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Mitchell AJ, Alexy T, Rubinsztain L, Iqbal A, Shah A, Zafari M, Searles CD. Rheumatoid Arthritis Presenting as Acute Myopericarditis. Am J Med 2016; 129:e17-8. [PMID: 26797082 PMCID: PMC5125546 DOI: 10.1016/j.amjmed.2015.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 12/18/2015] [Accepted: 12/21/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Adam J. Mitchell
- Division of Cardiology, Department of Medicine, Emory University
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, Emory University
| | - Leon Rubinsztain
- Division of Rheumatology, Department of Medicine, Emory University
| | - Ayesha Iqbal
- Division of Rheumatology, Department of Medicine, Emory University
| | - Amit Shah
- Division of Cardiology, Department of Medicine, Emory University
| | - Maziar Zafari
- Division of Cardiology, Department of Medicine, Emory University
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Zegkos T, Kitas G, Dimitroulas T. Cardiovascular risk in rheumatoid arthritis: assessment, management and next steps. Ther Adv Musculoskelet Dis 2016; 8:86-101. [PMID: 27247635 DOI: 10.1177/1759720x16643340] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rheumatoid arthritis (RA) is associated with increased cardiovascular (CV) morbidity and mortality which cannot be fully explained by traditional CV risk factors; cumulative inflammatory burden and antirheumatic medication-related cardiotoxicity seem to be important contributors. Despite the acknowledgment and appreciation of CV disease burden in RA, optimal management of individuals with RA represents a challenging task which remains suboptimal. To address this need, the European League Against Rheumatism (EULAR) published recommendations suggesting the adaptation of traditional risk scores by using a multiplication factor of 1.5 if two of three specific criteria are fulfilled. Such guidance requires proper coordination of several medical specialties, including general practitioners, rheumatologists, cardiologists, exercise physiologists and psychologists to achieve a desirable result. Tight control of disease activity, management of traditional risk factors and lifestyle modification represent, amongst others, the most important steps in improving CV disease outcomes in RA patients. Rather than enumerating studies and guidelines, this review attempts to critically appraise current literature, highlighting future perspectives of CV risk management in RA.
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Affiliation(s)
- Thomas Zegkos
- First Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - George Kitas
- Arthritis Research UK Epidemiology Unit, School of Translational Medicine, University of Manchester, Manchester, UK
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokratio Hospital, 49 Konstantinoupoleos Str, 54642 Thessaloniki, Greece
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Cardiovascular magnetic resonance in rheumatology: Current status and recommendations for use. Int J Cardiol 2016; 217:135-48. [PMID: 27179903 DOI: 10.1016/j.ijcard.2016.04.158] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/25/2016] [Indexed: 01/14/2023]
Abstract
Targeted therapies in connective tissue diseases (CTDs) have led to improvements of disease-associated outcomes, but life expectancy remains lower compared to general population due to emerging co-morbidities, particularly due to excess cardiovascular risk. Cardiovascular magnetic resonance (CMR) is a noninvasive imaging technique which can provide detailed information about multiple cardiovascular pathologies without using ionizing radiation. CMR is considered the reference standard for quantitative evaluation of left and right ventricular volumes, mass and function, cardiac tissue characterization and assessment of thoracic vessels; it may also be used for the quantitative assessment of myocardial blood flow with high spatial resolution and for the evaluation of the proximal coronary arteries. These applications are of particular interest in CTDs, because of the potential of serious and variable involvement of the cardiovascular system during their course. The International Consensus Group on CMR in Rheumatology was formed in January 2012 aiming to achieve consensus among CMR and rheumatology experts in developing initial recommendations on the current state-of-the-art use of CMR in CTDs. The present report outlines the recommendations of the participating CMR and rheumatology experts with regards to: (a) indications for use of CMR in rheumatoid arthritis, the spondyloarthropathies, systemic lupus erythematosus, vasculitis of small, medium and large vessels, myositis, sarcoidosis (SRC), and scleroderma (SSc); (b) CMR protocols, terminology for reporting CMR and diagnostic CMR criteria for assessment and quantification of cardiovascular involvement in CTDs; and (c) a research agenda for the further development of this evolving field.
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Mavrogeni SI, Poulos G, Sfikakis PP, Kitas GD, Kolovou G, Theodorakis G. Is there a place for cardiovascular magnetic resonance conditional devices in systemic inflammatory diseases? Expert Rev Cardiovasc Ther 2016; 14:677-82. [DOI: 10.1586/14779072.2016.1154458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Mackey RH, Kuller LH, Deane KD, Walitt BT, Chang YF, Holers VM, Robinson WH, Tracy RP, Hlatky MA, Eaton C, Liu S, Freiberg MS, Talabi MB, Schelbert EB, Moreland LW. Rheumatoid Arthritis, Anti-Cyclic Citrullinated Peptide Positivity, and Cardiovascular Disease Risk in the Women's Health Initiative. Arthritis Rheumatol 2015; 67:2311-22. [PMID: 25988241 PMCID: PMC4551571 DOI: 10.1002/art.39198] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 05/05/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the incidence of cardiovascular disease (CVD) morbidity and mortality over the course of 10 years among the more than 160,000 postmenopausal women in the Women's Health Initiative (WHI) in relation to self-reported rheumatoid arthritis (RA), taking disease-modifying antirheumatic drugs (DMARDs), anti-cyclic citrullinated peptide (anti-CCP) positivity, rheumatoid factor (RF) positivity, CVD risk factors, joint pain, and inflammation (white blood cell count and interleukin-6 levels). METHODS Anti-CCP and RF were measured in a sample of WHI participants with self-reported RA (n = 9,988). RA was classified as self-reported RA plus anti-CCP positivity and/or taking DMARDs. Anti-CCP-negative women with self-reported RA and not taking DMARDs were classified as having "unverified RA." RESULTS Age-adjusted rates of coronary heart disease (CHD), stroke, CVD, fatal CVD, and total mortality were higher in women with RA than in women with no reported RA, with multivariable-adjusted hazard ratios of 1.46 (95% confidence interval [95% CI] 1.17-1.83) for CHD and 2.55 (95% CI 1.86-3.51) for fatal CVD. Among women with RA, anti-CCP positivity and RF positivity were not significantly associated with higher risk of any outcomes, despite slightly higher risk of death for those who were anti-CCP positive than for those who were anti-CCP negative. Joint pain severity and CVD risk factors were strongly associated with CVD risk, even in women with no reported RA. CVD incidence was increased in women with RA versus women with no reported RA at almost all risk factor levels, except for low levels of joint pain or inflammation. Among women with RA, inflammation was more strongly associated with fatal CVD and total mortality than with CHD or CVD. CONCLUSION Among postmenopausal women, RA was associated with 1.5-2.5-fold higher CVD risk. CVD risk was strongly associated with CVD risk factors, joint pain severity, and inflammation, but not with anti-CCP positivity or RF positivity.
