Prognostic importance of low body mass index in relation to cardiovascular mortality in rheumatoid arthritis

Hyperleptinemia as a Marker of Various Phenotypes of Obesity and Overweight in Women with Rheumatoid Arthritis and Systemic Lupus Erythematosus

The objective of the study was to identify different phenotypes of overweight in women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) based on body mass index (BMI) and serum leptin levels, as well as to determine the frequencies of various metabolic disorders, hypertension, and cardiovascular complications (CVCs) in individual phenotypes. The study included 50 women with RA and 46 with SLE aged 18 to 65 years without a history of diabetes and fasting hyperglycemia. In all patients, the concentration of leptin was determined by ELISA, the concentration of insulin was determined by electrochemiluminescence analysis, and the HOMA-IR index was calculated. Hyperleptinemia was diagnosed at leptin concentrations > 11.1 ng/mL; insulin resistance (IR), at HOMA-IR values ≥ 2.77. Three main phenotypes of overweight were distinguished: "classic" (BMI ≥ 25 kg/m2 + hyperleptinemia), "healthy" (BMI ≥ 25 kg/m2, without hyperleptinemia), "hidden" or "latent" (BMI < 25 kg/m2 + hyperleptinemia), as well as "normal weight" (BMI < 25 kg/m2, without hyperleptinemia). Patients with RA and SLE were similar in age (p = 0.4), disease duration (p = 0.2) and BMI (p = 0.5). Hyperleptinemia was found in 46% of women with RA and in 74% of women with SLE (p = 0.005), and IR was found in 10 and 22% of patients, respectively (p = 0.2). The "classic" phenotype of overweight was diagnosed in 30%, "healthy" in 8%, and "hidden" in 16% of cases with RA and in 44%, 0%, and 30% of cases with SLE, respectively. IR was found in 3% and hypertension in 6% of patients with "normal weight." With the "classic" phenotype, IR (29%) and hypertension (66%) were more common than with "normal weight" (p < 0.01 in all cases); with the "hidden" phenotype, significant differences were obtained only in hypertension frequency (45%; p = 0.0012), but not IR (18%). Three out of four women with a history of cardiovascular complications suffered from "classic" overweight, and one patient had a "normal weight." In women with SLE up to 65 years of age, the frequency of hyperleptinemia, but not IR, is higher than in patients with RA. In both diseases, the "classic" overweight phenotype is most common. In RA, a "hidden" phenotype was detected less often than in SLE, at the same time, a "healthy" phenotype is not characteristic of SLE. The frequency of metabolic disorders and hypertension is low with the "normal weight" and "healthy" phenotype, high with the "classic" phenotype, and intermediate with the "hidden" phenotype.

Association between the advanced lung cancer inflammation index and all-cause and cardiovascular mortality in patients with RA: Insights from NHANES data analysis

Background

Rheumatoid arthritis (RA) is associated with significant mortality, which is primarily due to cardiovascular complications. Despite advancements in RA treatment, mortality rates remain high, highlighting the need for reliable prognostic markers. The advanced lung cancer inflammation index (ALI), which integrates inflammatory and nutritional biomarkers, has shown promise in predicting outcomes in various medical conditions. However, its role in RA prognosis remains unclear.

Methods

This study aimed to investigate the associations between the ALI and all-cause mortality, as well as cardiovascular mortality, in RA patients using data from the National Health and Nutrition Examination Survey (NHANES). A total of 1568 RA patients were included, and the ALI was calculated using body mass index (BMI), serum ALB, and the neutrophil-to-lymphocyte ratio. Comprehensive demographic, lifestyle, and metabolic data from the NHANES enabled adjustments for potential confounders. Multivariate Cox regression and sensitivity analyses were conducted to assess the associations between the ALI and mortality outcomes.

Results

Our findings demonstrate an inverse association between the ALI and both all-cause and cardiovascular mortality in RA patients. Furthermore, a nonlinear relationship was observed, with mortality risk increasing significantly below a certain ALI threshold. Stratified analyses revealed a protective effect of the ALI across various demographic and clinical subgroups, underscoring its potential as a prognostic marker in patients with RA.

Conclusion

The ALI holds promise as a valuable prognostic marker for identifying high-risk individuals and guiding personalized management strategies for patients with RA. However, further validation in prospective studies is warranted to confirm its clinical utility. Nonetheless, the potential implications of the ALI for improving the prognosis of patients with RA underscore the importance of its continued investigation in clinical practice.

Tumor Necrosis Factor Alpha Inhibitors and Cardiovascular Risk in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by an increased risk of cardiovascular events, due to the complex interplay between traditional and disease-related risk factors. Chronic inflammation and persistent disease activity are the key determinants of this risk, but despite great improvement in the disease management and prognosis, cardiovascular events are still the main cause of morbidity and mortality in RA cohorts1. In the last decades, the advent of new biological and targeted-synthetic DMARDs was accompanied by an improvement in disease activity control, but the role of each class of drugs on CVD risk is still a matter a debate. Since their approval for RA treatment, tumor necrosis factor alpha (TNFα) inhibitors have been widely investigated to better understand their effects on cardiovascular outcomes. The hypothesis that the reduction of chronic inflammation with any treatment may reduce the cardiovascular risk has been recently confuted by the direct comparison of TNFα-inhibitors and JAK inhibitors in patients with RA and coexisting risk factors for cardiovascular disease. The aim of this literature review is to add to the available evidence to analyze the relationship between TNFα-inhibitors and CVD risk in patients with RA and also provide some clinical scenarios to better explain the treatment dilemmas. In particular, while data on major cardiovascular events and thromboembolism seem consistent with an inflammation-mediated benefit with TNFα-inhibitors, there remain concerns about the use of this class of bDMARDs in patients with chronic heart failure.

Prevalence of Malnutrition and Associated Factors in Older Patients with Rheumatoid Arthritis: A Cross-Sectional Study

OBJECTIVE

To describe the frequency of malnutrition in older patients with rheumatoid arthritis (RA) and investigate associated risk factors.

METHODS

This multicenter, cross-sectional study included participants aged ≥65 years who met the 2010 ACR/EULAR criteria for RA. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF) and based on variables, such as albumin level, the Geriatric Nutritional Risk Index (GNRI), and vitamin D. Data were also collected on epidemiological variables, inflammatory disease activity, quality of life, physical function, and frailty. Multivariate models were used to study factors associated with nutritional status.

RESULTS

The study population comprised 76 RA patients aged ≥65 years, of whom 68.4% had a normal nutritional status, and 31.5% had an impaired nutritional status: 28.9% were at risk of malnutrition, and 2.6% were malnourished. Additionally, 10% had albumin levels <3.8 g/L. Patients with impaired nutritional status had poorer quality of life and physical function. The factors associated with compromised nutritional status (OR [95% CI]) were age (1.0 [1.0-1.1]; p = 0.035), DAS28-ESR (1.8 [1.0-3.2]; p = 0.024), and EuroQoL-5D-5L (0.9 [0.9-0.9]; p = 0.040). Furthermore, the GNRI was associated with the MNA score (0.06 [0.0-0.1]; p = 0.014).

CONCLUSIONS

Approximately one-third of older patients with RA have impaired nutritional status. Older age, higher inflammatory disease activity, and decreased quality of life are associated with impaired nutritional status. The MNA and GNRI are valuable tools for assessing the nutritional status of patients with RA.

Physical attractiveness and cardiometabolic risk

OBJECTIVES

There is only limited evidence suggesting that physical attractiveness and individuals' actual health are causally linked. Past studies demonstrate that characteristics related to physical attractiveness are more likely to be present in healthy individuals, including those with better cardiovascular and metabolic health, yet many of these studies do not account for individuals' initial health and socioeconomic characteristics, which are related to both physical attractiveness and later life health.

METHODS

We use panel survey data from the National Longitudinal Study of Adolescent to Adult Health in the United States to examine the relationship between interviewer-rated in-person physical attractiveness and actual cardiometabolic risk (CMR) based on a set of relevant biomarkers: LDL cholesterol, glucose mg/dL, C-reactive protein, systolic and diastolic blood pressure, and resting heart rate.

