE

Plasma concentration of asymmetric dimethylarginine (ADMA), a major endogenous inhibitor of nitric oxide synthase, is considered a novel risk factor for endothelial dysfunction associated with enhanced atherosclerosis. Coronary microcirculation abnormalities have been demonstrated in patients with early rheumatoid arthritis (ERA) without any signs or symptoms of coronary artery disease (CAD). The aim of the study was to compare the ERA and control groups with ADMA, intima-media thickness (IMT) and coronary flow reserve (CFR) levels. It assessed whether ERA patients have more cardiovascular risk (endothelial dysfunction and coronary microvascular abnormalities), and evaluated whether any difference in IMT/CFR between ERA and controls can be explained by any difference in ADMA levels between the groups.

METHODS

The study involved 25 ERA patients (female/male 21/4; mean age 52.04 +/- 14.05 years; disease duration <or=12 months) and 25 healthy volunteers with no history or current signs of CAD or other traditional risk factors. Dipyridamole trans-thoracic stress echocardiography was preformed to evaluate CFR, and carotid ultrasound to measure the IMT of the common carotid arteries. Blood samples were obtained in order to assess ADMA levels before the patients had received any biological or non-biological DMARDs, or steroid therapy.

RESULTS

CFR was significantly reduced in the ERA patients (2.5 +/- 0.5 vs 3.5 +/- 0.8; P <0.01). In particular, 6/25 (24%) had a CFR of <2 consistent with potentially dangerous coronary flow impairment. Common carotid IMT was significantly greater in the ERA patients, although still within the normal range (0.68 +/- 0.1 vs 0.56 +/- 0.11 mm; P <0.01). There was a significant correlation between CFR and plasma ADMA levels in the ERA population (r = -0.53; P <0.01). IMT was negatively associated with CFR (P <0.05).

CONCLUSIONS

Plasma ADMA levels were significantly higher in the ERA patients. A statistically significant negative effect of ADMA levels on CFR value was observed. The effect of ADMA levels on IMT is not significant.

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.

Rheumatoid arthritis: a female challenge

Rheumatoid arthritis (RA) is two- to three-fold more frequent in women than in men and a strong association with sex hormones has been demonstrated. There is strong evidence that autoimmunity is under genetic control, and genes in sexual chromosomes can play a role in supporting the female prevalence. On the other hand, it is widely accepted that sex hormones--estrogens in particular--may regulate the immune response by favoring the survival of forbidden autoreactive clones and ultimately the prevalence of autoimmunity in women. Accordingly, estrogens have been suggested to be associated with the development of RA. Pregnancy in RA women is a common situation and most pregnant patients experience a remission. This has been closely related to a switch from Th1 to Th2 immune responses and to a decreased production of proinflammatory cytokines, at least in part supported by the changes of the hormonal profile in pregnancy. Pregnancy planning is required in RA in order to avoid unwanted complications. In particular, the need to control the disease requires safe use of antirheumatic drugs both during the pregnancy itself and in the breastfeeding period. Hormonal treatment for contraception is contraindicated in the case of positivity for antiphospholipid antibodies owing to the increased thrombophilic risk. Similarly, replacement hormonal treatment in postmenopausal women with RA to control osteoporosis is no longer recommended as a result of its ability to increase the cardiovascular risk closely associated with RA itself.

Hidden Cost of Rheumatoid Arthritis (RA): Estimating Cost of Comorbid Cardiovascular Disease and Depression Among Patients with RA

Objective.

To examine resource utilization and direct healthcare cost associated with comorbid cardiovascular disease (CVD) and depression among patients with prevalent rheumatoid arthritis (RA) based on analyses of retrospective healthcare claims data.

Methods.

The index date was set as the first observed claim with an RA diagnosis. Patients were required to be ≥ 18 years of age, to have received RA-related treatment during the pre-index period, and to have 12-month pre- and post-index data. Based on pre-index utilization, patients were classified into 4 diagnosis groups: RA alone, RA + CVD, RA + depression, and RA + CVD + depression. Analyses focused on annual differences in costs between patients with RA alone and those with CVD and/or depression. A generalized linear model was applied to control for demographic and clinical characteristics and to estimate cohort-specific adjusted mean annual healthcare cost.

Results.