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Affiliation(s)
| | | | | | | | | | | | - William H. Robinson
- Stanford University, Stanford, CA, and VA Palo Alto Health Care System, Palo Alto, CA
| | | | | | | | | | - Matthew S. Freiberg
- Vanderbilt University School of Medicine, and Nashville Veterans Affairs Medical Center, Nashville, TN
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Ntusi NA, Piechnik SK, Francis JM, Ferreira VM, Matthews PM, Robson MD, Wordsworth PB, Neubauer S, Karamitsos TD. Diffuse Myocardial Fibrosis and Inflammation in Rheumatoid Arthritis. JACC Cardiovasc Imaging 2015; 8:526-536. [DOI: 10.1016/j.jcmg.2014.12.025] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 12/15/2014] [Accepted: 12/17/2014] [Indexed: 01/18/2023]
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Deciphering Cardiovascular Disease in Systemic Inflammatory Diseases Using Advanced Magnetic Resonance Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kobayashi Y, Kobayashi H, Hirano M, Giles JT. Left ventricular regional dysfunction using cardiac magnetic resonance imaging in rheumatoid arthritis patients without cardiac symptoms: comparison between methotrexate and biologics treatment groups. J Rheumatol 2015; 41:1560-2. [PMID: 24986967 DOI: 10.3899/jrheum.121363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yasuyuki Kobayashi
- Assistant Professor, Department of Radiology, St. Marianna University School of Medicine, Kawasaki
| | | | - Masaharu Hirano
- Division of Cardiology, Tokyo Medical School of Medicine, Tokyo, Japan
| | - Jon T Giles
- Assistant Professor, Division of Rheumatology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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Adlan AM, Panoulas VF, Smith JP, Fisher JP, Kitas GD. Association between corrected QT interval and inflammatory cytokines in rheumatoid arthritis. J Rheumatol 2015; 42:421-8. [PMID: 25593223 DOI: 10.3899/jrheum.140861] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Corrected QT (QTc) interval predicts all-cause and cardiovascular mortality and may contribute to the increased mortality risk in rheumatoid arthritis (RA). Animal experiments have shown that proinflammatory cytokines [tumor necrosis factor (TNF)-α and interleukin 1 (IL-1)] can prolong cardiomyocyte action potential. We sought to determine whether elevations in circulating inflammatory cytokines were independently associated with QTc prolongation in patients with RA. METHODS One hundred twelve patients [median age 62 (interquartile range 17) yrs; 80 women (71%)] from a well-characterized RA cohort underwent baseline 12-lead electrocardiograms for QT interval measurement and contemporary blood sampling to assess concentrations of inflammatory markers including C-reactive protein (CRP), TNF-α, and interleukins (IL-1α, IL-1β, IL-6, IL-10). QTc was calculated using the Bazett (QTBAZ = QT ÷ √RR) and Framingham Heart Study (QTFHS = QT + 0.154 × [1 - RR]) heart rate correction formulas. RESULTS Inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-10) were positively correlated with QTBAZ (Spearman rank correlation coefficient rho = 0.199, 0.210, 0.222, 0.333; all p < 0.05). In multivariable regression analysis, these associations were all confounded by age except IL-10, where higher tertile groups were independently and positively associated with QTBAZ (β = 0.202, p = 0.023) and QTFHS (β = 0.223, p = 0.009) when compared to the lower tertile. CRP (per unit increase) was independently associated with QTBAZ (β = 0.278, p = 0.001), but not QTFHS. CONCLUSION To our knowledge, ours is the first study demonstrating a contemporary link between inflammatory cytokines and QT interval in humans. Our results suggest that a lower inflammatory burden may protect against QTc prolongation in patients with RA. However, further studies are required to confirm the effects of pro- and antiinflammatory cytokines on QTc interval.
