Ezetimibe and Simvastatin Reduce Inflammation, Disease Activity, and Aortic Stiffness and Improve Endothelial Function in Rheumatoid Arthritis

Cardiovascular injury in systemic autoimmune diseases: an update

It is well known in literature that systemic autoimmune diseases (SADs) are associated with enhanced atherosclerosis and impaired endothelial function early after the onset of the disease. Cardiovascular (CV) disease represents one of the leading causes of morbidity and mortality in SADs. There is considerable evidence suggesting a pathogenetic role of chronic inflammation and immune dysregulation for enhanced atherosclerosis in SADs, as demonstrated in several recent studies. Moreover, chronic inflammation, accelerated atherosclerosis and functional abnormalities of the endothelium suggest a subclinical CV involvement beginning rapidly soon after the onset of the disease and progressing with disease duration.

Vascular function and morphology in rheumatoid arthritis: a systematic review

OBJECTIVES

RA associates with significantly increased morbidity and mortality from cardiovascular disease (CVD). This may be due to complex interactions between traditional CVD risk factors, systemic rheumatoid inflammation and the vasculature. We reviewed the current literature to answer: (i) whether there is sufficient evidence that patients with RA have altered vascular function and morphology compared with normal controls; (ii) whether there is sufficient evidence to determine if such changes relate predominantly to systemic inflammation; and (iii) whether any changes of vascular function and morphology in RA can be modified with therapy.

METHODS

The MEDLINE database was searched to identify publications from 1974 to 1 November 2010 pertaining to vascular function and morphology in RA. The total number of articles included in the present review was 93. This included 57 cross-sectional studies, 27 longitudinal studies without randomization and 9 longitudinal studies with randomization.

RESULTS

Vascular function and morphology was impaired in RA relative to healthy controls. The majority of studies reported no associations between systemic inflammation and vascular function. Treatment with anti-inflammatory medication resulted in both transient and long-term improvements in the vasculature, but only a few studies reported associations between change in inflammation and change in vascular function and morphology.

CONCLUSION

The link between systemic inflammation and vascular function and morphology is not wholly supported by the available literature. Long-term studies examining specific predictors (including CVD risk factors) on the vasculature in RA are needed.

The pleiotropic effects of the hydroxy-methyl-glutaryl-CoA reductase inhibitors in rheumatologic disorders: a comprehensive review

The hydroxy-methyl-glutaryl-CoA reductase inhibitors (statins) are used extensively in the treatment for hyperlipidemia. They have also demonstrated a benefit in a variety of other disease processes, including a wide range of rheumatologic disorders. These secondary actions are known as pleiotropic effects. Our paper serves as a focused and updated discussion on the pleiotropic effects of statins in rheumatologic disorders and emphasizes the importance of randomized, placebo-controlled trials to further elucidate this interesting phenomenon.

Cardiovascular co-morbidity in patients with rheumatic diseases

During recent years atherosclerosis, the major cause of cardiovascular disease (CVD), has been recognised as a chronic inflammatory condition in which rupture of atherosclerotic lesions appears to play a major role. The risk of CVD is raised in many rheumatic diseases. This risk is high in systemic lupus erythematosus - as much as a 50-times increase among middle-aged women has been reported. Studies on CVD and atherosclerosis in rheumatic disease could thus provide interesting information about CVD and atherosclerosis in addition to being an important clinical problem. A combination of traditional and nontraditional risk factors accounts for the increased risk of CVD and atherosclerosis in rheumatic disease. One interesting possibility is that atherosclerotic lesions in rheumatic disease are more prone to rupture than normal atherosclerotic lesions. It is also likely that increased risk of thrombosis may play an important role, not least in systemic lupus erythematosus. Further, it is not clear whether an increased risk of CVD is a general feature of rheumatic disease, or whether this only occurs among subgroups of patients. It should be emphasised that there is an apparent lack of treatment studies where CVD in rheumatic disease is the end point. Control of disease activity and of traditional risk factors, however, appears to be well founded in relation to CVD in rheumatic disease. Further studies are needed to determine the exact role of lipid-lowering drugs as statins. Hopefully novel therapies can be developed that target the causes of the inflammation in atherosclerotic lesions both in rheumatic patients and in the general population.

The effects of statin monotherapy and low-dose statin/ezetimibe on lipoprotein-associated phospholipase A₂

BACKGROUND

Many of the pleiotropic effects of statins remain to be elucidated.

HYPOTHESIS

Different statin regimens with similar lipid-lowering efficacy may have different effects on biomarkers of atherothrombosis including lipoprotein-associated phospholipase A₂ (Lp-PLA₂ ).

METHODS

After a 4-week dietary lead-in, 82 hypercholesterolemic patients were randomized to 1 of 2 treatment groups: atorvastatin 20 mg or atorvastatin/ezetimibe 5 mg/5 mg. After 8 weeks of drug treatment, the groups were compared for percent change in lipid parameters, Lp-PLA₂ , interleukin-6 (IL-6), monocyte chemoattractant protein-1, and fibrinogen.