Of 10,298 patients, 8,916 had RA alone (86.6%), 608 had RA + CVD (5.9%), 716 had RA + depression (7.0%), and 58 had RA + CVD + depression (0.5%). All patients with CVD and/or depression incurred significantly higher followup costs compared with patients with RA alone. Adjusted annual mean healthcare costs were highest for RA + CVD (US$14,145), followed by RA + CVD + depression ($13,513), RA + depression ($12,225), and RA alone ($11,404). Although patients with CVD and/or depression had a greater rate of RA-related hospitalization, adjusted RA-related healthcare costs did not reflect any statistically significant differences as compared to the RA-alone cohort.

Conclusion.

A significant proportion (13.4%) of patients with prevalent RA have comorbid CVD and/or depression. The presence of these conditions significantly affects annual healthcare costs as well as specific RA-related utilization patterns.

High HDL-cholesterol in women with rheumatoid arthritis on low-dose glucocorticoid therapy

BACKGROUND

Dyslipidaemia has been described in non-treated rheumatoid arthritis (RA), and improves after therapy with disease modifying anti-rheumatic drugs or glucocorticoids; however, it has generally been perceived that glucocorticoids adversely affect lipid metabolism. The association of low dose glucocorticoid therapy with plasma lipid levels was evaluated in female RA patients.

MATERIALS AND METHODS

A cross-sectional study was conducted in 78 female RA patients [mean age: 60 (12) years; mean disease duration: 13 (9) years]. Sixty-five (83%) were on glucocorticoid therapy [total equivalent mean prednisone dose: 5.1 (1.7) mg d(-1)]. Each patient was assessed through a self-reported questionnaire, structured interview and physical examination. Blood samples were obtained for routine biochemistry, lipid profile and haematological tests. Lipid profiles of RA patients who were and were not on glucocorticoid therapy were compared.

RESULTS

Clinical and laboratory features of the two groups of patients were similar, except for the Health Assessment Questionnaire and body mass index, which were significantly higher in the patients on glucocorticoid therapy. These patients had 14.7% higher serum high-density lipoprotein cholesterol (HDL-c) levels than untreated patients (P = 0.043), mainly at the expense of HDL2 subfraction, which was 24.4% higher (P < 0.039), whereas HDL3-c was only 7.4% higher (P = 0.219). Serum levels of glucose and total cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL -c), very low-density lipoprotein cholesterol, apolipoproteins A-I and B were not increased in patients on glucocorticoid therapy.

CONCLUSIONS

Low dose glucocorticoid therapy in RA patients is associated with an increase in HDL-c, without increasing LDL-c or triglyceride. These lipid changes may overall be considered favourable.

Association among rheumatoid arthritis, oral hygiene, and periodontitis

BACKGROUND

A limited number of studies suggest a higher prevalence of periodontal disease among individuals with rheumatoid arthritis (RA); however, results have been inconsistent. Further, it is unclear to what extent poor oral hygiene among patients with RA may account for this association.

METHODS

The association between RA and periodontitis was examined in 57 subjects with RA and 52 healthy controls, matched by age and gender. Oral examination included plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (CAL). Potential risk factors for periodontal disease, such as smoking, education, alcohol consumption, and body mass index (BMI), as well as chronic diseases associated with RA and periodontal disease were assessed through questionnaires.

RESULTS

In a stepwise logistic regression, including RA status, age, gender, education, smoking, alcohol consumption, and BMI, only RA status and age remained significant predictors of periodontal disease. Subjects with RA had a significant 8.05-fold increased odds (95% confidence interval: 2.93 to 22.09) of periodontitis compared to controls. The strength of the association was attenuated but remained statistically significant after further adjustment for PI, GI, or both. PI alone accounted for 12.4%, GI alone accounted for 11.1%, and PI and GI combined accounted for 13.4% of the association between RA and periodontitis.

CONCLUSIONS

Subjects with RA have significantly increased periodontal attachment loss compared to controls. Oral hygiene may only partially account for this association.

Inhibition of Interleukin-1 by Anakinra Improves Vascular and Left Ventricular Function in Patients With Rheumatoid Arthritis

Background— Interleukin-1 increases nitrooxidative stress. We investigated the effects of a human recombinant interleukin-1a receptor antagonist (anakinra) on nitrooxidative stress and vascular and left ventricular function.