RESULTS

We identify a robust relationship between individuals' physical attractiveness and 10-year follow up actual health measured by the levels of CMR. Individuals of above-average attractiveness appear to be noticeably healthier than those who are described as having average attractiveness. We find that individuals' gender and race/ethnicity do not have a major effect on the described relationship. The link between physical attractiveness and health is affected by interviewers' main demographic characteristics. We carefully address the possibility of confounders affecting our results including sociodemographic and socioeconomic characteristics, cognitive and personality traits, initial health problems and BMI.

CONCLUSION

Our findings are largely in line with the evolutionary perspective which assumes that physical attractiveness is linked to individuals' biological health. Being perceived as physically attractive might also imply, among other aspects, high levels of satisfaction with life, self-confidence and ease of finding intimate partners, all of which can positively affect individuals' health.

Comparison of Cardiovascular Outcomes in Patients With and Without Rheumatoid Arthritis: A Meta-Analysis of Observational Studies

The aim of this meta-analysis was to determine the risk of incident cardiovascular disease (CVD) in patients with rheumatoid arthritis compared to patients without rheumatoid arthritis. We conducted a thorough search of online databases, including PubMed, EMBASE, and Web of Science, to identify English-language publications examining cardiovascular outcomes in patients with rheumatoid arthritis from January 1, 2005, to May 15, 2023. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was performed using relevant keywords such as "rheumatoid arthritis," "cardiovascular diseases," and "risk," along with their synonyms. Medical subject heading (MeSH) terms and Boolean operators (AND, OR) were employed to optimize the search. Outcomes assessed in this study included composite cardiovascular events (as defined by individual studies), myocardial infarction, and stroke (including ischemic and hemorrhagic stroke). Overall, 14 studies met the inclusion criteria and were included in the present meta-analysis. We found that the risk of composite CVD was higher in patients with rheumatoid arthritis compared to patients without rheumatoid arthritis. We also found a higher risk of myocardial infarction and stroke in rheumatoid arthritis patients compared to their counterparts. This study demonstrates the elevated risk of CVD in patients with rheumatoid arthritis and highlights the importance of incorporating cardiovascular management and assessment into the care of these patients.

Atherosclerotic Cardiovascular Risk Stratification in the Rheumatic Diseases:: An Integrative, Multiparametric Approach

Cardiovascular disease (CVD) risk is increased in most inflammatory rheumatic diseases (IRDs), reiterating the role of inflammation in the initiation and progression of atherosclerosis. An inverse association of CVD risk with body weight and lipid levels has been described in IRDs. Coronary artery calcium scores, plaque burden and characteristics, and carotid plaques on ultrasound optimize CVD risk estimate in IRDs. Biomarkers of cardiac injury, autoantibodies, lipid biomarkers, and cytokines also improve risk assessment in IRDs. Machine learning and deep learning algorithms for phenotype and image analysis hold promise to improve CVD risk stratification in IRDs.

Rheumatoid cachexia in early rheumatoid arthritis: prevalence and associated variables

OBJECTIVE

Rheumatoid cachexia (RC) is prevalent among patients with established rheumatoid arthritis (RA). Although changes in muscle mass and fat mass have been reported in early RA, these findings have not been classified according to existing RC definitions. This study aimed to describe the prevalence of RC and associated variables in patients with early RA.

METHOD

This cross-sectional study included 87 patients. Body composition was evaluated with dual-energy X-ray absorptiometry after a median disease duration of 15 months. RC was defined as a fat-free mass index < 10th percentile and fat mass index > 25th percentile. We also assessed the erythrocyte sedimentation rate (ESR), C-reactive protein, Disease Activity Score in 28 joints, aerobic capacity, physical activity, traditional cardiovascular disease risk factors, functional disability, and sociodemographic data. Associations between RC and the independent variables were determined with logistic regression analyses.

RESULTS

The prevalence of RC was 24%. RC was significantly associated [odds ratio (95% confidence interval)] with aerobic capacity [0.28 (0.09-0.89), p = 0.030], low-intensity physical activity [0.77 (0.60-0.99), p = 0.048], body mass index [0.78 (0.70-0.92), p = 0.002], waist circumference [0.96 (0.92-0.99), p = 0.023], body weight [0.94 (0.90-0.98), p = 0.004], and ESR at the time of diagnosis [1.02 (1.00-1.05), p = 0.033]. All of these associations remained significant after adjusting for age and gender.

CONCLUSION

RC was highly prevalent in early RA. Patient outcome may be improved by detecting this condition early and applying treatments for improving inflammation, aerobic capacity, physical activity, and body composition.

Efficacy of Siwan Traditional Therapy on Erythrocyte Sedimentation Rate, Lipid Profile, and Atherogenic Index as Cardiac Risk Factors Related to Rheumatoid Arthritis

Background and Objectives: The most frequent cause of mortality in rheumatoid arthritis (RA) patients is cardiovascular disease (CVD). Inflammation, dyslipidemia, and decreased physical activity are some of the main risk factors for CVD. Siwan sand therapy is a type of traditional therapy used in Egypt to treat RA. The approach of this therapy depends on the experience of the healers. The aim of the current study was to compare the effects of three sessions of Siwan traditional therapy to five sessions on common CVD risk factors and physical function in rheumatoid arthritis patients. Materials and Methods: Thirty patients (9 male and 21 female) were assigned into two groups of equal size: group (A) received three sessions of Siwan traditional therapy in the form of a sand bath. Group (B) received the same form of therapy for five days. Erythrocyte sedimentation rate (ESR), lipid profile, atherogenic index of plasma (AIP), and a health assessment questionnaire (HAQ) were measured before and after treatment. Results: There was a significant increase above normal within group (A) for ESR (p = 0.001), triglycerides (TG; p = 0.015), total cholesterol (Tot-Chol; p = 0.0001), and low-density lipoprotein (LDL; p = 0.0001). However, there were no considerable differences in high-density lipoprotein (HDL; p = 0.106), very low-density lipoprotein (VLDL; p = 0.213), AIP (p = 0.648), and HAQ (p = 0.875). For the second group, there were significant changes within group B only in Tot-Chol (p = 0.0001), HDL (p = 0.0001), VLDL (p = 0.0001), AIP (p = 0.008), and HAQ (p = 0.014). There was a significant difference between both groups regarding HDL (p = 0.027), LDL (p = 0.005), AIP (p = 0.029), ESR (p = 0.016), and HAQ (p = 0.036). Conclusions: For RA patients, five days of Siwan traditional therapy caused significant changes regarding inflammation, Tot-Chol, LDL, HDL, AIP, and functional activity when compared to three days of Siwan hot sand therapy.

Frailty in people with rheumatoid arthritis: a systematic review of observational studies

Background: Frailty, an age-related decline in physiological reserve, is an increasingly important concept in the management of chronic diseases. The implications of frailty in people with rheumatoid arthritis are not well understood. We undertook a systematic review to assess prevalence of frailty in people with rheumatoid arthritis, and the relationship between frailty and disease activity or clinical outcomes. Methods: We searched four electronic databases (January 2001 to April 2021) for observational studies assessing the prevalence of frailty (any frailty measure) in adults (≥18 years) with rheumatoid arthritis, or analysing the relationship between frailty and disease activity or clinical outcomes (e.g. quality of life, hospitalisation or mortality) in people with rheumatoid arthritis. Study quality was assessed using an adapted Newcastle-Ottawa Scale. Screening, quality assessment and data extraction were performed independently by two reviewers. We used narrative synthesis. Results: We identified 17 analyses, from 14 different populations. 15/17 were cross-sectional. Studies used 11 different measures of frailty. Frailty prevalence ranged from 10% (frailty phenotype) to 36% (comprehensive rheumatologic assessment of frailty) in general adult populations with rheumatoid arthritis. In younger populations (<60 or <65 years) prevalence ranged from 2.4% (frailty phenotype) to 19.9% (Kihon checklist) while in older populations (>60 or >65) prevalence ranged from 31.2% (Kihon checklist) to 55% (Geriatric 8 tool). Frailty was cross-sectionally associated with higher disease activity (10/10 studies), lower physical function (7/7 studies) and longer disease duration (2/5 studies), and with hospitalization and osteoporotic fractures (1/1 study, 3.7 years follow-up). Conclusion: Frailty is common in rheumatoid arthritis, including those aged <65 years, and is associated with a range of adverse features. However, these is heterogeneity in how frailty is measured. We found few longitudinal studies making the impact of frailty on clinical outcomes over time and the extent to which frailty is caused by rheumatoid arthritis unclear.