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Affiliation(s)
- Ahmed M Adlan
- From the College of Life and Environmental Sciences, University of Birmingham, Birmingham; Imperial College London, National Heart and Lung Institute, South Kensington Campus, London; and the Department of Rheumatology, Dudley Group of Hospitals National Health Service (NHS) Trust, Russells Hall Hospital, Dudley, UK.A.M. Adlan, MBBS, MRCP, College of Environmental Sciences; J.P. Fisher, BSc (Hons), PhD, College of Life and Environmental Sciences, University of Birmingham; V.F. Panoulas, MD, PhD, Imperial College London, National Heart and Lung Institute, Department of Rheumatology, Dudley Group of Hospitals NHS Trust; J.P. Smith, BSc (Hons), MSc; G.D. Kitas, MD, PhD, FRCP, Department of Rheumatology, Dudley Group of Hospitals NHS Trust.
| | - Vasileios F Panoulas
- From the College of Life and Environmental Sciences, University of Birmingham, Birmingham; Imperial College London, National Heart and Lung Institute, South Kensington Campus, London; and the Department of Rheumatology, Dudley Group of Hospitals National Health Service (NHS) Trust, Russells Hall Hospital, Dudley, UK.A.M. Adlan, MBBS, MRCP, College of Environmental Sciences; J.P. Fisher, BSc (Hons), PhD, College of Life and Environmental Sciences, University of Birmingham; V.F. Panoulas, MD, PhD, Imperial College London, National Heart and Lung Institute, Department of Rheumatology, Dudley Group of Hospitals NHS Trust; J.P. Smith, BSc (Hons), MSc; G.D. Kitas, MD, PhD, FRCP, Department of Rheumatology, Dudley Group of Hospitals NHS Trust
| | - Jacqueline P Smith
- From the College of Life and Environmental Sciences, University of Birmingham, Birmingham; Imperial College London, National Heart and Lung Institute, South Kensington Campus, London; and the Department of Rheumatology, Dudley Group of Hospitals National Health Service (NHS) Trust, Russells Hall Hospital, Dudley, UK.A.M. Adlan, MBBS, MRCP, College of Environmental Sciences; J.P. Fisher, BSc (Hons), PhD, College of Life and Environmental Sciences, University of Birmingham; V.F. Panoulas, MD, PhD, Imperial College London, National Heart and Lung Institute, Department of Rheumatology, Dudley Group of Hospitals NHS Trust; J.P. Smith, BSc (Hons), MSc; G.D. Kitas, MD, PhD, FRCP, Department of Rheumatology, Dudley Group of Hospitals NHS Trust
| | - James P Fisher
- From the College of Life and Environmental Sciences, University of Birmingham, Birmingham; Imperial College London, National Heart and Lung Institute, South Kensington Campus, London; and the Department of Rheumatology, Dudley Group of Hospitals National Health Service (NHS) Trust, Russells Hall Hospital, Dudley, UK.A.M. Adlan, MBBS, MRCP, College of Environmental Sciences; J.P. Fisher, BSc (Hons), PhD, College of Life and Environmental Sciences, University of Birmingham; V.F. Panoulas, MD, PhD, Imperial College London, National Heart and Lung Institute, Department of Rheumatology, Dudley Group of Hospitals NHS Trust; J.P. Smith, BSc (Hons), MSc; G.D. Kitas, MD, PhD, FRCP, Department of Rheumatology, Dudley Group of Hospitals NHS Trust
| | - George D Kitas
- From the College of Life and Environmental Sciences, University of Birmingham, Birmingham; Imperial College London, National Heart and Lung Institute, South Kensington Campus, London; and the Department of Rheumatology, Dudley Group of Hospitals National Health Service (NHS) Trust, Russells Hall Hospital, Dudley, UK.A.M. Adlan, MBBS, MRCP, College of Environmental Sciences; J.P. Fisher, BSc (Hons), PhD, College of Life and Environmental Sciences, University of Birmingham; V.F. Panoulas, MD, PhD, Imperial College London, National Heart and Lung Institute, Department of Rheumatology, Dudley Group of Hospitals NHS Trust; J.P. Smith, BSc (Hons), MSc; G.D. Kitas, MD, PhD, FRCP, Department of Rheumatology, Dudley Group of Hospitals NHS Trust
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Acar G, Yorgun H, Inci MF, Akkoyun M, Bakan B, Nacar AB, Dirnak I, Cetin GY, Bozoglan O. Evaluation of Tp-e interval and Tp-e/QT ratio in patients with ankylosing spondylitis. Mod Rheumatol 2014; 24:327-30. [PMID: 24593208 DOI: 10.3109/14397595.2013.854072] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Ankylosing spondylitis (AS) is a chronic multi-systemic inflammatory rheumatic disorder. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate ventricular repolarization by using Tp-e interval and Tp-e/QT ratio in patients with AS, and to assess the relation with inflammation. METHODS Sixty-two patients with AS and 50 controls were included. Tp-e interval and Tp-e/QT ratio were measured from a 12-lead electrocardiogram, and the Tp-e interval corrected for heart rate. The plasma level of high sensitive C-reactive protein (hsCRP) was measured. These parameters were compared between groups. RESULTS In electrocardiographic parameters analysis, QT dispersion (QTd) and corrected QTd were significantly increased in AS patients compared to the controls (31.7 ± 9.6 vs 28.2 ± 7.4 and 35.8 ± 11.5 vs 30.6 ± 7.9 ms, P = 0.03 and P = 0.007, respectively). cTp-e interval and Tp-e/QT ratio were also significantly higher in AS patients (92.1 ± 10.2 vs 75.8 ± 8.4 and 0.22 ± 0.02 vs 0.19 ± 0.02 ms, all P values <0.001). cTp-e interval and Tp-e/QT ratio were significantly correlated with hsCRP (r = 0.63, P < 0.001 and r = 0.49, P < 0.001, respectively). CONCLUSIONS Our study revealed that Tp-e interval and Tp-e/QT ratio were increased in AS patients. These electrocardiographic ventricular repolarization indexes were significantly correlated with the plasma level of hsCRP.
