Atherosclerotic disease is increased in recent-onset rheumatoid arthritis: a critical role for inflammation

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.

Atherosclerosis in early rheumatoid arthritis: very early endothelial activation and rapid progression of intima media thickness

Introduction

In this study we aimed to investigate whether there are indications of premature atherosclerosis, as measured by endothelial dependent flow-mediated dilation (ED-FMD) and intima media thickness (IMT), in patients with very early RA, and to analyze its relation to biomarkers of endothelial dysfunction, taking inflammation and traditional cardiovascular disease (CVD) risk factors into account.

Methods

Patients from the three northern counties of Sweden diagnosed with early RA are followed in an ongoing prospective study of CVD co-morbidity. Of these, all patients aged ≤60 years were consecutively included in this survey of CVD risk factors (n = 79). Forty-four age and sex matched controls were included. IMT of common carotid artery and ED-FMD of brachial artery were measured using ultrasonography. Blood was drawn for analysis of lipids, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA)-mass, VonWillebrand factor (VWF), soluble intercellular adhesion molecule-1 (sICAM), soluble vascular cell adhesion molecule-1 (sVCAM), sE-selectin, sL-selectin and monocyte chemotactic protein-1 (MCP-1). In a subgroup of 27 RA patients and their controls the ultrasound measurements were reanalysed after 18 months.

Results

There were no significant differences between RA patients and controls in terms of IMT or ED-FMD at the first evaluation. However after 18 months there was a significant increase in the IMT among the patients with RA (P < 0.05). Patients with RA had higher levels of VWF, sICAM-1 (P < 0.05) and of MCP-1 (P = 0.001) compared with controls. In RA, IMT was related to some of the traditional CVD risk factors, tPA-mass, VWF (P < 0.01) and MCP-1 and inversely to sL-selectin (P < 0.05). In RA, ED-FMD related to sL-selectin (P < 0.01). DAS28 at baseline was related to PAI-1, tPA-mass and inversely to sVCAM-1 (P < 0.05) and sL-selectin (P = 0.001).

Conclusions

We found no signs of atherosclerosis in patients with newly diagnosed RA compared with controls. However, in patients with early RA, IMT and ED-FMD were, to a greater extent than in controls, related to biomarkers known to be associated with endothelial dysfunction and atherosclerosis. After 18 months, IMT had increased significantly in RA patients but not in controls.

Rheumatic Disease and Carotid Intima-Media Thickness

Objective— To perform a systematic review and meta-analysis to examine whether rheumatic disease is associated with an increased carotid intima-media thickness (CIMT; increasingly used as a surrogate marker for atherosclerosis) when compared with healthy control subjects.

Methods and Results— A prespecified search strategy was used to identify relevant studies in the MEDLINE and EMBASE databases (January 1, 1986 to December 31, 2008). Methodological quality was assessed using the Newcastle-Ottawa score for observational studies. A total of 68 controlled comparisons from 60 different studies were reviewed: 25 (37%) on rheumatoid arthritis, 24 (35%) on systemic lupus erythematosus, 6 (9%) on systemic sclerosis, and 13 (19%) on other rheumatic diseases. Random-effects meta-regression analysis was performed. The estimated summary effect size between control and study subject CIMT measurement comparisons, with preexisting cardiovascular disease excluded, was 0.64 (95% CI, 0.46 to 0.82). This represented an overall absolute mean difference of 0.06 mm (95% CI, 0.05 to 0.06 mm). Preexisting cardiovascular disease, rheumatic disease type, and disease duration contributed to heterogeneity.

Conclusion— Accelerated atherosclerosis is a common complication of autoimmune rheumatic diseases, with early changes seen even in pediatric patients. CIMT was significantly increased in rheumatic disease populations. Future studies need to use a standardized protocol to ensure clinically meaningful results when measuring CIMT as a surrogate for premature atherosclerosis.