Frailty in people with rheumatoid arthritis: a systematic review of observational studies

Background: Frailty, an age-related decline in physiological reserve, is an increasingly important concept in the management of chronic diseases. The implications of frailty in people with rheumatoid arthritis are not well understood. We undertook a systematic review to assess prevalence of frailty in people with rheumatoid arthritis, and the relationship between frailty and disease activity or clinical outcomes. Methods: We searched four electronic databases (January 2001 to April 2021) for observational studies assessing the prevalence of frailty (any frailty measure) in adults (≥18 years) with rheumatoid arthritis, or analysing the relationship between frailty and disease activity or clinical outcomes (e.g. quality of life, hospitalisation or mortality) in people with rheumatoid arthritis. Study quality was assessed using an adapted Newcastle-Ottawa Scale. Screening, quality assessment and data extraction were performed independently by two reviewers. We used narrative synthesis. Results: We identified 17 analyses, from 14 different populations. 15/17 were cross-sectional. Studies used 11 different measures of frailty. Frailty prevalence ranged from 10% (frailty phenotype) to 36% (comprehensive rheumatologic assessment of frailty) in general adult populations with rheumatoid arthritis. In younger populations (<60 or <65 years) prevalence ranged from 2.4% (frailty phenotype) to 19.9% (Kihon checklist) while in older populations (>60 or >65) prevalence ranged from 31.2% (Kihon checklist) to 55% (Geriatric 8 tool). Frailty was cross-sectionally associated with higher disease activity (10/10 studies), lower physical function (7/7 studies) and longer disease duration (2/5 studies), and with hospitalization and osteoporotic fractures (1/1 study, 3.7 years follow-up). Conclusion: Frailty is common in rheumatoid arthritis, including those aged <65 years, and is associated with a range of adverse features. However, these is heterogeneity in how frailty is measured. We found few longitudinal studies making the impact of frailty on clinical outcomes over time and the extent to which frailty is caused by rheumatoid arthritis unclear.

Assessment of Cardiac Risk in Women with Autoimmune Disease

PURPOSE OF REVIEW

The purpose of our review was to evaluate current standards in clinical practice in determining overall cardiac risk in female patients with chronic rheumatologic diseases. We hoped to not only summarize known cardiac manifestations of various chronic rheumatologic diseases but also determine the effectiveness of new risk scores in determining cardiac risk in this patient population.

RECENT FINDINGS

Chronic rheumatologic diseases have been associated with various cardiac manifestations for some time, with initial studies involving risk of coronary artery disease (CAD) in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, recent studies have shown numerous other cardiac manifestations associated with these and other chronic rheumatologic diseases. Risk scores have been used for several decades to help determine overall cardiac risk in the general population, but these risk scores have notoriously underestimated the risk of cardiac disease in woman and in patients with chronic rheumatologic diseases. These diseases, often with a female predominance, can impact long-term mortality and have devastating consequences if not monitored and treated appropriately. Thus, new risk scores have been developed over the last several years to help improve detection and awareness of cardiac disease in these patients. Novel modified risk scores have found some success at improving the detection of cardiac disease in patients with chronic rheumatologic diseases. Further studies looking at these risk scores need to determine the accuracy of these scores and where they fall short. With the advent of advanced imaging technologies, future risk scores may involve certain imaging-based markers to help guide accurate risk determination.

Perioperative and anesthetic management of patients with rheumatoid arthritis

Our understanding and management of rheumatoid arthritis (RA) have greatly improved, but perioperative and anesthetic management remain challenging. RA is not limited to joints; systemic evaluation is thus required when planning perioperative management. Especially, careful airway evaluation is needed; management of airway-related arthritis is challenging. A multidisciplinary approach is essential to prevent complications without exacerbating RA disease activity. Guidelines published in 2017 are available for perioperative management of anti-rheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. However, the guidelines focus only on anti- rheumatic medications, and do not consider all aspects of perioperative management (including anesthesia). Here, we discuss the perioperative and anesthetic management of patients with RA.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Body mass index trend and variability in rheumatoid arthritis

OBJECTIVE

To characterize and compare trends in body mass index (BMI) and variability in BMI between subjects with rheumatoid arthritis (RA) and matched non-RA subjects and to determine predictors of BMI trends and variability within RA subjects.

METHODS

This retrospective population-based cohort study included 1114 Olmsted County, Minnesota residents, 558 with incident RA (age ≥ 18 years, 1987 ACR criteria met in 1995-2009) and 556 non-RA subjects from the same underlying population with similar age, sex, and index calendar year. All subjects were followed until death, migration, or 12/31/2018. Generalized linear models with smoothing splines and random effects to account for multiple measurements per subject were used to examine trends in BMI measurements over time.

RESULTS

Mean BMI of patients with incident RA (28.8 kg/m2) was not significantly different from that of non-RA subjects (28.9 kg/m2). There was no significant difference in BMI trends over time between RA and non-RA cohorts, or between seropositive for rheumatoid factor (RF) and/or citrullinated antibody (CCP-antibody) and seronegative RA patients, or between male and female subjects. RA subjects were noted to have significantly higher BMI variability following diagnosis compared to non-RA subjects [difference in standard deviation between RA and non-RA subjects prior to index (p = 0.12), 0-5 years after index (p = 0.044), and 5-15 years after index (p = 0.013)].

CONCLUSION

The BMI trajectory of the RA population is not significantly different compared to that of the non-RA population, but patients with RA demonstrate higher variability in BMI following diagnosis compared to the non-RA population. Key Points • This study uniquely characterizes longitudinal trajectory in BMI measures and their variability in the RA population versus the non-RA population • This study suggests that RA patients have greater BMI variability compared to the non-RA population, which is highly relevant as BMI variability is increasingly understood as a cardiovascular risk factor.

Low body mass is associated with reduced left ventricular mass in Chinese elderly with severe COPD

There is limited information on the association of body mass index (BMI) with left ventricular (LV) remodeling corresponding to severity of reduced lung function in patients with chronic obstructive pulmonary disease (COPD). Therefore, we investigated whether BMI is associated with cardiac atrial and ventricular dimensions according to severity of lung functional impairment in Chinese COPD elderly. A total of 563 hospitalized COPD patients with lung function impairment and 184 patients with non-COPD (aged 65–92 years) were collected retrospectively in a cross-sectional study in a university affiliated tertiary hospital in China. BMI and cardiac echocardiographic parameters were compared according to severity of lung functional impairment in COPD patients. BMI was 22.9 ± 3.9 kg/m² in COPD patients, 24.0 ± 4.1 kg/m² in non-COPD patients respectively. Reduced BMI, LV mass index, LV wall thickness and left atrial diameter, and dilated right ventricle (RV) existed in COPD patients with severe lung dysfunction as compared the COPD patients with mild to moderate lung functional reduction and non-COPD patients (P < 0.05), while there were no differences in BMI and echocardiographic parameters between the COPD patients with mild to moderate lung functional decline and non-COPD patients (P > 0.05). Logistic regression analysis showed that low BMI (BMI < 18.5 kg/m²) was correlated with reduced LV mass and wall thickness, dilated RV and reduced lung function in the COPD patients with severe lung dysfunction. In conclusion, this study demonstrates that lower BMI is associated not only with dilated RV and impaired pulmonary function, but also it is related to reduced LV mass in Asian COPD elderly with severe lung dysfunction.