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Affiliation(s)
- Gurkan Acar
- Kardiyoloji Anabilim Dali, Tıp Fakultesi, Kahramanmaraş Sutcu Imam Universitesi , Kahramanmaras , Turkey
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Serhal M, Longenecker CT. Preventing Heart Failure in Inflammatory and Immune Disorders. CURRENT CARDIOVASCULAR RISK REPORTS 2014; 8. [PMID: 26316924 DOI: 10.1007/s12170-014-0392-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with chronic inflammatory diseases are at increased risk for heart failure due to ischemic heart disease and other causes including heart failure with preserved ejection fraction. Using rheumatoid arthritis and treated HIV infection as two prototypical examples, we review the epidemiology and potential therapies to prevent heart failure in these populations. Particular focus is given to anti-inflammatory therapies including statins and biologic disease modifying drugs. There is also limited evidence for lifestyle changes and blockade of the renin-angiotensin-aldosterone system. We conclude by proposing how a strategy for heart failure prevention, such as the model tested in the Screening To Prevent Heart Failure (STOP-HF) trial, may be adapted to chronic inflammatory disease.
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Affiliation(s)
- Maya Serhal
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Chris T Longenecker
- University Hospitals Case Medical Center, Cleveland, OH, USA ; Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Lazzerini PE, Capecchi PL, Acampa M, Galeazzi M, Laghi-Pasini F. Arrhythmic risk in rheumatoid arthritis: the driving role of systemic inflammation. Autoimmun Rev 2014; 13:936-44. [PMID: 24874445 DOI: 10.1016/j.autrev.2014.05.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/20/2014] [Indexed: 01/08/2023]
Abstract
When compared to the general population, patients with rheumatoid arthritis (RA) have an overall standard mortality ratio of approximately two, with more than 50% of premature deaths attributable to cardiovascular disease (CVD). Moreover, RA patients were twice as likely to experience sudden cardiac death (SCD) compared with non-RA subjects, as a putative consequence of an increased incidence of malignant arrhythmias. Accordingly, mounting data indicate that in patients affected with RA the risk of developing rhythm disturbances, particularly tachyarrhythmias, is high. Although a number of papers reviewing the problem of cardiovascular involvement in RA are currently available, the main focus is on the mechanisms of accelerated atherosclerosis and related ischemic consequences in the clinical setting. On the contrary, only little consideration has been specifically given to the arrhythmic risk so far. In the light of this concern, in the present paper we reviewed the topic with the aim to put together the apparently fragmentary existing information, with particular attention to the putative role of chronic systemic inflammation characterizing the disease. In fact, although the underlying mechanisms accounting the arrhythmogenic substrate in RA are probably intricate, the leading role seems to be played by inflammatory activation, able to promote arrhythmias either indirectly, by accelerating the development of structural CVD, and directly by affecting cardiac electrophysiology. In this view, lowering inflammatory burden through an increasingly tight control of disease activity may represent the most effective intervention to reduce arrhythmic risk and prevent life-threatening complications in these patients.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy.
| | | | | | - Mauro Galeazzi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy
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Mavrogeni S, Sfikakis PP, Gialafos E, Bratis K, Karabela G, Stavropoulos E, Spiliotis G, Sfendouraki E, Panopoulos S, Bournia V, Kolovou G, Kitas GD. Cardiac tissue characterization and the diagnostic value of cardiovascular magnetic resonance in systemic connective tissue diseases. Arthritis Care Res (Hoboken) 2014; 66:104-12. [PMID: 24106233 DOI: 10.1002/acr.22181] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 09/10/2013] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Accurate diagnosis of cardiovascular involvement in connective tissue diseases (CTDs) remains challenging. We hypothesized that cardiovascular magnetic resonance (CMR) demonstrates cardiac lesions in symptomatic CTD patients with normal echocardiography. METHODS CMR from 246 CTD patients with typical cardiac symptoms (TCS; n = 146, group A) or atypical cardiac symptoms (ATCS; n = 100, group B) was retrospectively evaluated. Group A included 9 patients with inflammatory myopathy (IM), 35 with sarcoidosis, 30 with systemic sclerosis (SSc), 14 with systemic lupus erythematosus (SLE), 10 with rheumatoid arthritis (RA), and 48 with small vessel vasculitis. Group B included 25 patients with RA, 20 with SLE, 20 with sarcoidosis, 15 with SSc, 10 with IM, and 10 with small vessel vasculitis. CMR was performed by 1.5T; left ventricular ejection fraction, T2 ratio (edema imaging), and late gadolinium enhancement (LGE; fibrosis imaging) were evaluated. Acute and chronic lesions were characterized as LGE positive plus T2 ratio >2 and T2 ratio ≤2, respectively. According to LGE, lesions were characterized as diffuse subendocardial, subepicardial, and subendocardial/transmural due to vasculitis, myocarditis, and myocardial infarction, respectively. A stress study by dobutamine echocardiography or stress, nuclear, or adenosine CMR was performed in CTD patients with negative rest CMR. RESULTS Abnormal CMR was identified in 32% (27% chronic) and 15% (12% chronic) of patients with TCS and ATCS, respectively. Lesions due to vasculitis, myocarditis, and myocardial infarction were evident in 27.4%, 62.6%, and 9.6% of CTD patients, respectively. Stress studies in CTD patients with negative CMR revealed coronary artery disease in 20%. CONCLUSION CMR in symptomatic CTD patients with normal echocardiography can assess disease acuity and identify vasculitis, myocarditis, and myocardial infarction.
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Edema and fibrosis imaging by cardiovascular magnetic resonance: how can the experience of Cardiology be best utilized in rheumatological practice? Semin Arthritis Rheum 2014; 44:76-85. [PMID: 24582213 DOI: 10.1016/j.semarthrit.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/19/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis. METHOD CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies. RESULTS Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs. CONCLUSION The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.