Antibodies against oxidized low-density lipoprotein are associated with subclinical atherosclerosis in recent-onset rheumatoid arthritis

Rheumatoid arthritis (RA) patients have increased mortality largely as a result of cardiovascular diseases (CVD) that cannot be explained by traditional risk factors, suggesting that systemic inflammation may accelerate atherosclerosis. We investigated the presence of subclinical atherosclerosis in early RA (<12 months) and the possible association of RA-related risk factors. Forty patients with early RA and 40 controls matched for age, sex, and traditional risk factors for CVD were selected. Carotid US examination, assay of lipogram, C-reactive protein (CRP), and oxidized low-density lipoprotein antibodies (OxLDL-ab) were done. RA patients had significantly higher carotid intima-media thickness (cIMT) values and more plaque than the control (P<0.001 and P=0.0122, respectively). CRP and OxLDL-ab were significantly higher in RA patients than controls. Traditional risk factors and RA-related risk factors (disease duration, DAS-28, duration of treatment with steroids, erythrocyte sedimentation rate, and CRP) as well as OxLDL and cIMT were significantly higher in RA with plaques compared to those without plaques. Regression analysis identified the age of patients, CRP, and OxLDL-ab as an independent risk factor associated with the presence of atherosclerosis.

CONCLUSION

there is increased prevalence of carotid plaques in patients with recent-onset RA compared to matched controls. The accelerated atherosclerosis is predicted by age, CRP, and oxLDL-ab. The association of plaques with elevated CRP and OxLDL-ab support the hypothesis that chronic systemic autoimmune inflammatory process is probably a driving force for premature atherosclerosis.

Increased prevalence of carotid artery atherosclerosis in rheumatoid arthritis is artery-specific

OBJECTIVE

Cardiovascular (CV) morbidity and mortality are increased in rheumatoid arthritis (RA). Prior investigations of the association of RA with measures of carotid atherosclerosis have yielded conflicting results. We compared carotid intima-media thickness (IMT) of both the common carotid (CCA) and proximal internal carotid (bulb-ICA) arteries, and plaque prevalence, between RA and non-RA participants.

METHODS

Subjects with RA were participants in a cohort study of subclinical CV disease in RA. Non-RA controls were selected from the Multi-Ethnic Study of Atherosclerosis. Both groups underwent B-mode ultrasonography of the right and left CCA and bulb-ICA. Linear regression was used to model the association of RA status with CCA and bulb-ICA-IMT, and logistic regression for the association of RA status with plaque.

RESULTS

We compared 195 RA patients to 198 non-RA controls. CV risk factors were similarly distributed, except for a higher prevalence of hypertension in the RA group. Mean adjusted bulb-ICA-IMT was higher in RA patients than controls (1.16 vs 1.02 mm, respectively; p < 0.001), while mean adjusted CCA-IMT did not differ significantly. After adjusting for CV risk factors, the odds of plaque were significantly increased in RA participants compared to controls (OR 2.41, 95% CI 1.26-4.61). The association of gender, age, smoking, and hypertension with bulb-ICA-IMT and plaque did not significantly differ by RA status. Interleukin 6 was strongly associated with bulb-ICA-IMT and plaque in controls but not in RA patients. In the RA group, shared epitope was associated with an increased prevalence of plaque.

CONCLUSION

Compared to controls, RA was associated with a higher prevalence and higher severity of atherosclerosis in the bulb-ICA but not the CCA. Our data suggest that future studies in RA that utilize carotid artery measurements should include assessment of the bulb-ICA.

Inflammatory mediators and premature coronary atherosclerosis in rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is an inflammatory disease associated with premature atherosclerosis. We hypothesized that mediators of inflammation associated with atherosclerosis in other populations (interleukin-6 [IL-6], tumor necrosis factor alpha [TNFalpha], serum amyloid A [SAA], vascular endothelial growth factor, neutrophil count, IL-1alpha, E-selectin, intercellular adhesion molecule 1 [ICAM-1], myeloperoxidase [MPO], matrix metalloproteinase 9, and vascular cell adhesion molecule 1) would be increased and associated with the severity of coronary atherosclerosis in patients with RA.