Biologics and atherosclerotic cardiovascular risk in rheumatoid arthritis: a review of evidence and mechanistic insights

Introduction: Cardiovascular disease is a leading comorbidity in rheumatoid arthritis. Timely introduction of biologic therapies in a treat-to-target approach has optimized disease-related outcomes and attenuated accrual of comorbidities, including cardiovascular risk.Areas covered: A literature search in MEDLINE (via PubMed) was performed between January 2009 and November 2020. This manuscript explores recent developments in atherosclerotic cardiovascular risk in RA compared with non-RA individuals; it synopsizes differences in vascular function and inflammation, prevalence, burden, vulnerability, and progression of atherosclerotic plaque and their underlying cellular and molecular mechanisms. Finally, it reviews the recent literature on cardioprotective benefits of biologics and draws mechanistic links with inhibition of new plaque formation, stabilization of high-risk lesions and improvement in endothelial function, arterial stiffness, lipid metabolism, and traditional cardiac risk factors.Expert opinion: Increasing evidence points to a solid cardioprotective influence of earlier, longer, and ongoing use of biologic treatments in RA. Nevertheless, the precise mechanistic effects of plaque progression and remodeling, vascular stiffness, endothelial dysfunction, lipid metabolism, and traditional cardiac risk factors are less rigorously characterized.

Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a progressive articular disease. In addition to damaging the joints, it may cause multiple organ complications, and considerably impair the patient’s functioning. Elderly patients with RA report pain, fatigue, mood disorders, sleep disorders and insomnia, accompanied by weakness, poor appetite, and weight loss. All these factors combined have an adverse effect on the patient’s perceived quality of life (QoL). Due to the chronic nature of RA and the high risk of malnutrition in this patient group, the present study investigated QoL, activities of daily living, and frailty syndrome severity in relation to MNA (Mini Nutritional Assessment) questionnaire scores among elderly RA patients. The study included 98 patients (aged over 60) diagnosed with RA per the ARA (American Rheumatism Association) criteria. The following standardized instruments were used: WHOQoL-BREF for QoL, the Edmonton Frail Scale for frailty syndrome severity, MNA for nutritional status assessment, and MMSE (Mini-Mental State Examination) to assess any cognitive impairment. Medical data were obtained from hospital records. Patients with a different nutritional status differed significantly in terms of limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). Higher levels of malnutrition were associated with greater limitations in activity. An adverse impact of lower body weight on cognitive function was also observed (dementia was identified in 33.33% of malnourished patients vs. 1.79% in patients with a normal body weight). Likewise, frailty was more common in malnourished patients (mild frailty syndrome in 33.3%, moderate in 16.67%, and severe in 16.67%). Malnourished patients had significantly lower QoL scores in all WHOQoL-BREF questionnaire domains than those with a normal body weight, and multiple-factor analysis for the impact of selected variables on QoL in each domain demonstrated that frailty was a significant independent determinant of poorer QoL in all domains: perceived quality of life (β = −0.069), perceived health (β = −0.172), physical domain (β = −0.425), psychological domain (β = −0.432), social domain (β = −0.415), environmental domain (β = −0.317). Malnutrition was a significant independent determinant of QoL in the “perceived health” domain (β = −0.08). In addition, regression analysis demonstrated the positive impact of male sex on QoL scores in the psychological (β = 1.414) and environmental domains (β = 1.123). Malnourished patients have a lower QoL than those with a normal body weight. Malnutrition adversely affects daily functioning, cognitive function, and the severity of frailty syndrome. Frailty syndrome is a significant independent determinant of poorer QoL in all WHOQoL BREF domains.

Beyond Rheumatoid Arthritis Evaluation: What are We Missing?

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.

Muscle deterioration due to rheumatoid arthritis: assessment by quantitative MRI and strength testing

OBJECTIVES

RA patients often present with low muscle mass and decreased strength. Quantitative MRI offers a non-invasive measurement of muscle status. This study assessed whether MRI-based measurements of T2, fat fraction, diffusion tensor imaging and muscle volume can detect differences between the thigh muscles of RA patients and healthy controls, and assessed the muscle phenotype of different disease stages.

METHODS

Thirty-nine RA patients (13 'new RA'-newly diagnosed, treatment naïve, 13 'active RA'-persistent DAS28 >3.2 for >1 year, 13 'remission RA'-persistent DAS28 <2.6 for >1 year) and 13 age and gender directly matched healthy controls had an MRI scan of their dominant thigh. All participants had knee extension and flexion torque and grip strength measured.

RESULTS

MRI T2 and fat fraction were higher in the three groups of RA patients compared with healthy controls in the thigh muscles. There were no clinically meaningful differences in the mean diffusivity. The muscle volume, handgrip strength, knee extension and flexion were lower in all three groups of RA patients compared with healthy controls.

CONCLUSION

Quantitative MRI and muscle strength measurements can potentially detect differences within the muscles between RA patients and healthy controls. These differences may be seen in RA patients who are yet to start treatment, those with persistent active disease, and those who were in clinical remission. This suggests that the muscles in RA patients are affected in the early stages of the disease and that signs of muscle pathology and muscle weakness are still observed in clinical remission.

Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment

Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.

Nutritional Pearls: Diet and Rheumatoid Arthritis

Various studies have investigated the effect of diet on rheumatoid arthritis (RA) as a complimentary treatment along with standard drug therapy. Various types of diet have been investigated. Fasting, the Mediterranean diet, the Cretan Mediterranean diet, vegetarian diet, an anti-inflammatory diet and the use of various specific food substances have been in the focus of research interest. The relationship of obesity with disease activity in RA has also been investigated. A period of fasting followed by Mediterranean diet, the Cretan Mediterranean diet and an anti-inflammatory diet have been found to have a beneficial effect on disease activity in RA. Obesity has been found to be associated with increased disease activity in RA. However, weight loss appears to be related to increased mortality in RA. The use of flavonoids, resveratrol and curcumin may have a beneficial effect in RA. It appears that diet may aid in RA management as a complimentary factor to standard drug treatment.

Early-onset subclinical cardiovascular damage assessed by non-invasive methods in children with Juvenile Idiopathic Arthritis: analytical cross-sectional study

Chronic inflammation starting early in life and continuing into adulthood may predispose children with Juvenile Idiopathic Arthritis (JIA) to cardiovascular (CV) complications. To compare non-invasive CV risk markers- left ventricular mass index (LVMi), brachial artery flow mediated dilatation (FMD) and carotid artery intima-media thickness (CIMT) between patients with JIA and healthy controls. Measurements of LVMi, CIMT and FMD and lipid profile were compared between 4 and 18 year old 81 patients with JIA and 78 age and sex matched healthy controls. Among 81, 20 had systemic onset, 19 enthesitis related arthritis, 9 polyarticular rheumatoid factor (RF) + ve, 19 polyarticular RF -ve, 11 oligo-articular, and 3 un-differentiated JIA. FMD was significantly lower (p < 0.001), CIMT and LVMi significantly higher in patients (p ≤  0.001). CIMT showed positive correlation with blood pressure (p = 0.001), disease duration (p  ≤  0.001) and negative correlation with high density lipoprotein (HDL) (p ≤  0.001). FMD correlated positively with HDL (p = 0.006) and negatively with disease duration (p ≤  0.001). CIMT (p = 0.017) and FMD (p = 0.04) were significantly worse in active than inactive disease. Children with JIA have worse lipid profile, increased LVMi, CIMT, and reduced brachial artery FMD, suggestive of early cardiovascular dysfunction.

The relationship between weight status and metabolic syndrome in patients with rheumatoid arthritis and spondyloarthritis

OBJECTIVES

To compare the prevalence and correlates of metabolic syndrome (MetS) stratified by body mass index (BMI) categories in rheumatoid arthritis (RA) and spondyloarthritis (SpA).

METHODS

The age- and sex-standardized prevalence of MetS was calculated by BMI categories and compared between RA and SpA patients before starting first biologic, and controls. The determinants of metabolic syndrome in patients without obesity were investigated.