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Okada M, Wong TY, Kawasaki R, Baharuddin NB, Colville D, Buchanan R, Savige J. Retinal venular calibre is increased in patients with autoimmune rheumatic disease: a case-control study. Curr Eye Res 2014; 38:685-90. [PMID: 23654356 DOI: 10.3109/02713683.2012.754046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To examine retinal vessel calibre in autoimmune rheumatic disease. MATERIALS AND METHODS Patients with autoimmune rheumatic disease were recruited from a Rheumatology clinic. Retinal vessel calibre was measured from fundus photographs, and summarised as the central retinal artery and vein equivalents (CRAE and CRVE) using a semi-automated computer-assisted method. RESULTS The 124 patients studied had rheumatoid arthritis (n = 76, 61%), systemic lupus erythematosus (n = 17, 14%), psoriatic arthritis (n = 11, 9%) or another rheumatological disease (n = 20, 16%). Retinal venular calibre was increased in patients with autoimmune rheumatic disease (+11.6 µm, 95% Confidence interval [CI] 3.8 - 19.3, p = 0.01) compared with other hospital patients, after adjusting for baseline differences. This increase was also present in the subgroup with rheumatoid arthritis (p = 0.01). Patients with a rheumatic disease and elevated C-reactive protein (CRP) levels had wider retinal venules than those with a lower CRP (mean CRVE: 247.8 ± 28.0 versus 216.6 ± 25.3, p < 0.01), and than other hospital patients with increased CRP (mean CRVE: 247.8 ± 28.0 versus 216.4 ± 25.9, p < 0.01). CONCLUSIONS Individuals with an autoimmune rheumatic disease have wider retinal venules than other hospital patients. This increase in calibre may be due to the underlying inflammatory activity.
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Affiliation(s)
- Mali Okada
- Centre for Eye Research Australia, The University of Melbourne, Melbourne, Australia
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Kadi H, Inanir A, Habiboglu A, Ceyhan K, Koc F, Çelik A, Onalan O, Arslan S. Frequency of fragmented QRS on ECG is increased in patients with rheumatoid arthritis without cardiovascular disease: a pilot study. Mod Rheumatol 2014. [DOI: 10.3109/s10165-011-0493-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. Clinical Use of Cardiac Magnetic Resonance in Systemic Heart Disease. Eur Cardiol 2014; 9:21-27. [PMID: 30310481 DOI: 10.15420/ecr.2014.9.1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A systemic disease is one that affects a number of organs and tissues, or the body as a whole. Systemic diseases include endocrine, metabolic, nutritional, multisystem (rheumatic) and HIV disease. Cardiovascular involvement is a common and underestimated problem in systemic diseases, and may present with disease associated cardiac involvement at diagnosis or later in the course of the systemic disease. The cardiac involvement in these diseases is usually silent or oligo-symptomatic and includes different pathophysiological mechanisms such as, myocardial inflammation, infarction, diffuse, subendocardial vasculitis, valvular disease and different patterns of fibrosis. Furthermore, acuity of heart involvement may be underestimated due to non-specific cardiac signs, and finally, most of patients are female and unable to exercise, due to arthritis or muscular discomfort/weakness or may have limited acoustic window, due to increased breast size. Cardiovascular magnetic resonance (CMR), due to its ability to reliably assess cardiac anatomy, function, inflammation, stress perfusion-fibrosis, aortic distensibility, and iron and fat deposition, constitutes an excellent tool for early diagnosis of heart involvement, risk stratification, treatment evaluation and long-term follow-up of patients with cardiac disease due to systemic diseases.
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68
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Imaging patterns of heart failure in rheumatoid arthritis evaluated by cardiovascular magnetic resonance. Int J Cardiol 2013; 168:4333-5. [DOI: 10.1016/j.ijcard.2013.05.085] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 05/04/2013] [Indexed: 11/21/2022]
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69
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Jin Y, Wang HS, Wang ZW, Li XM, Yin ZT, Zhu Y. Risk factors for midterm cardiac function deterioration after valve replacement surgery in patients with rheumatic mitral stenosis. J Card Fail 2013; 19:565-70. [PMID: 23910586 DOI: 10.1016/j.cardfail.2013.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/17/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND A symptomatic reduction in left ventricular ejection fraction (LVEF) is the main reason for postoperative heart failure after valve replacement surgery. However, postoperative heart failure occurs in patients with normal preoperative LVEF. Therefore, we examined clinical and echocardiographic data of patients with rheumatic heart disease to determine additional risk factors for low LVEF in the postoperative period. METHODS AND RESULTS Ninety-seven patients with rheumatic heart disease (RHD) who underwent mitral valve replacement for severe mitral valve stenosis were included retrospectively in this study. All patients had normal LVEF before surgery. Patients were divided into 2 groups based on postoperative LVEF 6 months after surgery. Groups A had normal postoperative LVEF (82 cases, 84.5%), and group B had low postoperative LVEF (15 cases, 15.5%). Clinical and electrocardiographic data were collected to determine risk factors for deterioration in cardiac function. Multivariate analysis revealed that preoperative low systolic peak velocities at the lateral tricuspid annulus (St) and no or mild aortic stenosis were independent risk factors for cardiac deterioration in patients with normal preoperative LVEF. Individuals with preoperative St ≤ 4.8 cm/s were more likely to develop lower LVEF at follow-up (χ(2) = 7.54; P = .006; odds ratio 5.03, 95% confidence interval 1.31-20.82). All 15 patients who had normal preoperative LVEF but abnormal postoperative LVEF had no or only mild aortic valve stenosis. CONCLUSIONS Decreased right ventricular function and no or mild aortic stenosis were independent risk factors for low LVEF at follow-up in patients with RHD who had normal preoperative LVEF. The velocity of the tricuspid valve ring should be included in preoperative evaluations to improve the accuracy of postsurgical prognosis and clinical decision making.