RESULTS

Low-density lipoprotein cholesterol (LDL-C) lowering was comparable between the 2 groups (-47% ± 11% and -49% ± 7% in the atorvastatin and combination groups, respectively). Although Lp-PLA₂ was reduced in both groups, the reduction was greater in the atorvastatin group (-42% and -9% [median], respectively, P = 0.03). Although IL-6 was decreased only in the atorvastatin group, IL-6 changes were not significantly different between the 2 groups. The changes in monocyte chemoattractant protein-1 and fibrinogen were similar in each group.

CONCLUSIONS

Atorvastatin monotherapy was stronger at reducing plasma Lp-PLA₂ than the low-dose atorvastatin/ezetimibe combination after equivalent LDL-C lowering. This result may provide evidence of potential statin effects beyond the lowering of LDL-C.

Impact of hypertriglyceridemia on endothelial dysfunction during statin ± ezetimibe therapy in patients with coronary heart disease

Despite the use of statin therapy and achieving the target for low-density lipoprotein cholesterol, a substantial number of coronary events are not prevented, and residual risk factors remain unsettled. Recently, ezetimibe has been shown to reduce not only low-density lipoprotein cholesterol but also triglyceride (TG) levels. The aim of this study was to investigate the associations of residual risk factors, mainly hypertriglyceridemia, with endothelial function during statin therapy in patients with coronary heart disease and examine the effect of ezetimibe add-on therapy. A total of 109 consecutive patients with coronary heart disease during statin therapy were enrolled. Lipid profile was measured and endothelial function was assessed by flow-mediated dilation (FMD) of the brachial artery in a fasting state. Next, 32 patients with high TG levels (≥150 mg/dl) were prospectively assigned to the ezetimibe add-on group or the no-ezetimibe group, and endothelial function was assessed after 3 months. Multivariate linear regression analysis demonstrated that serum TG and high-density lipoprotein cholesterol levels were independent determinants of percentage FMD (β = -0.210 and 0.208, respectively, p <0.05). In patients with high TG levels, ezetimibe add-on therapy significantly improved percentage FMD (from 3.3 ± 1.1% to 4.0 ± 1.1%, p <0.005), whereas no significant change was observed in the no-ezetimibe group. Moreover, the improvement in percentage FMD was significantly associated with reduction in serum TG levels (β = -0.387, p <0.05) independent of the change in serum low-density lipoprotein cholesterol levels. In conclusion, hypertriglyceridemia is independently associated with endothelial dysfunction in patients with coronary heart disease during statin therapy. Ezetimibe add-on therapy improves endothelial function in these high-risk populations.

Dextromethorphan, chlorphenamine and serotonin toxicity: case report and systematic literature review

The aim of this review was to describe a patient with serotonin toxicity after an overdose of dextromethorphan and chlorphenamine and to perform a systematic literature review exploring whether dextromethorphan and chlorphenamine may be equally contributory in the development of serotonin toxicity in overdose. A Medline literature review was undertaken to identify cases of serotonin toxicity due to dextromethorphan and/or chlorphenamine. Case reports were included if they included information on the ingested dose or plasma concentrations of dextromethorphan and/or chlorphenamine, information about co-ingestions and detailed clinical information to evaluate for serotonin toxicity. Cases were reviewed by two toxicologists and serotonin toxicity, defined by the Hunter criteria, was diagnosed when appropriate. The literature was then reviewed to evaluate whether chlorphenamine may be a serotonergic agent. One hundred and fifty-five articles of dextromethorphan or chlorphenamine poisoning were identified. There were 23 case reports of dextromethorphan, of which 18 were excluded for lack of serotonin toxicity. No cases were identified in which serotonin toxicity could be solely attributed to chlorphenamine. This left six cases of dextrometorphane and/or chlorphenamine overdose, including our own, in which serotonin toxicity could be diagnosed based on the presented clinical information. In three of the six eligible cases dextromethorphan and chlorphenamine were the only overdosed drugs. There is substantial evidence from the literature that chlorphenamine is a similarly potent serotonin re-uptake inhibitor when compared with dextrometorphan. Chlorphenamine is a serotonergic medication and combinations of chlorphenamine and dextromethorphan may be dangerous in overdose due to an increased risk of serotonin toxicity.

Atorvastatin upregulates regulatory T cells and reduces clinical disease activity in patients with rheumatoid arthritis

In this study, we investigated the hypothesis that regulatory T cells (T(reg)) are involved in the immunomodulatory effects of statins on rheumatoid arthritis (RA) patients. The 12-week study cohort consisted of 55 RA patients and 42 control subjects allocated to either a group treated with atorvastatin (AT) (20 mg/day) or a non-AT group. T(reg) numbers, suppressive function, serum inflammatory markers, and disease activity were evaluated before and after the therapy. Furthermore, the effects of AT on the frequency and suppressive function of T(reg) were determined in vitro. Our data revealed that the suppressive function of T(reg) from RA patients significantly decreased compared with that of control subjects. AT significantly reduced erythrosedimentation, C-reactive protein, and disease activity. Concomitantly, T(reg) numbers and suppressive functions were significantly improved by AT. Consistent with the in vivo experiments, AT promoted the generation of T(reg) from primary T cells and enhanced preexisting T(reg) function in vitro. Moreover, we showed that PI3K-Akt-mTOR and ERK signal pathways were involved in the induction of T(reg) by AT. In conclusion, AT significantly increased T(reg) numbers and restored their suppressive function in the RA patients, and this may be relevant in the modulation of uncontrolled inflammation in this disorder.