RESULTS

MetS was observed in 28% of RA (21/75), 22.5% of SpA (18/80), 19% of controls (187/998). The age- and sex-standardized prevalence of MetS was not significantly different between RA 19% (95% CI: 11-27%), SpA 26% (95% CI: 16-36%) and controls 16% (95% CI: 14-18%). When stratified by BMI, the standardized prevalence of MetS was less frequent in obese RA patients (15%, 95% CI: 4-27%) compared to obese controls (48%, 95% CI: 40-55%) or to obese SpA (36%, 95% CI: 26-45%). In normal-weight RA patients, MetS standardized prevalence was 16% (95% CI: 7-25%) compared to 5% (95% CI: 0-11%) in SpA, and 6% (95% CI: 4-8%) in controls. In non-obese SpA, MetS was associated with abdominal obesity, visceral fat mass and cardiovascular risk. In non-obese RA patients with metabolic syndrome, body composition did not differ from metabolically healthy RA patients.

CONCLUSIONS

MetS is not uniform among patients with similar BMI. In RA, MetS was less frequent in obese patients, and unlike SpA, was not associated with body fat composition in non-obese patients. Differences between RA and SpA for metabolic health suggest various pathophysiological mechanisms.

Adjustment of the multi-biomarker disease activity score to account for age, sex and adiposity in patients with rheumatoid arthritis

Objective

To develop and evaluate an adjusted score for the multi-biomarker disease activity (MBDA) test to account for the effects of age, sex and adiposity in patients with RA.

Methods

Two models were developed to adjust MBDA score for age, sex and adiposity, using either serum leptin concentration or BMI as proxies for adiposity. Two cohorts were studied. A cohort of 325 781 RA patients who had undergone commercial MBDA testing and had data for age, sex and serum leptin concentration was used for both models. A cohort of 1411 patients from five studies/registries with BMI data was used only for the BMI-adjusted MBDA score. Univariate and multivariate linear regression analyses evaluated the adjusted MBDA scores and conventional clinical measures as predictors of radiographic progression, assessed in terms of modified total Sharp score (ΔmTSS).

Results

Two models were developed, based on findings that MBDA score was higher in females than males and increased with age, leptin concentration and BMI. In pairwise regression analyses, the leptin-adjusted (P = 0.00066) and BMI-adjusted (P = 0.0027) MBDA scores were significant independent predictors of ΔmTSS after adjusting for DAS28-CRP, whereas DAS28-CRP was not, after adjusting for leptin-adjusted (P = 0.74) or BMI-adjusted (P = 0.87) MBDA score. Moreover, the leptin-adjusted MBDA score was a significant predictor of ΔmTSS after adjusting for the BMI-adjusted MBDA score (P = 0.025) or the original MBDA score (0.027), whereas the opposite was not true.

Conclusion

Leptin-adjusted MBDA score significantly adds information to DAS28-CRP and the original MBDA score in predicting radiographic progression. It may offer improved clinical utility for personalized management of RA.

Could Omega 3 Fatty Acids Preserve Muscle Health in Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by a high prevalence of death due to cardiometabolic diseases. As observed during the aging process, several comorbidities, such as cardiovascular disorders (CVD), insulin resistance, metabolic syndrome and sarcopenia, are frequently associated to RA. These abnormalities could be closely linked to alterations in lipid metabolism. Indeed, RA patients exhibit a lipid paradox, defined by reduced levels of total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol whereas the CVD risk is increased. Moreover, the accumulation of toxic lipid mediators (i.e., lipotoxicity) in skeletal muscles can induce mitochondrial dysfunctions and insulin resistance, which are both crucial determinants of CVD and sarcopenia. The prevention or reversion of these biological perturbations in RA patients could contribute to the maintenance of muscle health and thus be protective against the increased risk for cardiometabolic diseases, dysmobility and mortality. Yet, several studies have shown that omega 3 fatty acids (FA) could prevent the development of RA, improve muscle metabolism and limit muscle atrophy in obese and insulin-resistant subjects. Thereby, dietary supplementation with omega 3 FA should be a promising strategy to counteract muscle lipotoxicity and for the prevention of comorbidities in RA patients.

Factors Associated With Low Lean Mass in Early Rheumatoid Arthritis: A Cross- Sectional Study

Background and Objectives: The aim of the study was to evaluate body composition (BC) of rheumatoid arthritis (RA) patients at disease onset compared to population controls focusing on the associations between low lean mass and disease specific parameters, nutritional factors and physical activity. Materials and Methods: 91 patients with early rheumatoid arthritis (ERA) (72% female) and 328 control subjects (54% female) were studied. BC- lean and fat mass parameters were measured with a Lunar Prodigy Dual Energy X-Ray Absorptiometry (DXA) machine. The prevalence, age and gender adjusted odds ratios of having low lean mass and overfat, associations between nutrition, physical activity, and ERA disease specific parameters and the presence of low lean mass were evaluated. Results: We found that the BC of patients with recent onset RA differs from control subjects-ERA patients had a higher mean body fat percentage (BFP) and lower appendicular lean mass (ALM). 41.8% of the ERA patients and 19.8% of the controls were classified as having low lean mass adjusted OR 3.3 (95% C.I. 1.9-5.5, p < 0.001). 68.1% of the ERA subjects and 47.3% of the controls were overfat (adjusted OR 1.9 (95% C.I. 1.1-3.3, p = 0.02)) and the adjusted odds of having both low lean mass and overfat were 4.4 times higher (26.4% vs. 7.0% 95% C.I. 2.3-8.4, p < 0.001) among the ERA group. Higher ESR (OR 1.03, C.I.1.002-1.051, p = 0.03), CRP (OR 1.03, C.I. 1.002-1.061, p = 0.04), lower protein intake (OR 0.98 C.I. 0.96-0.99, p = 0.04), corticosteroid usage (OR 3.71 C.I. 1.4-9.9, p < 0.01) and lower quality of life (higher HAQ score OR 2.41 C.I. 1.24-4.65, p < 0.01) were associated with having low lean mass in the ERA group (adjusted to age and gender). Conclusions: Patients with early RA have lower appendicular lean mass and higher body fat percentage compared to healthy controls. Loss of lean mass in early RA is associated with elevated inflammatory markers inducing catabolism, lower protein intake and also with GCS treatment.

Nutritional status as the risk factor of serious infection in patients with rheumatoid arthritis

Objectives: The aim of this study was to identify the risk factors associated with severe infection in RA patients, with a particular focus on the association of the nutritional status.Methods: We retrospectively analyzed data from 74 patients with RA (male, n = 21; female, n = 53; age 74.2 ± 12.4) admitted to our hospital between 2016 and 2017 for infection (infection group). We also recruited control RA patients (n = 222) who were matched for age, gender and disease duration, with a match ratio of 1:3 (non-infection group). The nutritional condition was assessed based on controlling nutrition status (CONUT) score, and prognostic nutritional index (PNI). The data of the infection group were obtained from the most recent visit prior to the present admission, and non-infection group from the last regular visit in 2017.Results: The respiratory tract was the most frequent site of infection. The BMI and PNI were significantly lower and the CONUT score significantly higher in the infection group than in the non-infection group. A logistic regression analysis revealed that the CONUT score, underlying lung disease and use of prednisolone and biological disease-modifying anti-rheumatic drugs were independent and significant risk factors for serious infection.Conclusion: Poor nutritional status increases the risk of serious infection.

Exploring the Lipid Paradox Theory in Rheumatoid Arthritis: Associations of Low Circulating Low-Density Lipoprotein Concentration With Subclinical Coronary Atherosclerosis

OBJECTIVE

Rheumatoid arthritis (RA) patients with the lowest circulating low-density lipoprotein (LDL) concentrations are at heightened risk of cardiovascular events. However, the atherosclerosis burden within this subgroup is unknown.

METHODS

RA patients pooled from 4 cohort studies of cardiovascular disease (CVD; n = 546) were compared with non-RA controls from the Multi-Ethnic Study of Atherosclerosis (n = 5,279). Those taking lipid-lowering medications were excluded. Differences in cardiac computed tomography-derived Agatston coronary artery calcium (CAC) scores between the RA and control groups were compared across strata of LDL concentration.