METHODS

Clinical variables, concentrations of inflammatory mediators, and coronary artery calcification were measured in 169 patients with RA and 92 control subjects. Differences in concentrations of inflammatory mediators were compared using median quantile regression. The relationship of inflammatory mediators with the severity of coronary calcification in RA and control subjects was examined using proportional odds logistic regression, allowing for interaction with disease status. Models were adjusted for traditional cardiovascular risk factors.

RESULTS

Median serum concentrations of IL-6, SAA, ICAM-1, E-selectin, TNFalpha, and MPO and peripheral blood neutrophil count were higher in patients with RA than controls (all P < 0.05), independent of Framingham risk score and diabetes mellitus (DM). IL-6 (main effect odds ratio [OR] 1.72; 95% confidence interval [95% CI] 1.12, 2.66) and TNFalpha (main effect OR 1.49; 95% CI 1.16, 1.90) concentrations were significantly associated with higher amounts of coronary calcium, independent of Framingham risk score and DM, and such main effects significantly differed from controls (P = 0.001 and 0.03 for interaction, respectively).

CONCLUSION

TNFalpha and IL-6 are significantly associated with the severity of subclinical atherosclerosis, independent of Framingham risk score, in RA.

Role for TNF in atherosclerosis? Lessons from autoimmune disease

Inflammatory pathways have been implicated in the initiation and progression of cardiovascular diseases. Accelerated atherosclerosis has been described in patients with chronic inflammatory diseases, particularly rheumatoid arthritis, disproportionate to individuals' detectable traditional vascular risk factors. This finding suggests that other pathways associated with inflammation might account for increased vascular risk in such diseases. Highly specific biologic agents can precisely block the activity of cytokines generated during inflammatory cascades; the effects of these inflammatory moieties on vascular physiology and overall risk of cardiovascular events has been directly evaluated. This review summarizes key epidemiologic, physiologic and model data, which together suggest that tumor necrosis factor, a pivotal cytokine in the inflammatory cascade, is directly involved in vascular pathophysiology and that its inhibition might confer an overall advantage to the recipient. Moreover, such data obtained in chronic inflammatory diseases likely have relevance to primary atherosclerosis.

Inflammation predicts accelerated brachial arterial wall changes in patients with recent-onset rheumatoid arthritis

Introduction

Patients with recent-onset rheumatoid arthritis (RA) have impaired brachial artery endothelial function compared with controls matched for age, sex and cardiovascular risk factors. The present study examined endothelium-dependent (flow-mediated dilatation (FMD)) and independent (glyceryl trinitrate (GTN)-mediated dilatation (GMD)) structural responses in early RA patients, and determined progress over one year.

Methods

Brachial artery FMD and GMD and carotid intima media thickness (cIMT) were studied using ultrasound in 20 patients diagnosed with early RA in whom symptoms had been present for less than 12 months, and in 20 control subjects matched for age, sex and established cardiovascular risk factors. FMD and GMD were re-assessed after 12 months in RA patients and the change in each parameter was calculated. Data were analysed by univariate regression.

Results

Mean FMD and GMD were significantly lower in early RA patients at baseline than in controls, but each parameter significantly improved in one year. FMD and GMD responses were positively associated with each other. Patients' age, C-reactive protein (CRP) level and cIMT at baseline and CRP level at one year, were negatively associated with change in brachial responses in one year.

Conclusions

Patients with recent-onset RA have altered brachial artery responses signifying both functional and structural abnormalities. However, early control of inflammation may reduce arterial dysfunction and thus the tendency for atherosclerotic progression.