Coronary endothelial dysfunction is associated with a reduction in coronary artery compliance and an increase in wall shear stress

OBJECTIVE

Endothelial dysfunction is associated with arterial stiffness in large arteries. The purpose of this study was to investigate the association between coronary endothelial dysfunction, coronary artery compliance and wall shear stress in patients with early atherosclerosis.

METHODS

Coronary endothelial function was assessed according to responses to intracoronary acetylcholine in 120 patients without significant coronary stenosis. Acceleration of peak velocity (ACC), which is inversely related to coronary artery compliance, was derived from coronary flow velocity spectra, and wall shear rate (WSR) was calculated. Measurements were performed at baseline and after intracoronary nitroglycerin in order to eliminate the contribution of vascular smooth muscle tone to coronary artery compliance.

RESULTS

In all patients, heart rate significantly increased (72+/-1 to 77+/-1 bpm, p<0.01) and mean arterial pressure decreased (97+/-2 to 93+/-1 mm Hg, p<0.01) after nitroglycerin. Coronary blood flow (CBF) and resistance were not significantly changed, but the diastolic to systolic velocity ratio increased significantly (2.15+/-0.08 to 5.36+/-0.61, p<0.01). Patients with abnormal endothelial function (n=70) had a higher WSR at baseline (559+/-41 vs 440+/-26 s(-1), p<0.05) and after nitroglycerin (457+/-41 vs 339+/-29 s(-1), p<0.05), and a higher ACC after nitroglycerin (3.9+/-0.4 vs 2.8+/-0.4 m/s(2), p<0.05) than patients with normal function (n=50).

CONCLUSIONS

The current study demonstrates that intracoronary nitroglycerin does not contribute to an increase of CBF but alters the phasic coronary flow pattern. Furthermore, early coronary atherosclerosis characterised by endothelial dysfunction is associated with a decrease in coronary artery compliance and an increase in wall shear stress. Therefore, coronary wall properties are affected early in the atherosclerosis process.

Comparative study between high-dose fluvastatin and low-dose fluvastatin and ezetimibe with regard to the effect on endothelial function in diabetic patients

It is well established that statins improve the prognosis of patients with coronary artery disease. However, it is still unclear whether the protective effects of statins relate to lipid lowering alone or whether other pleiotropic effects may contribute. Thus, we compared the endothelial function among two groups of diabetic patients treated with fluvastatin 60 mg (F60) or fluvastatin 20 mg combined with ezetimibe 10 mg (F20/E10). The endothelial function was evaluated by measuring flow-mediated vasodilatation (FMD) at baseline and follow-up at 10 weeks. Similar improvements in FMD were observed in the two groups. The reduction in low-density lipoprotein cholesterol (LDL-C) was less pronounced in the F60 group, compared with the F20/E10 group. A significant reduction in remnant-like lipoprotein particles cholesterol (RLP-C) was observed in the F20/E10 group, but not in the F60 group. A correlation between the observed reduction in LDL-C or RLP-C and the improvement in FMD was observed in F20/E10 group. These results suggest that high-dose fluvastatin might have pleiotropic effects of potential clinical benefit, and that the combination of ezetimibe with a reduced dose of fluvastatin may also significantly improve endothelial function with reduction of LDL-C and RLP-C.

Assessment of endothelial function as a marker of cardiovascular risk in patients with rheumatoid arthritis

The endothelium is a major regulator of cardiovascular function and maintains an atheroprotective role through several mechanisms, including vasodilatation, inhibition of platelet aggregation, having anticoagulant and profibrinolytic effects, and having an anti-inflammatory effect. Early changes in the normal functioning of the endothelium are key initiating factors in the development and progression of atherosclerosis. These changes are present well before the presentation of clinical symptoms. Thus, researchers have focused much attention on developing methods for reliable non-invasive testing of endothelial function to allow early detection and monitoring and progression of subclinical atherosclerosis. To date, there is a wide range of methods in use to assess endothelial function, each with its own advantages and limitations. Ideally, the tests should be non-invasive to allow repeated measurements and be applicable in normal healthy subjects and also in children. Given the wide range of regulatory functions of the endothelium, it is not surprising that there is no single measure of endothelial function that provides all the necessary information regarding vascular integrity in different vascular beds. Therefore, a combination of tests examining different components of the vascular system is more appropriate. Since patients with rheumatoid arthritis have increased mortality due to cardiovascular disease, assessment of endothelial function could prove to be useful tools in the identification and monitoring of cardiovascular risk. The purpose of this review is to give a brief overview of some of the commonly used techniques for assessment of endothelial function, and in particular on those that have been used in studies of patients with rheumatoid arthritis.