RESULTS

Among those with low LDL concentrations (<70 mg/dl), mean adjusted CAC scores were >4-fold higher for RA patients than for controls (18.6 versus 4.6 Agatston units, respectively; P < 0.001), a difference significantly greater than that in any other LDL concentration stratum except LDL concentration ≥160 mg/dl. Similarly, 32% of the RA patients with low LDL concentration had a CAC score of ≥100 Agatston units compared with only 7% of controls in the same LDL concentration stratum (odds ratio 5.97; P < 0.001), a difference significantly greater than that in all of the other LDL concentration strata. Low LDL concentration was most strongly associated with higher CAC score among RA patients who were white, had ever smoked, or were not obese. Other than a higher frequency of current smokers, RA patients with low LDL concentrations did not have more CVD risk factors or higher measures of RA disease activity or severity than RA patients with higher LDL concentrations.

CONCLUSION

RA patients with low LDL concentration may represent a group for whom heightened screening and prevention of atherosclerotic CVD is appropriate.

Extra-articular Manifestations and Comorbidity in Rheumatoid Arthritis: Potential Impact of Pre-Rheumatoid Arthritis Prevention

Rheumatoid arthritis (RA) is associated with a wide variety of extra-articular manifestations and comorbidities, several of which can be organ- or even life-threatening. These extra-articular manifestations and comorbidities can also contribute to the physical disability and psychological morbidity of RA that lead to reduced quality of life, higher direct and indirect costs, and societal burden of the disease. Although the expansion of RA treatment options and adoption of treat-to-target approaches has reduced the incidence and severity of several nonarticular manifestations of RA, such as rheumatoid vasculitis and cardiovascular disease events, this does not seem to be shared by all RA comorbidities. Moreover, a number of highly prevalent and impactful RA-driven comorbidities, such as accelerated atherosclerosis, interstitial lung disease, and sarcopenia, can present clinically in the years before the manifestation of joint pain or observable synovitis. A larger proportion of patients with RA have atherosclerosis, myocardial dysfunction, interstitial lung disease, and sarcopenia that is subclinical in the preclinical and earliest clinical phases of RA, emphasizing the importance of targeting the pre-RA phase for the prevention of comorbidities that are often poorly responsive to treatment once they develop. Herein, we review the potential impact of pre-RA prevention on the incidence and burden of extra-articular manifestations and nonarticular comorbidities.

Rheumatoid Arthritis: Atherosclerosis Imaging and Cardiovascular Risk Assessment Using Machine and Deep Learning-Based Tissue Characterization

PURPOSE OF THE REVIEW

Rheumatoid arthritis (RA) is a chronic, autoimmune disease which may result in a higher risk of cardiovascular (CV) events and stroke. Tissue characterization and risk stratification of patients with rheumatoid arthritis are a challenging problem. Risk stratification of RA patients using traditional risk factor-based calculators either underestimates or overestimates the CV risk. Advancements in medical imaging have facilitated early and accurate CV risk stratification compared to conventional cardiovascular risk calculators.

RECENT FINDING

In recent years, a link between carotid atherosclerosis and rheumatoid arthritis has been widely discussed by multiple studies. Imaging the carotid artery using 2-D ultrasound is a noninvasive, economic, and efficient imaging approach that provides an atherosclerotic plaque tissue-specific image. Such images can help to morphologically characterize the plaque type and accurately measure vital phenotypes such as media wall thickness and wall variability. Intelligence-based paradigms such as machine learning- and deep learning-based techniques not only automate the risk characterization process but also provide an accurate CV risk stratification for better management of RA patients. This review provides a brief understanding of the pathogenesis of RA and its association with carotid atherosclerosis imaged using the B-mode ultrasound technique. Lacunas in traditional risk scores and the role of machine learning-based tissue characterization algorithms are discussed and could facilitate cardiovascular risk assessment in RA patients. The key takeaway points from this review are the following: (i) inflammation is a common link between RA and atherosclerotic plaque buildup, (ii) carotid ultrasound is a better choice to characterize the atherosclerotic plaque tissues in RA patients, and (iii) intelligence-based paradigms are useful for accurate tissue characterization and risk stratification of RA patients.

Performance of the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis in a geographically distant National Register-based cohort: an external validation

BACKGROUND

Cardiovascular (CV) risk stratification for patients with rheumatoid arthritis (RA) should facilitate evidence-based management. Prior work has derived an internally validated a CV risk score, the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA), using US data. The aim of this study was to perform an external validation among unselected patients with RA from Europe.

METHODS

Three large, partially overlapping, cohorts of patients with RA from the Swedish Rheumatology Quality register were identified for external validation, two with information on smoking and two with close to 10 years of median follow-up. The 10 -year rate of first CV events was assessed using the Kaplan-Meier method. The performance of ERS-RA was assessed using C-index and comparisons of observed versus predicted risks.

RESULTS

The C-index for ERS-RA varied across the three RA cohorts, from 0.75 to 0.78. Predicted risks corresponded well to observed risks among individuals with ≤10 % observed 10- year CV risk, but underestimated risk in individuals with a higher observed risk. In the absence of data on smoking, ERS-RA underestimated the CV risk by 3.3%, whereas in the cohorts including data on smoking, the calibration was within 1% (0.06% and 0.7%). In the clinically relevant risk intervals (<5%, 5.0%-<7.5%, 7.5%-<10%), ERS-RA performed well.

CONCLUSIONS

In an unselected Swedish population with RA, ERS-RA performed well, although the 10-year CV risk was underestimated in high-risk groups and in the absence of data on smoking. ERS-RA could be considered as a risk stratification tool for targeted preventive interventions in clinical rheumatology practice.

Non-obese visceral adiposity is associated with the risk of atherosclerosis in Japanese patients with rheumatoid arthritis: a cross-sectional study

Rheumatoid arthritis (RA) patients often have altered body composition including reduced muscle mass and increased fat mass. Some RA patients are likely to increase visceral fat without obesity [Body Mass Index (BMI) ≥ 25]. The objective of the study was to determine the association between obesity and/or visceral adiposity and the risk for atherosclerosis in Japanese RA patients. Obesity was evaluated using the BMI, with visceral adiposity evaluated using the visceral fat area (VFA) and the visceral/subcutaneous fat ratio (V/S ratio), quantified using the dual bioelectrical impedance method. Atherosclerosis was evaluated based on the intima–media thickness (IMT) and Plaque score (PS) of the carotid artery, measured using ultrasonography. Multivariate analysis was performed to determine the factors associated with IMT and PS. IMT and PS were compared among groups of patients sub-classified according to BMI and VFA levels. The V/S ratio was higher in RA patients than healthy controls, after adjustment for age, BMI, and waist circumference. On multivariate analysis, the V/S ratio, but not the BMI, was independently associated with the IMT and PS. Among the sub-classifications for BMI and VFA, non-obese patients with a high visceral adiposity (18.5 ≤ BMI < 25 kg/m² and VFA ≥ 100 cm²) had the highest IMT (mean IMT, 0.93 ± 0.29 mm; maximum IMT, 1.44 ± 0.71 mm) and PS (1.43 ± 0.61), compared to all other BMI and VFA subgroups. RA patients have increased visceral adiposity, which is associated with a high prevalence of atherosclerotic of plaques. Non-obese RA patients who have visceral adiposity have a specifically higher risk for atherosclerosis.

Leptin as an obesity marker in rheumatoid arthritis

The determination of excess of body fat mass provides a more suitable determinant of obesity in rheumatoid arthritis patients; however, body mass index (BMI) may not be accurate for the quantification of adiposity. To identify a marker of excess adiposity in women with rheumatoid arthritis (RA) using different methods for fat mass evaluation. A cross-sectional study was conducted in adult female patients with RA. Disease activity was assessed by DAS28-ESR, and obesity was determined by waist circumference (WC), BMI and dual-energy X-ray absorptiometry (DXA). The Human Bone Metabolism kit (Merck Millipore, Darmstadt, Alemanha) was used to determine the plasma levels of leptin, TNF-α, IL-6, and IL-1β by quantification of serum proteins by technical microspheres (LUMINEX, TX, USA). Adiponectin was measured by enzyme-linked immunosorbent assay sandwich kit (R&D Systems, Minneapolis, MN, USA). Eighty-nine female patients, median age of 55.4 (± 11.6) years, and median disease duration of 16.4 (± 14.9) years were included. The frequency of obesity was 33.7% according to BMI, 89.9% with WC, and 56.1% with DXA. The median serum leptin concentration was the only marker that correlated with body fat percentage according to the three methods. This correlation was positive and not influenced by DAS28, C-reactive protein, erythrocyte sedimentation rate, or inflammatory cytokines levels (IL-6, TNF-α, IL-1β). Analysis of ROC curves determined the cut-off point of 10.3 ng/mL of leptin as an obesity marker, with a sensitivity of 96.43% and a specificity of 23.81%. Serum leptin correlates positively with fat mass and is potentially useful in excess fat mass determination in clinical practice.