Methods and Results— In an acute, double-blind trial, 23 patients with rheumatoid arthritis were randomized to receive a single injection of anakinra (150 mg SC) or placebo and, after 48 hours, the alternative treatment. At baseline and 3 hours after the injection, we assessed (1) coronary flow reserve, aortic distensibility, systolic and diastolic (Em) velocity of the mitral annulus, and E to Em ratio (E/Em) using echocardiography; (2) flow-mediated, endothelium-dependent dilation of the brachial artery; and (3) malondialdehyde, nitrotyrosine, interleukin-6, endothelin-1, and C-reactive protein. In a chronic, nonrandomized trial, 23 patients received anakinra and 19 received prednisolone for 30 days, after which all indices were reassessed. Compared with baseline, there was a greater reduction in malondialdehyde, nitrotyrosine, interleukin-6, and endothelin-1 and a greater increase in flow-mediated dilation, coronary flow reserve, aortic distensibility, systolic velocity of mitral annulus, and E/Em after anakinra than after placebo (malondialdehyde −25% versus 9%; nitrotyrosine −38% versus −11%; interleukin-6 −29% versus 0.9%; endothelin-1 −36% versus −11%; flow-mediated dilation 45% versus −9%; coronary flow reserve 29% versus 4%; and aortic distensibility 45% versus 2%; P <0.05 for all comparisons). After 30 days of treatment, the improvement in biomarkers and in vascular and left ventricular function was greater in the anakinra group than in the prednisolone group ( P <0.05).

Conclusions— Interleukin-1 inhibition improves vascular and left ventricular function and is associated with reduction of nitrooxidative stress and endothelin.

Cardiovascular disease in patients with rheumatoid arthritis: results from the QUEST-RA study

Introduction

We analyzed the prevalence of cardiovascular (CV) disease in patients with rheumatoid arthritis (RA) and its association with traditional CV risk factors, clinical features of RA, and the use of disease-modifying antirheumatic drugs (DMARDs) in a multinational cross-sectional cohort of nonselected consecutive outpatients with RA (The Questionnaires in Standard Monitoring of Patients with Rheumatoid Arthritis Program, or QUEST-RA) who were receiving regular clinical care.

Methods

The study involved a clinical assessment by a rheumatologist and a self-report questionnaire by patients. The clinical assessment included a review of clinical features of RA and exposure to DMARDs over the course of RA. Comorbidities were recorded; CV morbidity included myocardial infarction, angina, coronary disease, coronary bypass surgery, and stroke. Traditional risk factors recorded were hypertension, hyperlipidemia, diabetes mellitus, smoking, physical inactivity, and body mass index. Unadjusted and adjusted hazard ratios (HRs) (95% confidence interval [CI]) for CV morbidity were calculated using Cox proportional hazard regression models.

Results

Between January 2005 and October 2006, the QUEST-RA project included 4,363 patients from 48 sites in 15 countries; 78% were female, more than 90% were Caucasian, and the mean age was 57 years. The prevalence for lifetime CV events in the entire sample was 3.2% for myocardial infarction, 1.9% for stroke, and 9.3% for any CV event. The prevalence for CV risk factors was 32% for hypertension, 14% for hyperlipidemia, 8% for diabetes, 43% for ever-smoking, 73% for physical inactivity, and 18% for obesity. Traditional risk factors except obesity and physical inactivity were significantly associated with CV morbidity. There was an association between any CV event and age and male gender and between extra-articular disease and myocardial infarction. Prolonged exposure to methotrexate (HR 0.85; 95% CI 0.81 to 0.89), leflunomide (HR 0.59; 95% CI 0.43 to 0.79), sulfasalazine (HR 0.92; 95% CI 0.87 to 0.98), glucocorticoids (HR 0.95; 95% CI 0.92 to 0.98), and biologic agents (HR 0.42; 95% CI 0.21 to 0.81; P < 0.05) was associated with a reduction of the risk of CV morbidity; analyses were adjusted for traditional risk factors and countries.

Conclusion

In conclusion, prolonged use of treatments such as methotrexate, sulfasalazine, leflunomide, glucocorticoids, and tumor necrosis factor-alpha blockers appears to be associated with a reduced risk of CV disease. In addition to traditional risk factors, extra-articular disease was associated with the occurrence of myocardial infarction in patients with RA.