Hypercholesterolemia and microvascular dysfunction: interventional strategies

Hypercholesterolemia is defined as excessively high plasma cholesterol levels, and is a strong risk factor for many negative cardiovascular events. Total cholesterol levels above 200 mg/dl have repeatedly been correlated as an independent risk factor for development of peripheral vascular (PVD) and coronary artery disease (CAD), and considerable attention has been directed toward evaluating mechanisms by which hypercholesterolemia may impact vascular outcomes; these include both results of direct cholesterol lowering therapies and alternative interventions for improving vascular function. With specific relevance to the microcirculation, it has been clearly demonstrated that evolution of hypercholesterolemia is associated with endothelial cell dysfunction, a near-complete abrogation in vascular nitric oxide bioavailability, elevated oxidant stress, and the creation of a strongly pro-inflammatory condition; symptoms which can culminate in profound impairments/alterations to vascular reactivity. Effective interventional treatments can be challenging as certain genetic risk factors simply cannot be ignored. However, some hypercholesterolemia treatment options that have become widely used, including pharmaceutical therapies which can decrease circulating cholesterol by preventing either its formation in the liver or its absorption in the intestine, also have pleiotropic effects with can directly improve peripheral vascular outcomes. While physical activity is known to decrease PVD/CAD risk factors, including obesity, psychological stress, impaired glycemic control, and hypertension, this will also increase circulating levels of high density lipoprotein and improving both cardiac and vascular function. This review will provide an overview of the mechanistic consequences of the predominant pharmaceutical interventions and chronic exercise to treat hypercholesterolemia through their impacts on chronic sub-acute inflammation, oxidative stress, and microvascular structure/function relationships.

Effect of atorvastatin on inflammation and modification of vascular risk factors in rheumatoid arthritis

OBJECTIVE

To investigate the effect of atorvastatin therapy on inflammation, disease activity, endothelial dysfunction, and arterial stiffness in patients with rheumatoid arthritis (RA).

METHODS

This study included 30 patients with early RA, randomly divided into 2 groups. Group 1 (n = 15) received methotrexate (MTX; 0.2 mg/kg/week; mean (15.5 ± SD 1.3) plus prednisone (10 mg/day). Group 2 (n = 15) received MTX and prednisone with the same previous doses plus atorvastatin therapy (40 mg/day). Ten healthy individuals of similar age and sex served as controls. Disease activity, lipid profile, serum malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), resistin, adiponectin, and brachial artery flow-mediated dilation (FMD) were measured before and after 6 months of treatment.

RESULTS

Atorvastatin combined with MTX therapy significantly reduced serum total cholesterol, low-density lipoprotein cholesterol, and triglycerides, and increased high-density lipoprotein cholesterol (p < 0.001). Disease activity variables, serum MDA, TNF-α, resistin, adiponectin, and FMD were significantly improved by the drug combinations (p < 0.001).

CONCLUSION

Atorvastatin therapy in patients with RA reduced disease activity and conventional and novel vascular risk factors that promote the atheromatous lesion. Therapy was also associated with concomitant improvement in endothelial function.

Intensive lipid lowering in patients with rheumatoid arthritis and previous myocardial infarction: an explorative analysis from the incremental decrease in endpoints through aggressive lipid lowering (IDEAL) trial

OBJECTIVES

Documentation on secondary prevention with statins in RA patients with coronary heart disease (CHD) is limited, despite the increased risk of CHD in RA. Our objective was to describe the effect of statin treatment on lipid levels and cardiovascular disease (CVD) events in patients with RA who participated in the incremental decrease in endpoints through aggressive lipid lowering (IDEAL) study.

METHODS

Patients with previous myocardial infarction (MI) were randomly assigned to atorvastatin 80 mg daily or simvastatin 20-40 mg daily and followed for 4.8 years. We focused on changes in lipid levels in the current exploratory analyses and used the composite secondary endpoint in the IDEAL study: any CVD event. Out of the 8888 patients in the IDEAL study, 87 had RA.

RESULTS

RA patients had significantly lower baseline levels of total- and low-density lipoprotein (LDL) cholesterol than patients without RA; 4.8 + 1.0 vs 5.1 + 1.0 (P = 0.023) and 2.9 + 0.9 vs 3.1 + 0.9 mmol/l (P = 0.034) for total cholesterol and LDL, respectively. The lipid reductions with either simvastatin or atorvastatin were comparable. Cardiovascular events occurred in 23/87 (26.4%) of the RA patients compared with 2523/8801 (28.7%; P = 0.70) in the general IDEAL population. The occurrence of these events was not related to the duration of RA, age, gender or treatment assignment.

CONCLUSION

Patients with RA and previous MI had comparable lipid-lowering effect and similar rates of cardiovascular events as those without RA, although the RA patients had lower baseline cholesterol levels than patients without RA.

Statins and the joint: multiple targets for a global protection?

OBJECTIVES

Evidence exists that the pleiotropic properties of the hydroxy-methyl-glutaryl Coenzyme A reductase inhibitors (statins) are not restricted to the cardiovascular system, as they can also favorably affect the joints, with intriguing implications for the treatment of many rheumatic diseases. In the view of the increasing interest on this topic, we here review the current state of the art.

METHODS

The PubMed database was searched for articles published between 1966 and 2010 for key words referring to statins and joint diseases. All relevant English-written articles were reviewed.