Cardiovascular outcomes of patients with rheumatoid arthritis prescribed disease modifying anti-rheumatic drugs: a review

INTRODUCTION

Rheumatoid arthritis (RA) is associated with a heightened risk of cardiovascular disease (CVD), with both traditional CV risk factors and inflammation contributing to this risk.

AREAS COVERED

This review highlights the burden of CVD in RA and associated traditional CV risk factors, including the complexity of dyslipidemia in RA and the so-called 'lipid paradox.' Furthermore, the recognized RA-disease-specific factors associated with higher risk of CVD and the role of systemic inflammation in the pathogenesis of CVD in RA will be addressed. With the advent of biologic and targeted synthetic therapies in the treatment of RA, the effect of conventional and newer generation disease modifying anti-rheumatic therapies (DMARDs) on CV risk and associated risk factors will also be discussed.

EXPERT OPINION

Identifying the RA phenotype at greatest risk of CVD, understanding the interplay of increased traditional risk factors, common inflammatory processes and RA-specific factors, and personalized use of DMARDs according to disease phenotype and comorbidity to reduce this risk are key areas for future research.

Atherosclerotic vascular disease in the autoimmune rheumatologic woman

Autoimmune rheumatologic conditions have increased cardiovascular morbidity and mortality compared to the general population. Many of these diseases occur more commonly in women, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis, and Sjogren's. Most of the literature that has identified the link between autoimmune diseases and atherosclerotic cardiovascular disease (ASCVD) has been regarding patients with RA and SLE. The reason for the increased ASCVD is related to both traditional risk factors for atherosclerosis and nontraditional risk factors such as the burden of inflammation. Presently, our ability to adequately determinecardiovascular risk in the autoimmune patient is subpar, as scoring systems fail to take into account the role of inflammation. No present guidelines exist that take into account the increased burden of cardiovascular disease in this complex patient cohort.

Atherosclerotic Heart Disease in Women With Autoimmune Rheumatologic Inflammatory Conditions

Women have a higher prevalence of several inflammatory rheumatologic conditions. These include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc) to name a few. These conditions are all associated with higher rates of cardiovascular (CV) morbidity and mortality, which is driven primarily by atherosclerotic heart disease. Traditional risk factors are important considerations in the assessment of CV risk in the rheumatologic patient; however, these factors do not appear to impart a similar weight of risk in women with inflammatory autoimmune rheumatologic conditions. In addition, even when controlling for traditional risk factors, patients with RA or SLE continue to have a higher risk of CV events, which has been linked to the burden of systemic inflammation. Currently, the CV risk scoring systems available for the general population underestimate the burden of the problem in these complex patients. The increased CV risk in patients with rheumatologic diseases has been reported in the literature for years but remains underrecognized by internists and cardiologists. Although these conditions themselves are relatively rare, the further study of inflammation and its treatment in CV disease will be beneficial to the general population.

Body Mass Index, Weight Loss, and Cause-Specific Mortality in Rheumatoid Arthritis

OBJECTIVE

To examine associations of body mass index (BMI) and weight loss with cause-specific mortality in rheumatoid arthritis (RA).

METHODS

A cohort of US veterans with RA was followed until death or through 2013. BMI was categorized as underweight, normal, overweight, and obese. Weight loss was calculated as the 1) annualized rate of change over the preceding 13 months, and 2) cumulative percent. Vital status and cause of death were obtained from the National Death Index. Multivariable competing-risks regression models were utilized to assess the time-varying associations of BMI and weight loss with cause-specific mortality.

RESULTS

Among 1,600 participants and 5,789 patient-years of followup, 303 deaths occurred (95 cardiovascular, 74 cancer, and 46 respiratory). The highest weight-loss rate and weight-loss percent were associated with a higher risk of cardiovascular mortality (rate: subdistribution hazard ratio [sHR] 2.27 [95% confidence interval (95% CI) 1.61-3.19]; percent: sHR 2.31 [95% CI 1.06-5.01]) and cancer mortality (rate: sHR 2.36 [95% CI 1.11-5.01]; percent: sHR 1.90 [95% CI 1.00-3.62]). Overweight BMI was protective of cardiovascular mortality (sHR 0.59 [95% CI 0.38-0.91]), while underweight BMI was associated with a near 3-fold increased risk of respiratory mortality (sHR 2.93 [95% CI 1.28-6.67]). Incorporation of time-varying BMI and weight loss in the same models did not substantially alter individual associations for cardiovascular and cancer mortality, but an association between weight-loss percentage and respiratory mortality was attenuated after BMI adjustment.

CONCLUSION

Both BMI and weight loss are predictors of cause-specific mortality in RA. Weight loss is a strong predictor of cardiovascular and cancer mortality, while underweight BMI is a stronger predictor of respiratory mortality.

Weight Change During the Early Rheumatoid Arthritis Period and Risk of Subsequent Mortality in Women With Rheumatoid Arthritis and Matched Comparators

OBJECTIVE

To investigate whether weight change during the early rheumatoid arthritis (RA) period is associated with subsequent mortality and to evaluate whether there is an RA-specific effect.

METHODS

We identified patients with incident RA during the Nurses' Health Study (NHS; 1976-2016) and created a comparison cohort by matching each RA patient with up to 10 non-RA comparators by age and calendar year of the RA diagnosis (index date). To capture weight change around the early RA period ("peri-RA/index"), we used weight measurements collected 2-4 years before and 2-4 years after the index date. We used Cox regression analysis to estimate hazard ratios (HRs) for mortality according to peri-RA/index weight change categories, separately in each cohort and in the combined cohorts, evaluating for an RA-specific effect.

RESULTS

Among 121,701 women in the NHS, 902 patients with incident RA were identified and matched to 7,884 non-RA comparators. In the RA cohort, 371 deaths (41.1%) occurred during a mean follow-up of 17.0 years after the early RA period, and 2,303 deaths (29.2%) occurred in the comparison cohort during a mean follow-up of 18.4 years. Weight loss of >30 pounds during the peri-RA period had a hazard ratio (HR) for mortality of 2.78 (95% confidence interval [95% CI] 1.58-4.89) compared to stable weight; results in the comparison cohort were similar (HR 2.16, 95% CI 1.61-2.88). A weight gain of >30 pounds had no association with mortality in patients with RA (HR 1.45, 95% CI 0.69-3.07) or comparators (HR 1.19, 95% CI 0.89-1.59). For mortality, there was no statistically significant interaction between RA/comparator status and weight change category (P = 0.68).

CONCLUSION

Severe weight loss during the early RA period was associated with an increased subsequent mortality risk for women with and those without RA. These results extend prior observations by including non-RA comparators and finding no protective association between weight gain and mortality, providing evidence against an RA-specific obesity paradox for mortality.

Changes in body composition and metabolic profile during interleukin 6 inhibition in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by increased mortality associated with cardiometabolic disorders including dyslipidaemia, insulin resistance, and cachectic obesity. Tumour necrosis factor inhibitors and interleukin 6 receptor blocker licensed for the treatment of RA decrease inflammation and could thus improve cardiovascular risk, but their effects on body composition and metabolic profile need to be clarified. We investigated the effects of tocilizumab (TCZ), a humanized anti-interleukin 6 receptor antibody, on body composition and metabolic profile in patients treated for RA.