Factors that impact decision making among rheumatologists in the initiation of treatment for hypertension in rheumatoid arthritis

BACKGROUND

Increased risks of morbidity and mortality from cardiovascular (CV) events are reported in patients with rheumatoid arthritis (RA). Recent reviews recommend aggressive treatment of modifiable CV risk factors, including systemic hypertension (HTN).

OBJECTIVES

We examined possible contributory factors influencing HTN treatment among RA patients by rheumatologists.

METHODS

We conducted a cross-sectional 36-item survey of randomly chosen rheumatologists from the American College of Rheumatology directory collecting the rheumatologists' demographics, practice, and perceptions regarding HTN treatment in their RA patients. Our response variable was initiation of HTN treatment. Independent variables were derived from responses to the survey, and data were analyzed using bivariate analysis and logistic regression.

RESULTS

Of 938 rheumatologists surveyed, 285 (30%) responded, 236 were subsequently analyzed. Respondents' mean age was 52.8 years; 75% were male and most were white (83%). Respondents reported routinely screening for HTN (92.8%), and initiating treatment for HTN (31%) in RA patients. Rheumatologists who believed that their RA patients did not have adequate visits with their primary care providers (PCP) were 2.2 times as likely to initiate treatment for HTN (41.1% vs. 24.3%; P = 0.006). Conversely, 33% of rheumatologists who did not routinely initiate treatment for HTN in their RA patients also did not believe patient access to PCP care was adequate. No associations were observed between initiation of HTN treatment and physician demographic or practice items.

CONCLUSION

The need for more effective minimization of CV risks in RA patients should prompt rheumatologists to consider a revision of routine practice standards to include treatment of uncontrolled HTN or promotion of improved communication with their PCPs.

Comorbidities in rheumatoid arthritis

Rheumatoid arthritis (RA) is often characterized by the burden of swollen joints, pain, and decreased physical function, but less understood are the many manifestations of additional health conditions that are associated with RA and its treatments. First brought to light with observations of increased mortality in RA, studies noted the increased rates of cardiovascular and infection events. The chronic, debilitating, autoimmune nature of RA affects the patient directly or indirectly in almost all organ systems, from cardiovascular problems and infections to depression and gastrointestinal ulcers. On average, the established RA patient has two or more comorbid conditions. It should be the responsibility of the rheumatologist to take these and the risk of additional conditions into account when treating the patient. This chapter reviews important comorbidities in patients with RA, their prevalence, and their relation to RA.

The effect of infliximab treatment on insulin resistance in patients with rheumatoid arthritis

AIM

It is well known that increased insulin resistance is associated with the development of cardiovascular disease in patients with rheumatoid arthritis and that tumour necrosis factor-alpha plays an important role in this process. Infliximab is a chimeric monoclonal anti-tumour necrosis factor-alpha antibody. This study investigates the effects of long term infliximab treatment on insulin resistance in patients with rheumatoid arthritis.

MATERIALS AND METHODS

Seven rheumatoid arthritis patients (6 female and 1 male; mean age: 44.6 +/- 12.3, mean duration of disease: 6.8 y) for whom infliximab treatment had been planned at the rheumatology and internal medicine clinics were included. Patients were evaluated during and at the end of the study with a mean follow-up duration of 9.6 months. Fasting plasma glucose, fasting plasma insulin levels and serum lipid profile were assessed at baseline and throughout the treatment period (prior to every infusion). Homeostasis Model Assessment of Insulin Resistance model was used for the assessment of insulin sensitivity.

RESULTS

Fasting insulin and Homeostasis Mode Assessment of Insulin Resistance levels decreased after treatment (from 19.4 +/- 7.7 microU/ml to 8.9 +/- 4.1 microU/ml and from 2.4 +/- 1 to 1.1 +/- 0.5, respectively; p < 0.05 for both). No significant change was observed in other parameters.

CONCLUSION

An improvement in insulin sensitivity was observed in patients receiving long term infliximab treatment for rheumatoid arthritis.