RESULTS

Many pivotal studies clearly demonstrated that HMG-CoA reductase inhibitors exert a wide spectrum of beneficial effects on the 3 main compartments of the joint, ie, the synovium, the cartilage, and the subchondral bone. Such (1) anti-inflammatory, (2) immunomodulating, and (3) anabolic effects strongly support a potential role of these drugs in the treatment and/or the prevention of the most important chronic joint diseases. However, although the majority of the in vivo studies with statins on animal models of inflammatory and degenerative joint diseases showed a marked protective activity substantially confirming the in vitro experiments, data arising from clinical trials are less probative and more conflicting.

CONCLUSIONS

Statins display multiple joint-protective effects. Since oral administration of statins could result in a relatively low drug bioavailability to the joints, alternative routes of administration of the drug (transdermal, intra-articular) and/or specific delivery systems should be developed to establish the entire therapeutic potential of statins in this clinical setting.

Assessment of atherosclerosis: the role of flow-mediated dilatation

Evidence suggests that endothelial dysfunction is on the causal pathway for both atherogenesis and destabilization of established plaques. In this review, the role of flow-mediated dilatation (FMD) as a non-invasive method to assess endothelial function is discussed. Technical modifications and development of analysis software have significantly improved the variability of the method. Following a strict standardized protocol enables reproducible measurements to be achieved and export of the technique from specialized laboratories to population studies and multicentre settings. Endothelial function assessed by FMD has been shown to be affected by cardiovascular risk factors, to be related to structural arterial disease and to cardiovascular outcome, validating its use for studying the pathophysiology of arterial disease. Numerous studies have also demonstrated that it is responsive to physiological and pharmacological interventions. Flow-mediated dilatation provides unique opportunities in drug development programmes to assess an early rapidly responsive signal of risk or benefit, complementing endpoints of structural arterial disease and cardiovascular outcomes that take much longer and are more expensive.

Cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment

Morbidity and mortality rates are higher in individuals with rheumatoid arthritis (RA) than in the general population. Ischemic heart disease and heart failure now represent one of the most common causes of death in RA. Indeed, RA appears to represent an independent risk factor for ischemic heart disease, similar to diabetes mellitus. However, no clear guidelines with regard to cardiovascular disease diagnosis and prevention in RA have been developed. This review highlights recent investigations on the assessment, prevention, and treatment of cardiovascular disease in RA.

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.

Non-atheroprotective effects of statins: a systematic review

Since the introduction of HMG-CoA reductase inhibitors (statins) for lowering lipids, a large amount of data has been published demonstrating their potential benefits in conditions as varied as cancer, osteoporosis, and Alzheimer's dementia. We reviewed the published literature on MEDLINE from articles between 1950 and 2008 on the non-atheroprotective effects of statins and noted consistent benefits of statin use in improving outcomes of ventricular arrhythmias, sudden cardiac death, cardiac transplant rejection, chronic obstructive pulmonary disease, and sepsis. However, for these conditions, the level of evidence was inadequate to recommend statin use. The evidence for improving outcomes in atrial fibrillation, mortality in heart failure, contrast-induced nephropathy, cataract, age-related macular degeneration, sub-arachnoid hemorrhage, osteoporosis, dementia, and cancer incidence was conflicting and inconclusive. Furthermore, we found that most of the literature consists of small observational studies and their conclusions are often not corroborated by results from larger or randomized studies. Pending large, well designed, randomized trials, we conclude that there is no definite evidence for the use of statins in any condition besides hyperlipidemia and atherosclerosis.

Relationship between arterial stiffness and Stanford Health Assessment Questionnaire disability in rheumatoid arthritis patients without overt arterial disease

OBJECTIVE

To quantify the relationship between Stanford Health Assessment Questionnaire (HAQ) disability and arterial stiffness in patients with rheumatoid arthritis (RA).

METHODS

A consecutive series of 114 patients with RA but without overt arterial disease, aged 40-65 years, were recruited from rheumatology clinics. A research nurse measured blood pressure (BP), arterial stiffness (heart rate-adjusted augmentation index), fasting lipids, glucose, erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF). A self-completed patient questionnaire included HAQ, damaged joint count, EuroQol measure of health outcome, and Godin physical activity score. Multiple linear regression (MLR) adjusted for age, sex, smoking pack-years, cholesterol, mean arterial BP, physical activity, daily fruit and vegetable consumption, arthritis duration, ESR, and RA criteria.

RESULTS

Mean age was 54 years (81% women) with a median HAQ of 1.13 (interquartile range 0.50; 1.75). Median RA duration was 10 years, 83% were RF-positive, and median ESR was 16 mm/h. Mean arterial stiffness was 31.5 (SD 7.7), BP 125/82 mm Hg, cholesterol 5.3 mmol/l, and 24% were current smokers. Current therapy included RA disease-modifying agents (90%), prednisolone (11%), and antihypertensive therapy (18%). Arterial stiffness was positively correlated with HAQ (r = 0.42; 95% CI 0.25 to 0.56). On MLR, a 1-point increase in HAQ disability was associated with a 2.8 increase (95% CI 1.1 to 4.4; p = 0.001) in arterial stiffness. Each additional damaged joint was associated with a 0.17 point increase (95% CI 0.04 to 0.29; p = 0.009) in arterial stiffness. The relationship between EuroQol and arterial stiffness was not statistically significant.