[Anti-TNF drugs: New results on efficacy]

Anti-TNF drugs have represented a great advancement in the treatment of rheumatoid arthritis since their introduction in the late 1990s. The development of these products has been very similar for etanercept, infliximab and adalimumab, the 3 approved TNF blockers for the treatment of RA. The first studies centered their attention on patients with active disease and refractory to several disease modifying treatments, finding very significant differences when compared to placebo or methotrexate in the ACR improvement scores. Trials in patients who had not been previously treated with methotrexate show less differences between anti-TNF and methotrexate, but becomes more significant when the two drugs are used combined. In this manuscript we analyze the results of the registry of anti-TNF studies with regard to other improvement indexes such as quality of life, reduction in cardiovascular risk, maintained efficacy through time and progression of joint erosions. We also contemplate the possibility of using lower doses than those authorized for rheumatoid arthritis and analyze factors related to a poor prognosis in patients refractory to methotrexate, which is currently the indication for the use of anti-TNF in RA accordiong to the SER consensus.

Common inflammatory mediators orchestrate pathophysiological processes in rheumatoid arthritis and atherosclerosis

RA is characterized by a systemic inflammatory state, in which immune cells and soluble mediators play a crucial role. These inflammatory processes resemble those in other chronic inflammatory diseases, such as atherosclerosis. The chronic systemic inflammation in RA can be considered as an independent risk factor for the development of atherosclerosis, and represents an important field to investigate the reasons of the increase of acute cardiovascular events in RA. In the present review, we focused on several mediators of autoimmunity, inflammation and endothelial dysfunction, which can be considered the most promising targets to prevent atherogenesis in RA. Among several mediators, the pro-inflammatory cytokine TNF-alpha has been shown as a crucial factor to induce atherosclerosis in RA patients.

Inflammation, carotid intima-media thickness and atherosclerosis in rheumatoid arthritis

Carotid intima-media thickness (cIMT) reflects early atherosclerosis and predicts cardiovascular events in the general population. An increased cIMT is present in patients with rheumatoid arthritis, compared with control individuals, from the early stages of the disease and is thought to indicate accelerated atherosclerosis, but direct evidence is not available. Whether cIMT is susceptible to rapid and potentially reversible change depending on the intensity of inflammation in states of high-grade systemic inflammation, such as rheumatoid arthritis, remains unknown. If this is the case, an increased cIMT in such disease states may not reflect structural vessel wall damage, and may not be a good predictor of future cardiovascular events in these particular populations. Prospective, long-term, longitudinal studies are needed to address these questions.

Effect of conjugated linoleic acid, vitamin E and their combination on lipid profiles and blood pressure of Iranian adults with active rheumatoid arthritis

The aim of this study was to assess the impact of conjugated linoleic acids (CLAs), vitamin E, and combination of these nutrients on serum lipid profiles and blood pressure (BP) in patients with active rheumatoid arthritis (RA). In a randomized, double-blind, placebo-controlled trial, 87 patients with active RA were divided into four groups receiving one of the following daily supplements for three months: Group C: CLAs 2.5 g equivalent to 2 g mixture of cis 9-trans 11 and trans 10-cis12 CLAs in a rate of 50/50; Group E: vitamin E: 400 mg; Group CE: CLAs and vitamin E at above doses: Group P: placebo. After supplementation, SBP levels decreased significantly in the group C in comparison with groups E and P and mean arterial pressure reduced significantly in groups C and CE. There weren't significant differences in the levels of prostaglandin E2 (PGE2), triglycerides, cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), LDL/HDL, cholesterol/HDL, fasting blood sugar, C-reactive protein (CRP), arylestrase activity, platelet count and body mass index between groups. CRP dropped nonsignificantly in groups P, C, E and CE (19%, 24%, 55%, and 39%, respectively). Erythrocytes sedimentation rate levels decreased in groups C, E and CE (P < or = 0.05, P < or = 0.05, P < or = 0.001, respectively). It is concluded that supplementation of CLAs decreased BP and vitamin E decreased CRP. Therefore co-supplementation of CLAs and vitamin E might be profitable for heart disease prevention in RA patients.