Accelerated Atherosclerosis in Rheumatoid Arthritis

Cardiovascular disease is a leading cause of mortality in rheumatoid arthritis (RA). Endothelial dysfunction often precedes manifest atherosclerosis. Both traditional, Framingham risk factors and inflammation-associated factors are involved in RA-associated atherosclerosis. Among imaging techniques, the early determination of common carotid intima-media thickness (ccIMT), flow-mediated vasodilation (FMD), and nitroglycerine-mediated vasodilation (NMD) may be useful to determine atherosclerosis and endothelial dysfunction. We and others found increased ccIMT and impaired FMD in RA patients. Among immunological and metabolic laboratory markers, anticyclic citrullinated peptide (anti-CCP) antibodies, IgM rheumatoid factor, circulating immune complexes, pro-inflammatory cytokines including tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6), Th0/Th1 T cells, homocysteine, dyslipidemia, decreased folate and vitamin B12 production, and impaired paraoxonase activity may all be involved in the development of vascular disease in RA. The early diagnosis of endothelial dysfunction and atherosclerosis, active immunosuppressive treatment, the use of drugs that control atherosclerosis, changes in sedentary lifestyle, and the close follow-up of RA patients may help to minimize cardiovascular risk in these individuals.

Stress, visceral obesity, and metabolic complications

Stress is a state of threatened homeostasis or disharmony caused by intrinsic or extrinsic adverse forces and is counteracted by an intricate repertoire of physiologic and behavioral responses that aim to reestablish the challenged body equilibrium. The adaptive stress response depends upon an elaborate neuroendocrine, cellular, and molecular infrastructure, the stress system. Crucial functions of the stress system response are mediated by the hypothalamic-pituitary-adrenal (HPA) axis and the central and peripheral components of the autonomic nervous system (ANS). The integrity of the HPA axis and the ANS and their precise interactions with other CNS components are essential for a successful response to the various stressors. Chronic stress represents a prolonged threat to homeostasis by persistent or frequently repeated stressors and may lead to manifestations that characterize a wide range of diseases and syndromes. Such states progressively lead to a deleterious overload with complications caused by both the persistent stressor and the detrimental prolongation of the adaptive response. The metabolic syndrome can be described as a state of deranged metabolic homeostasis characterized by the combination of central obesity, insulin resistance, dyslipidemia, and hypertension. The incidence of both obesity and the metabolic syndrome in modern Western societies has taken epidemic proportions over the past decades and often correlates with indices of stress in the affected populations. Stress, primarily through hyperactivation of the HPA axis, appears to contribute to the accumulation of fat tissue, and vice versa, obesity itself seems to constitute a chronic stressful state and may cause HPA axis dysfunction. In addition, the description of obesity as a systemic low grade inflammatory condition that contributes to the derangement of the metabolic equilibrium implies that the proinflammatory cytokines which are secreted by the adipocytes hold a potentially important pathogenetic role. In this article we describe the physiology of the stress system response, with emphasis on metabolism, and review the recent data that implicate several neuroendocrine and inflammatory mechanisms mobilized during chronic stress in the development of the metabolic complications that characterize central obesity and the metabolic syndrome.

Progressive and Concordant Expression of PKC-η and iNOS Phenotypes in Monocytes From Patients With Rheumatoid Arthritis: Association With Disease Severity

Rheumatoid arthritis (RA) is a relatively common autoimmune disease with strong genetic and environmental determinants. The disease manifests itself as inflammation of the synovia and usually progresses to joint erosion and destruction. The disease can also be considered as a systemic disease because extra-articular manifestations are often observed throughout many organs and tissues of the body. Patients with severe RA have altered peripheral blood monocytes (PBM) that express activation markers. Two such markers, PKC-η and iNOS, were studied using confocal laser scanning microscopy to determine how these markers are expressed during disease progression. Healthy individuals expressed neither of the two markers, but there was an elevated level of PKC-η observed as the disease progressed (40% in mild RA and 100% in severe RA patients). Concordant expression of the two markers was observed in only 3% of PBM from mild RA patients, reaching 38% in severe RA patients. No cells expressing iNOS alone were observed in any of the patients studied. These data support the hypothesis linking PKC-η expression with the regulation and predisposition to the development of the iNOS phenotype in severe RA patients. PKC-η may therefore be a key regulator in the production of elevated plasma nitric oxide (NO) and corresponding circulating reactive nitrogen intermediates in severe RA and may be a possible target to regulate iNOS induction and NO production by monocytic cells in RA patients and possibly other inflammatory diseases.