METHODS

Twenty-one active RA patients treated with TCZ were included in a 1 year open follow-up study. Waist circumference, body mass index, blood pressure, lipid profile, fasting glucose, insulin, serum levels of adipokines and pancreatic/gastrointestinal hormones, and body composition (dual-energy X-ray absorptiometry) were measured at baseline and 6 and 12 months of treatment. At baseline, RA patients were compared with 21 non-RA controls matched for age, sex, body mass index, and metabolic syndrome.

RESULTS

Compared with controls, body composition was altered in RA with a decrease in total and appendicular lean mass, whereas fat composition was not modified. Among RA patients, 28.6% had a skeletal muscle mass index below the cut-off point for sarcopaenia (4.8% of controls). After 1 year of treatment with TCZ, there was a significant weight gain without changes for fat mass. In contrast, an increase in lean mass was observed with a significant gain in appendicular lean mass and skeletal muscle mass index between 6 and 12 months. Distribution of the fat was modified with a decrease in trunk/peripheral fat ratio and an increase in subcutaneous adipose tissue. No changes for waist circumference, blood pressure, fasting glucose, and atherogenic index were observed.

CONCLUSIONS

Despite weight gain during treatment with TCZ, no increase in fat but a modification in fat distribution was observed. In contrast, muscle gain suggests that blocking IL-6 might be efficient in treating sarcopaenia associated with RA.

Unmet Needs in the Pathogenesis and Treatment of Cardiovascular Comorbidities in Chronic Inflammatory Diseases

The developments that have taken place in recent decades in the diagnosis and therapy of a number of diseases have led to improvements in prognosis and life expectancy. As a consequence, there has been an increase in the number of patients affected by chronic diseases and who can face new pathologies during their lifetime. The prevalence of chronic heart failure, for example, is approximately 1-2% of the adult population in developed countries, rising to ≥10% among people >70 years of age; in 2015, more than 85 million people in Europe were living with some sort of cardiovascular disease (CVD) (Lubrano and Balzan World J Exp Med 5:21-32, 5; Takahashi et al. Circ J 72:867-72, 8; Kaptoge et al. Lancet 375:132-40, 9). Chronic disease can become, in turn, a major risk factor for other diseases. Furthermore, several new drugs have entered clinical practice whose adverse effects on multiple organs are still to be evaluated. All this necessarily involves a multidisciplinary vision of medicine, where the physician must view the patient as a whole and where collaboration between the various specialists plays a key role. An example of what has been said so far is the relationship between CVD and chronic inflammatory diseases (CIDs). Patients with chronic CVD may develop a CID within their lifetime, and, vice versa, a CID can be a risk factor for the development of CVD. Moreover, drugs used for the treatment of CIDs may have side effects involving the cardiovascular system and thus may be contraindicated. The purpose of this paper is to investigate the close relationship between these two groups of diseases and to provide recommendations on the diagnostic approach and treatments in light of the most recent scientific data available.

Cardiovascular risk in patients with rheumatoid arthritis

Substantial epidemiologic data have shown an increased risk of cardiovascular (CV) disease in rheumatoid arthritis (RA) patients. Traditional CV risk factors may partly contribute to CV disease in RA; however, current evidence underlines the important role of inflammation in the pathogenesis of atherosclerosis and amplification of CV risk. Interplays between inflammation and lipid metabolism in the development of atherosclerosis have been established by recent scientific advances. Atherosclerosis is currently viewed as an inflammatory disease, and modifications of lipoproteins during inflammation accelerate atherogenesis. The role of inflammation in the increased CV risk in RA has been further demonstrated by the CV protective effect of methotrexate and TNF antagonists, particularly in patients responding to these treatments. The management of CV risk in RA should include the use of effective disease-modifying anti-rheumatic drugs to control disease activity and the treatment of traditional CV risk factors.

Sarcopenia in rheumatoid arthritis: prevalence, influence of disease activity and associated factors

Evaluate the prevalence of sarcopenia on patients with rheumatoid arthritis (RA), the influence of sarcopenia on disease activity and factors associated with sarcopenia. One hundred and twenty-three patients aged over 18 years with RA based on the 1987 ACR/EULAR classification criteria were enrolled. We performed a whole body DXA scan using a dual-energy X-ray absorptiometry (DXA) scanner lunar prodigy to measure fat mass, lean mass, and bone mass in the whole body and body parts. According to the anthropometric equation by Baumgartner et al., sarcopenia was defined as Relative skeletal mass index (RSMI) <5.5 kg/m² on women and <7.26 kg/m² on men. Body mass index (BMI) and waist circumference were measured and patients were classified according to World Health Organization. Disease activity was evaluated by: disease activity score 28 ESR (DAS28 ESR), disease activity score 28 CRP (DAS28 CRP), clinical disease activity index (CDAI), simplify disease activity index (SDAI). We measured functional disability by Health assessment questionnaire (HAQ). History and previous medication use including steroids were also checked, and comorbidities were recorded. We analyzed the relation between disease parameters and sarcopenia with the r of Pearson and Spearman. Factors associated and related to sarcopenia were assessed using multiple regression analysis and t independent test. We included 123 patients (107 women). 49 subjects (39.8%) where suffering from sarcopenia, of which 40 women. Most of the sarcopenic patients were between 41 and 50 years old. Sarcopenia on female subjects was not related to parameters of disease activity evaluated by DAS 28, CDAI and SDAI. Most of the sarcopenic patients had normal BMI and abnormal waist circumference. In simple regression analysis sarcopenia was related to BMI, DAS 28 ESR, bone erosion, waist circumference and HAQ. In multiple regression analysis, sarcopenia was positively related to an increase cardiometabolic risk [p = 0.025, OR 0.176, CI (0.038-0.980)], normal BMI [p = 0.004, OR 12.3, CI (2.27-67.6)], over fat BMI [p = 0.004, OR 12.3, CI (2.27-67.6)] and bone erosion [p = 0.012, OR 0.057 CI (0.006-0.532)]. No statistical difference was found according to disease duration and steroids use between sarcopenic and non sarcopenic patients. Sarcopenia is prevalent and related to age, bone erosion, normal/over fat BMI and high cardiometabolic risk according to waist circumference but not with disease activity.

Impact of Obesity on Remission and Disease Activity in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

To summarize the relationship between obesity and remission in rheumatoid arthritis (RA); secondary objectives were to summarize other measures of treatment response and mortality in RA.

METHODS

Medline and Embase searches were performed in March 2016 using relevant MeSH and keyword terms for obesity and RA. Articles were selected if they reported estimates for achieving remission in obese subjects relative to other body mass index (BMI) categories, or changes in composite or individual disease activity measures or patient-reported outcomes during therapy, or mortality rates, in relation to BMI category or on a continuous scale. Remission outcomes were conducive to meta-analysis, and all other outcomes were summarized.

RESULTS

A total of 3,368 records were screened; we included 8 reporting remission rates, 9 reporting disease activity measures or patient-reported outcomes, and 3 examining mortality by obesity status or BMI. Obese patients attain remission less frequently than nonobese and/or normal-weight patients. In adjusted models, obese patients demonstrated lower odds of achieving remission (pooled odds ratio [OR] 0.57 [95% confidence interval (95% CI) 0.45, 0.72]) and sustained remission (pooled OR 0.49 [95% CI 0.32, 0.74]) relative to nonobese subjects. Most studies found obese patients to have worse Disease Activity Scores or Disease Activity Scores in 28 joints, tender joint counts, inflammatory markers, patient global evaluation scores, pain scores, and physical function scores during followup, but not worse swollen joint counts. Obesity was not associated with increased mortality.

CONCLUSION

Obesity decreases the odds of achieving remission in RA and negatively impacts disease activity and patient-reported outcomes during therapy. Interventions to reduce BMI should be investigated for their ability to improve disease outcomes.

Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations

Patients with inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, have higher rates of cardiovascular mortality. While the increased cardiovascular risk is only explained to some extent, a lot of research is currently conducted to improve our understanding of its pathogenesis, risk stratification, and optimal cardiovascular risk management. This review sought to report epidemiological data pertaining to the cardiovascular disease burden in patients with inflammatory arthritis, underlying mechanisms accounting for excessive cardiovascular risk, along with recommendations regarding risk assessment and management in this patient population.