CONCLUSION

In patients with RA who are free of overt arterial disease, higher RA disability is associated with increased arterial stiffness independently of traditional cardiovascular risk factors and RA characteristics.

Differential effects of fluvastatin alone or in combination with ezetimibe on lipoprotein subfractions in patients at high risk of coronary events

BACKGROUND

Ezetimibe, a cholesterol-absorption inhibitor, significantly lowers low-density lipoprotein cholesterol (LDL-C) when administered in addition to statin treatment. The effect of ezetimibe on the incidence and progression of vascular disease is elusive. The objective of the study was to examine the effects of fluvastatin plus ezetimibe on lipoprotein subfractions in patients with type 2 diabetes and/or coronary heart disease.

MATERIALS AND METHODS

Ninety patients with LDL-C between 100 and 160 mg dL(-1) were enrolled in this prospective, randomized, single-blind, single-centre study. A total of 84 patients were treated with either fluvastatin 80 mg (n = 28) alone or in combination with ezetimibe 10 mg (n = 56) for 12 weeks to determine the effects on lipids, apolipoproteins and LDL subfractions by equilibrium density gradient ultracentrifugation. This study is registered with ClinicalTrials.gov, number NCT00814723.

RESULTS

Total cholesterol, LDL-C and apolipoprotein B were significantly more reduced in the combined therapy group. High density lipoproteins increased in the fluvastatin-only group and decreased in the combined therapy group. There was a significant difference between the two groups in buoyant and intermediate, but not in dense LDL particles.

CONCLUSIONS

Addition of ezetimibe to fluvastatin resulted in a further reduction of buoyant and intermediate, but not of dense LDL compared with fluvastatin alone.

Pleiotropic effects of ezetimibe: do they really exist?

Ezetimibe represents a new lipid lowering agent which inhibits cholesterol absorption. It effectively reduces low-density lipoprotein cholesterol when administered either alone or in combination with statins. However, its effect on cardiovascular mortality remains under question since it failed to demonstrate any significant changes in the primary endpoints of the recently published ENHANCE and SEAS studies. A possible explanation for this unsuccessful outcome is that ezetimibe lacks pleiotropic effects. This article aims to review the potential pleiotropic effects of the drug mainly on inflammation markers, lipoprotein subfractions and endothelial function.

Targeting cardiovascular risk in rheumatoid arthritis: a dual role for statins

Rheumatoid arthritis (RA) is a prototypical immune-mediated inflammatory disease that is characterized by increased cardiovascular morbidity and mortality, independent of the traditional risk factors for cardiovascular disease. The chronic inflammatory state--a hallmark of RA--is considered to be a driving force for accelerated atherogenesis. Consequently, aggressive control of RA disease activity is thought to be instrumental for cardiovascular risk reduction. Currently, statin-mediated reduction of LDL-cholesterol levels is considered to be the cornerstone of cardiovascular disease prevention. In addition to their lipid-lowering capabilities, statins exert immunomodulatory effects, which could be of dual benefit in the treatment of RA. Guidelines on the reduction of cardiovascular risk in patients with RA are lacking, however, largely owing to the absence of data from randomized controlled trials. This Review focuses on the pathophysiology of cardiovascular events in RA, as well as the need to adjust cardiovascular risk engines to better-accommodate the impact of chronic inflammatory disease over and above the established risk factors to predict cardiovascular risk in patients with RA.

Increased incidence of cardiovascular events in patients with antineutrophil cytoplasmic antibody-associated vasculitides: a matched-pair cohort study

OBJECTIVE

To explore the risk of cardiovascular disease in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAVs) and to assess contributing risk factors.

METHODS

In a retrospective matched-pair cohort study, 113 of 131 patients with AAVs from a vasculitis clinic registry were matched 1:1 for renal function, age at diagnosis, sex, smoking status, and previous history of a cardiovascular disease to patients with noninflammatory chronic kidney disease (CKD). Cardiovascular events were defined as acute coronary syndrome, new-onset angina, symptomatic peripheral vascular disease, stroke, and transient ischemic attack.

RESULTS

Median followup times were 3.4 years for the AAV patients and 4.2 years for the CKD patients. More cardiovascular events occurred in the AAV group (23 of 113) than in the CKD group (16 of 113). Cox regression survival analysis showed a significantly increased risk of a cardiovascular event for AAV patients, with a hazard ratio (HR) of 2.23 (95% confidence interval [95% CI] 1.1-4.4) (P = 0.017). Within the cohort of AAV patients, the most strongly predictive factors were previous history of cardiovascular disease (HR 4 [95% CI 1.7-9.8]), history of dialysis dependency (HR 4.3 [95% CI 1.5-12.1]), ever having smoked (HR 3.9 [95% CI 1.5-10]), age at diagnosis (HR 1.038 [95% CI 1.006-1.072]), estimated glomerular filtration rate at remission (HR 0.977 [95% CI 0.957-0.998]), and serum cholesterol concentration at presentation (HR 0.637 [95% CI 0.441-0.92]).