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Affiliation(s)
- Yan Jin
- Cardiovascular Institute and Shenyang Northern Hospital, Shenyang City, China.
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70
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Camellino D, Masoero G, Bauckneht M, Rosa GM, Cimmino MA. Cardiovascular diseases in patients with rheumatoid arthritis: comment on the article by Koivuniemi et al. Scand J Rheumatol 2013; 42:422-3. [PMID: 23848174 DOI: 10.3109/03009742.2013.800132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- D Camellino
- Rheumatology Clinic, Department of Internal Medicine, University of Genoa , Italy
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71
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Abstract
Rheumatoid arthritis (RA) represents an autoimmune disease affecting mostly joints, in particular small finger and toe joints. In addition RA can show extra-articular manifestations in many organs. Information on the frequency of extra-articular manifestations (EAMs) in RA varies greatly in different publications from 17.8% to 40.9% and EAMs tend to become higher with increasing duration and severity of the disease. The exact etiology and pathogenesis are still unclear but vasculitic alterations together with deposition of immune complexes can often be found histopathologically in affected organs. It must also be taken into consideration that EAMs can also be a result of the pharmaceutical therapy. The organ findings can vary greatly which is also reflected in the multitude of clinical symptoms. Possible target organs are the blood vessels, kidneys, central nervous system, cardiovascular system, the lungs, eyes, skin, nails as well as blood and the hemopoetic system. The prognosis for RA becomes progressively worse in the presence of EAMs. Regular and continuous control investigations are necessary in order to be able to diagnose EAMs early and to begin therapy. Therapy includes the administration of non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) and especially in advanced stages cyclophosphamide or biologicals. Therapy is still very empirical due to the lack of appropriate studies.
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72
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Heart involvement in rheumatoid arthritis: multimodality imaging and the emerging role of cardiac magnetic resonance. Semin Arthritis Rheum 2013; 43:314-24. [PMID: 23786873 DOI: 10.1016/j.semarthrit.2013.05.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 04/22/2013] [Accepted: 05/02/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Patients with rheumatoid arthritis (RA) exhibit a high risk of cardiovascular disease (CVD). CVD in RA can present in many guises, commonly detected at a subclinical level only. METHODS Modern imaging modalities that allow the noninvasive assessment of myocardial performance and are able to identify cardiac abnormalities in early asymptomatic stages may be useful tools in terms of screening, diagnostic evaluation, and risk stratification in RA. RESULTS The currently used imaging techniques are echocardiography, single-photon emission computed tomography (SPECT), and cardiac magnetic resonance (CMR). Between them, echocardiography provides information about cardiac function, valves, and perfusion; SPECT provides information about myocardial perfusion and carries a high amount of radiation; and CMR-the most promising imaging modality-evaluates myocardial function, inflammation, microvascular dysfunction, valvular disease, perfusion, and presence of scar. Depending on availability, expertise, and clinical queries, "right technique should be applied for the right patient at the right time." CONCLUSIONS In this review, we present a short overview of CVD in RA focusing on the clinical implication of multimodality imaging and mainly on the evolving role of CMR in identifying high-risk patients who could benefit from prevention strategies and early specific treatment targeting the heart. Advantages and disadvantages of each imaging technique in the evaluation of RA are discussed.
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73
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Acar G, Yorgun H, Inci MF, Akkoyun M, Bakan B, Nacar AB, Dirnak I, Cetin GY, Bozoglan O. Evaluation of Tp-e interval and Tp-e/QT ratio in patients with ankylosing spondylitis. Mod Rheumatol 2013. [PMID: 23579501 DOI: 10.1007/s10165-013-0881-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/30/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVES: Ankylosing spondylitis (AS) is a chronic multi-systemic inflammatory rheumatic disorder. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate ventricular repolarization by using Tp-e interval and Tp-e/QT ratio in patients with AS, and to assess the relation with inflammation. METHODS: Sixty-two patients with AS and 50 controls were included. Tp-e interval and Tp-e/QT ratio were measured from a 12-lead electrocardiogram, and the Tp-e interval corrected for heart rate. The plasma level of high sensitive C-reactive protein (hsCRP) was measured. These parameters were compared between groups. RESULTS: In electrocardiographic parameters analysis, QT dispersion (QTd) and corrected QTd were significantly increased in AS patients compared to the controls (31.7 ± 9.6 vs 28.2 ± 7.4 and 35.8 ± 11.5 vs 30.6 ± 7.9 ms, P = 0.03 and P = 0.007, respectively). cTp-e interval and Tp-e/QT ratio were also significantly higher in AS patients (92.1 ± 10.2 vs 75.8 ± 8.4 and 0.22 ± 0.02 vs 0.19 ± 0.02 ms, all P values <0.001). cTp-e interval and Tp-e/QT ratio were significantly correlated with hsCRP (r = 0.63, P < 0.001 and r = 0.49, P < 0.001, respectively). CONCLUSIONS: Our study revealed that Tp-e interval and Tp-e/QT ratio were increased in AS patients. These electrocardiographic ventricular repolarization indexes were significantly correlated with the plasma level of hsCRP.