Inflammatory rheumatic disease and smoking are predictors of aortic inflammation: A controlled study of biopsy specimens obtained at coronary artery surgery

OBJECTIVE

Several inflammatory rheumatic diseases are associated with accelerated atherosclerosis. Atherosclerosis may result from systemic and/or local vascular inflammation. The aim of this study was to evaluate the occurrence of chronic inflammatory infiltrates in the aortas of patients with and those without inflammatory rheumatic disease who had undergone coronary artery bypass graft (CABG) surgery, and to assess the relationship between the infiltrates and other factors thought to play a role in atherosclerosis, such as smoking.

METHODS

Aortic specimens routinely removed during CABG surgery in 66 consecutive patients with inflammatory rheumatic disease and 51 control patients without inflammatory rheumatic disease were examined by light microscopy for the occurrence, location, and severity of chronic inflammatory infiltrates and atherosclerotic lesions.

RESULTS

Mononuclear cell infiltrates in the inner adventitia (apart from those localized along the epicardium) were more frequent in the group of patients with inflammatory rheumatic disease (47% versus 20%; P = 0.002, odds ratio [OR] OR 3.6, 95% confidence interval [95% CI] 1.6-8.5), and the extent of these infiltrates was greater. Multivariate analyses revealed that the occurrence of mononuclear cell infiltrates was associated with inflammatory rheumatic disease (OR 2.99, P = 0.020) and current smoking (OR 3.93, P = 0.012), and they were observed in 6 of 7 patients with a history of aortic aneurysm. Inflammatory infiltrates in the media were seen only in patients with inflammatory rheumatic disease. The frequency of atherosclerotic lesions, inflammation within the plaques, and epicardial inflammatory infiltrates in the 2 groups was equal.

CONCLUSION

Among aortic samples collected during CABG surgery, those obtained from patients with inflammatory rheumatic disease had more pronounced chronic inflammatory infiltration in the media and inner adventitia than those obtained from control patients. Current smoking was an independent predictor of chronic inner adventitial infiltrates. The infiltrates may represent an inflammatory process that promotes atherosclerosis and formation of aneurysms.

Interleukin-18 as a potential therapeutic target in chronic autoimmune/inflammatory conditions

Interleukin-18 (IL-18), a recently identified immunoregulatory and inflammatory cytokine, has attracted a profound interest as a potential therapeutic target in autoimmune/inflammatory disorders. In this review the authors focus on: IL-18 biology as an important link between innate and adaptive immunity; evidence of its pro-inflammatory role in several human autoimmune and chronic inflammatory disorders; and data indicating that IL-18 blockade in animal models results in prevention/amelioration of the disease process and preservation of the target tissue integrity and function. Finally, the authors analyse strategies presently under development to block IL-18 function and potential pitfalls resulting from IL-18 blockade that should be considered in ongoing/future clinical trials.

Inflammatory response after influenza vaccination in men with and without carotid artery disease

OBJECTIVE

Inflammatory markers are associated with vascular disease; however, variation in the acute phase response (APR) has not been evaluated. We evaluated whether the APR magnitude in men with severe carotid artery disease (CAAD) (>80% stenosis) differed from that of men without stenosis (<15% stenosis).

METHODS AND RESULTS

White males with (n=43) and without (n=61) severe CAAD receiving clinical influenza vaccinations were recruited. Their baseline and 24-hour after -vaccination blood samples were assayed for C-reactive protein (CRP), IL-6, and serum amyloid-a (SAA). In vivo APR to vaccination was measurable and varied among subjects. Adjusted for age, smoking, oral hypoglycemics, aspirin, and stain use, the relative 24-hour changes in levels of ln(CRP), ln(IL-6), and ln(SAA) were higher in men with CAAD than in men without, but only the SAA response was significant (P=0.02); the relative SAA response was 1.6 (95% confidence interval, 1.1 to 2.5) times higher in men with than without CAAD. The APR for all markers appeared to be independent of baseline levels.

CONCLUSIONS

Influenza vaccination results in a mild, but measurable, APR in men with and without CAAD. SAA APR variability may be a predictor of severe vascular disease that is independent of basal SAA level.

Human telomere biology: pitfalls of moving from the laboratory to epidemiology

Remarkable progress has been made during the last 2 decades in understanding telomere biology at the molecular and cellular levels. Clinical epidemiology research of human telomeres, in contrast, is a discipline just coming into its own. The most important observation in studying human telomere biology is that telomere length is highly variable among humans. Here we explain some of the reasons for this variability and propose several principles that should be considered in conducting epidemiological telomere research. Ignoring these principles could lead to misleading conclusions.