CONCLUSION

In this retrospective study, patients with AAVs appear at greater risk of cardiovascular disease, with increased risk in those with a previous history of cardiovascular disease, dialysis dependency, poor renal function at remission, or a history of smoking. Measures to reduce the risk of cardiovascular disease should be integral to the management of systemic vasculitis.

Dietary supplementation with cis-9,trans-11 conjugated linoleic acid and aortic stiffness in overweight and obese adults

BACKGROUND

Animal studies suggest that dietary cis-9,trans-11 (c9,t11) conjugated linoleic acid (CLA) may inhibit or regress the development of atherosclerosis. The effect of CLA on atherosclerosis has not been assessed in humans.

OBJECTIVE

We investigated the effect of c9,t11 CLA supplementation on aortic pulse wave velocity (a marker of atherosclerosis) and on cardiovascular risk factors in overweight and obese but otherwise apparently healthy subjects.

DESIGN

In a double-blind, randomized, placebo-controlled, parallel-group trial, we randomly assigned 401 subjects, aged 40-70 y and with a body mass index (in kg/m(2)) > or = 25, to receive either 4 g CLA/d (2.5 g c9,t11 CLA/d and 0.6 g trans-10,cis-12 CLA/d) or placebo supplements for 6 mo. Aortic pulse wave velocity, blood pressure, anthropometric characteristics, and concentrations of fasting lipid, glucose, insulin, and C-reactive protein were measured before and after supplementation.

RESULTS

During the intervention, mean (+/-SE) pulse wave velocity did not change in the c9,t11 CLA group (Delta0.00 +/- 0.07) compared with the placebo group (Delta0.09 +/- 0.06). There was no effect of c9,t11 CLA supplementation on blood pressure, body composition, insulin resistance, or concentrations of lipid, glucose, and C-reactive protein.

CONCLUSION

This study does not support an antiatherosclerotic effect or an effect on cardiovascular risk factors of c9,t11 CLA. This trial was registered at www.clinicaltrials.gov as NCT00706745.

Tumor necrosis factor-alpha antagonists improve aortic stiffness in patients with inflammatory arthropathies: a controlled study

The chronic inflammatory state of rheumatoid arthritis and other inflammatory arthropathies, such as ankylosing spondylitis and psoriatic arthritis, contributes to the accelerated atherosclerosis associated with these conditions. This study evaluates the effect of treatment with tumor necrosis factor (TNF)-alpha antagonists on arterial stiffness in patients with inflammatory arthropathies. A total of 60 patients with rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis and clinical indication for anti-TNF-alpha therapy were included. Thirty-five patients started with anti-TNF-alpha therapy and were compared with a nontreatment group of 25 patients. Aortic stiffness (aortic pulse wave velocity), augmentation index, and disease activity were assessed at baseline and after 3 months. Aortic pulse wave velocity (mean+/-SD) was reduced in the treatment group but not in the control group (-0.50+/-0.78 m/s versus 0.05+/-0.54 m/s, respectively; P=0.002). Concomitantly, C-reactive protein and the disease activity score were reduced in the treatment group (-9.3+/-20.2 mg/L [P<0.001] and -0.74+/-0.91 [P=0.004]). Augmentation index remained unchanged in both groups (0.1+/-7.1% versus -1.0+/-5.8%, respectively; P=0.53). In a multivariate linear regression model, only treatment with TNF-alpha antagonist and change in mean arterial pressure predicted alterations in aortic pulse wave velocity. In summary, anti-TNF-alpha therapy improved aortic stiffness in patients with inflammatory arthropathies. These findings support the idea that anti-inflammatory treatment has a favorable effect on cardiovascular risk in patients with inflammatory arthropathies.

Effects of atorvastatin on arterial stiffness in chronic kidney disease: a randomised controlled trial

AIM

Central pulse pressure and measures of arterial stiffness (augmentation index (AIx) and aortic pulse wave velocity (PWV)) predict morbidity and mortality in patients with stage 2-4 chronic kidney disease (CKD). Although statin therapy may be of vascular benefit in patients with CKD, the long-term effect of statins on central pulse pressure and arterial stiffness has not been assessed in this patient population. Hence, the aim of this study was to assess the long-term effects of atorvastatin on arterial stiffness and central blood pressure in patients with CKD.

METHODS

We enrolled 37 patients with serum creatinine levels > 1.36 mg/dL into a randomized, double blind trial. Patients were allocated to receive 10 mg of atorvastatin per day (19) or placebo (18) for three years. Aortic PWV, AIx, estimated central and brachial blood pressures and were determined every nine months.

RESULTS

At baseline, there were no significant differences in aortic PWV, AIx, central or brachial blood pressures between atorvastatin-treated and placebo-treated patients. During the trial, aortic PWV significantly (p=0.05) increased in placebo-treated, but not (p=0.10) in atorvastatin-treated patients (0.51+/-0.95 vs. 0.30+/-0.75 m/sec/yr; p=0.48). This represented a 41% (but not statistically significant) slowing of the rate of increase in aortic stiffness. There were no significant changes between groups in the rate of change of AIx (atorvastatin -0.15+/-5.65 vs. placebo 0.39+/-5.38%/yr, p=0.53) or central pulse pressure (atorvastatin -2.32+/-7.46 vs. placebo -0.36+/-6.64 mmHg/yr p= 0.61).