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Affiliation(s)
- Gurkan Acar
- Kardiyoloji Anabilim Dali, Tıp Fakultesi, Kahramanmaraş Sutcu Imam Universitesi, Kahramanmaras, 46100, Turkey,
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74
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Chiribiri A, Hautvast GLTF, Lockie T, Schuster A, Bigalke B, Olivotti L, Redwood SR, Breeuwer M, Plein S, Nagel E. Assessment of coronary artery stenosis severity and location: quantitative analysis of transmural perfusion gradients by high-resolution MRI versus FFR. JACC Cardiovasc Imaging 2013; 6:600-9. [PMID: 23582358 DOI: 10.1016/j.jcmg.2012.09.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 09/20/2012] [Accepted: 09/27/2012] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This study sought to test the hypothesis that transmural perfusion gradients (TPG) on adenosine stress myocardial perfusion cardiac magnetic resonance (CMR) predict hemodynamically significant coronary artery disease (CAD) as defined by fractional flow reserve (FFR). BACKGROUND Myocardial ischemia affects the subendocardial layers of the left ventricular myocardium earlier and more severely than the outer layers, and the identification of TPG should be sensitive and specific for the diagnosis of CAD. Previous studies have shown that high spatial resolution myocardial perfusion CMR allows quantitation of TPG between the subendocardium and the subepicardium. METHODS Sixty-seven patients (53 men, age 61 ± 9 years) underwent coronary angiography and high-resolution (1.2 × 1.2-mm in-plane) adenosine stress perfusion CMR at 3.0-T. TPG was calculated for 3 coronary territories. Visual analysis was performed to identify myocardial ischemia. FFR was measured in all vessels with ≥50% severity stenosis. FFR <0.8 was considered hemodynamically significant. In a training group of 30 patients, the optimal threshold of TPG to detect significant CAD was determined (Group 1). This threshold was then tested prospectively in the remaining 37 patients (Group 2). RESULTS In Group 1, a 20% TPG provided the best diagnostic threshold on both per-segment and per-patient analysis. Applied to Group 2, this threshold yielded a sensitivity of 0.78, specificity of 0.94, and area under the curve of 0.86 for the detection of CAD in a per-segment analysis and of 0.89, 0.83, and 0.86 in a per-patient analysis, respectively. TPG had a similar diagnostic accuracy to visual assessment. Linear regression analysis showed a relationship between TPG and FFR values, with r = 0.63 (p < 0.001). CONCLUSIONS The quantitative analysis of transmural perfusion gradients on high-resolution myocardial perfusion CMR accurately predicts hemodynamically significant CAD as defined by FFR. A TPG diagnostic threshold of 20% is as accurate as visual assessment.
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Affiliation(s)
- Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering, King's College London British Heart Foundation Centre of Excellence, London, United Kingdom.
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75
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Koivuniemi R, Paimela L, Suomalainen R, Leirisalo-Repo M. Cardiovascular diseases in patients with rheumatoid arthritis. Scand J Rheumatol 2012; 42:131-5. [PMID: 23244227 DOI: 10.3109/03009742.2012.723747] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To study cardiovascular autopsy findings and the lifetime prevalence of cardiovascular diseases (CVDs) in patients with rheumatoid arthritis (RA). METHOD In 369 RA patients and their reference cases without any rheumatic disease (non-RA), we studied CVDs recorded on autopsy reports at consecutive autopsies from 1952 to 1991. From autopsy referrals by clinicians, we recorded lifetime CVDs. In RA patients autopsied from 1973, we evaluated clinical data. RESULTS From 1952 to 1991, RA patients had, compared with non-RA, myocardial infarction (MI; 26% vs. 41%) and cerebral infarction (14% vs. 28%) less frequently but cardiac amyloidosis (28% vs. 3%), pericarditis (27% vs. 8%), and diffuse myocardial abnormality (21% vs. 11%) more frequently reported at autopsy. Of RA patients autopsied from 1973, 40% had had a diagnosis of congestive heart failure (CHF) and coronary heart disease (CHD) during their lifetime. The RA patients with CHF had a higher mean erythrocyte sedimentation rate (ESR) than those without CHF. In RA patients, MI or myocardial abnormality at autopsy had no such correlation. In RA, male sex, ischaemic electrocardiogram changes, diabetes, hypertensive disease, and severe radiographic changes typical for RA were associated with MI detected at autopsy. No such associations emerged with respect to diffuse myocardial abnormality. When disorders potentially causing diffuse myocardial damage were excluded, RA patients had, on autopsy reports, compared to non-RA, diffuse myocardial abnormality more frequently (21% vs. 12%, p = 0.002). Cardiac amyloidosis showed no correlation to this. CONCLUSION RA patients seem to have an increased risk for myocardial damage. The influence of inflammation on the myocardium in RA needs further studies.
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Affiliation(s)
- R Koivuniemi
- Department of Medicine, Division of Rheumatology, Helsinki University Central Hospital, Helsinki, Finland.
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Sandoo A, Protogerou AD, Hodson J, Smith JP, Zampeli E, Sfikakis PP, Kitas GD. The role of inflammation, the autonomic nervous system and classical cardiovascular disease risk factors on subendocardial viability ratio in patients with RA: a cross-sectional and longitudinal study. Arthritis Res Ther 2012; 14:R258. [PMID: 23190682 PMCID: PMC3674609 DOI: 10.1186/ar4103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/12/2012] [Accepted: 11/22/2012] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Evidence indicates that rheumatoid arthritis (RA) patients have increased susceptibility to myocardial ischaemia that contributes to myocardial infarction. The subendocardial viability ratio (SEVR) can be measured using pulse wave analysis and reflects myocardial oxygen supply and demand. The objective of the present study was to examine specific predictors of SEVR in RA patients, with a specific focus on inflammation and classical cardiovascular disease (CVD) risk factors. METHODS Two patient cohorts were included in the study; a primary cohort consisting of 220 RA patients and a validation cohort of 127 RA patients. All patients underwent assessment of SEVR using pulse wave analysis. Thirty-one patients from the primary cohort who were about to start anti-inflammatory treatment were prospectively examined for SEVR at pretreatment baseline and 2 weeks, 3 months and 1 year following treatment. Systemic markers of disease activity and classical CVD risk factors were assessed in all patients. RESULTS The SEVR (mean ± standard deviation) for RA in the primary cohort was 148 ± 27 and in the validation cohort was 142 ± 25. Regression analyses revealed that all parameters of RA disease activity were associated with SEVR, along with gender, blood pressure and heart rate. These findings were the same in the validation cohort. Analysis of longitudinal data showed that C-reactive protein (P < 0.001), erythrocyte sedimentation rate (P < 0.005), Disease Activity Score in 28 joints (P < 0.001), mean blood pressure (P < 0.005) and augmentation index (P < 0.001) were significantly reduced after commencing anti-TNFα treatment. Increasing C-reactive protein was found to be associated with a reduction in SEVR (P = 0.02) and an increase in augmentation index (P = 0.001). CONCLUSION The present findings reveal that the SEVR is associated with markers of disease activity as well as highly prevalent classical CVD risk factors in RA, such as high blood pressure and diabetes. Further prospective studies are required to determine whether the SEVR predicts future cardiac events in RA.