CONCLUSION

In patients with CKD arterial stiffness measured by aortic PWV showed a significant increase over time in placebo-treated patients but not in atorvastatin-treated patients.

The role of flow-mediated dilatation in the evaluation and development of antiatherosclerotic drugs

PURPOSE OF REVIEW

The present article reviews the use of flow-mediated dilatation in clinical cardiovascular research. Its value as a surrogate tool for development of antiatherosclerotic drugs and noninvasive assessment of cardiovascular risk is also discussed.

RECENT FINDINGS

Atherosclerosis remains the leading cause of cardiovascular morbidity and mortality. Development of new drugs is required to target both the evolution of this disease and its clinical consequences. Noninvasive measures of arterial function and structure have been widely used as intermediate phenotypes in clinical trials. Numerous studies have demonstrated the interplay between vascular risk factors and endothelial function as assessed by flow-mediated dilatation in children and adults. Additionally, a number of studies have documented the prognostic value of the method.

SUMMARY

Detection of early arterial changes can prove particularly useful in clinical research for the development of antiatherosclerotic drugs. They permit identification of vascular toxicity as well as characterization of the safety and risk profile of a new cardiovascular treatment modality on vascular health. This approach is likely to prove cost-effective before embarking on large longitudinal studies to assess cardiovascular morbidity and mortality.

The impact of ezetimibe on endothelial function and other markers of cardiovascular risk

OBJECTIVE

To review the published literature characterizing the impact of ezetimibe-containing lipid-lowering regimens on endothelial function and other markers of cardiovascular risk and discuss the potential relevance of these effects to the clinical benefit of ezetimibe.

DATA SOURCES

A MEDLINE search (2000-August 2009) was completed using the key words ezetimibe, statins, endothelial function, flow-mediated dilation, pleiotropic, and inflammation to identify relevant literature. Bibliographies of identified literature were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION

All clinical studies published in English that evaluated the effect of ezetimibe on ancillary endpoints of cardiovascular disease risk, including endothelial function, inflammation, thrombosis, and oxidative stress, were evaluated.

DATA SYNTHESIS

Recent studies in patients with coronary artery disease (CAD), heart failure, and hypercholesterolemia have demonstrated that treatment with ezetimibe for 4-12 weeks elicits no improvement of endothelial function or other measures of cardiovascular disease risk. In contrast, other studies have reported that ezetimibe improves endothelial function in certain patient populations, including those with rheumatoid arthritis, CAD with type 2 diabetes, and metabolic syndrome. However, the statin monotherapy comparator groups in these studies that yielded equivalent reductions in cholesterol were superior, or at least equivalent to, ezetimibe-containing regimens in the improvement of these ancillary endpoints.

CONCLUSIONS

Overall, the evidence to date suggests that administration of ezetimibe, either as monotherapy or in combination with a statin, exerts minimal beneficial effects on endothelial function and other ancillary measures of cardiovascular disease risk beyond those conferred by its cholesterol-lowering effects. Studies with larger sample sizes and follow-up beyond 12 weeks remain necessary to further define the impact of ezetimibe on the processes integral to the pathogenesis and progression of cardiovascular disease.

Lipid lowering versus pleiotropic effects of statins on skin microvascular function in patients with dysglycaemia and coronary artery disease

OBJECTIVES

To investigate the impact of lipid lowering therapy by different means on skin microvascular function in patients with dysglycaemia and coronary artery disease (CAD).

DESIGN AND SETTING

Thirty-six patients were randomized to simvastatin 80 mg daily (S80, n = 19) or ezetimibe 10 mg and simvastatin 10 mg daily (E10/S10, n = 17) for 6 weeks. Skin microvascular function was assessed by laser Doppler fluxmetry (LDF) at rest, following arterial occlusion (peak postocclusive LDF) and following local heating on the forearm (heat arm LDF) and foot (heat foot LDF). LDF parameters and serum lipids were evaluated at baseline and follow-up.

RESULTS

At follow-up, LDL cholesterol had decreased from 3.1 (2.7-3.5) to 1.6 (1.5-1.8) (mmol L(-1)) and 3.0 (2.4-3.9) to 1.3 (1.1-1.8) (mmol L(-1)) in the E10/S10 and S80 groups respectively. In the entire study group (n = 32), LDF parameters increased significantly; postocclusive LDF from 22 (17-27) to 26 (21-32) perfusion units (PU) (P < 0.001), heat foot LDF from 61 (44-82) to 66 (45-83) PU (P < 0.001) and heat arm LDF from 60 (48-121) to 75 (54-125) PU (P < 0.01). The changes in LDF parameters did not differ between the E10/S10 and S80 groups.

CONCLUSIONS

Lipid lowering improves microvascular function in patients with dysglycaemia and CAD. The data suggest that lipid lowering per se is more important than pleiotropic effects of statins for this effect.