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Affiliation(s)
- Aamer Sandoo
- Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley DY1 2HQ, UK
- School of Sport and Exercise Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Athanassios D Protogerou
- First Department of Propaedeutic and Internal Medicine, University Medical School, Athens, Greece
| | - James Hodson
- Wolfson Computer Laboratory, University Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Jacqueline P Smith
- Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley DY1 2HQ, UK
| | - Evi Zampeli
- First Department of Propaedeutic and Internal Medicine, University Medical School, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine, University Medical School, Athens, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley DY1 2HQ, UK
- School of Sport and Exercise Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Arthritis Research UK Epidemiology Unit, University of Manchester, Oxford Road, Manchester M13 9PT, UK
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Toutouzas K, Sfikakis PP, Karanasos A, Aggeli C, Felekos I, Kitas G, Zampeli E, Protogerou A, Stefanadis C. Myocardial ischaemia without obstructive coronary artery disease in rheumatoid arthritis: hypothesis-generating insights from a cross-sectional study. Rheumatology (Oxford) 2012. [PMID: 23185038 DOI: 10.1093/rheumatology/kes349] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE RA is associated with increased cardiovascular events, reportedly to equal diabetes mellitus (DM). The presence of myocardial ischaemia was assessed in asymptomatic high-risk RA patients and compared with patients with DM and a healthy control group. METHODS Eighteen consecutive non-diabetic RA patients without known cardiovascular disease who developed a new carotid atheromatic plaque during the last 3 years were matched 1:1 for traditional cardiovascular risk factors with asymptomatic type 2 DM patients and 1:2 with asymptomatic non-RA, non-DM control subjects. After dobutamine stress contrast echocardiography with wall-motion and perfusion evaluation, coronary angiography was performed in those with positive stress tests. RESULTS Ischaemia by echocardiography was found in 67% of RA patients; this was significantly higher than controls (31%, P = 0.019) but comparable to those with DM (78%, P = 0.71). Angiography performed in eight consenting RA patients was normal in four, revealed non-flow-limiting coronary atheromatic lesions in two and significant lesions in two patients. RA patients with ischaemia had CRP serum levels significantly higher by six-fold compared with those with normal stress echocardiography. CONCLUSION Asymptomatic RA patients may display myocardial ischaemia at similar levels to DM patients but with low prevalence of obstructive coronary artery disease. Microvascular abnormalities associated with increased inflammatory response may account for these findings. Their exact nature and significance require further evaluation.
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Affiliation(s)
- Konstantinos Toutouzas
- 1st Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece.
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Furer V, Fayad ZA, Mani V, Calcagno C, Farkouh ME, Greenberg JD. Noninvasive Cardiovascular Imaging in Rheumatoid Arthritis: Current Modalities and the Emerging Role of Magnetic Resonance and Positron Emission Tomography Imaging. Semin Arthritis Rheum 2012; 41:676-88. [DOI: 10.1016/j.semarthrit.2011.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 08/30/2011] [Accepted: 08/31/2011] [Indexed: 01/07/2023]
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Frequency of fragmented QRS on ECG is increased in patients with rheumatoid arthritis without cardiovascular disease: a pilot study. Mod Rheumatol 2011; 22:238-42. [PMID: 21728076 DOI: 10.1007/s10165-011-0493-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 06/10/2011] [Indexed: 10/18/2022]
Abstract
Myocardial fibrosis causes the fragmentation of QRS complexes (fQRS) on ECGs. We hypothesized that the frequency of fQRS could be more common in patients with rheumatoid arthritis (RA) than in control subjects. A total of 56 patients with RA were compared with 35 age- and gender-matched fibromyalgia subjects for fQRS. The fQRS was defined as the presence of an additional R wave, or notching of the R or S wave, or the presence of fragmentation in 2 contiguous leads corresponding to the territory of a major coronary artery. Patients with bundle block on ECG and cardiovascular disease were excluded. Twenty-one patients (37.5%) in the RA group had fQRS, while two patients in the control group (5.7%) had fQRS (p = 0.001). No differences were found between the groups in terms of age, gender, or drug use. Duration of disease--years (interquartile range [IQR])--was 10 (8) in the fQRS (+) group, while it was 5 (2) in the fQRS (-) group (p < 0.001). Multivariate logistic regression analysis revealed that duration of disease was associated with the presence of fQRS (B = 1.5, odds ratio = 4.5, p = 0.004, 95% confidence interval = 1.6-12.7). We found that fQRS on ECG was more common in patients with RA without cardiovascular disease than in age- and gender-matched control subjects.
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