Ankylosing spondylitis and heart abnormalities: do cardiac conduction disorders, valve regurgitation and diastolic dysfunction occur more often in male patients with diagnosed ankylosing spondylitis for over 15 years than in the normal population?

A case of ankylosing spondylitis presenting with fever of unknown origin diagnosed as aortitis: A case report

Key Clinical Message

Clinicians should be aware of rare manifestations of AS, while considering a low threshold for screening vascular involvement in an axial SpA/nrxSpA/AS presenting with unexplained fevers and significant constitutional symptoms and elevated markers.

Abstract

Ankylosing spondylitis (AS) is a chronic inflammatory disease from the spondyloarthritis complex, which usually affects young men and primarily involves sacroiliac joints and the spine. It can also present with non-joint involvement, such as cardiovascular manifestations. Aortitis is a rare yet critical cardiovascular complication associated with AS, which can lead to life-threatening outcomes when undiagnosed. Here we report a 34-year-old man with intermittent fevers and significant weight loss, myalgia, and arthralgia for 1 year before being referred to our hospital due to undefinable causes despite multiple diagnostic efforts. The patient presented with elevated inflammatory markers and involvement of sacroiliac joints in favor of the AS. A positron emission tomography scan was also done to rule out underlying malignancy, which led to the detection of inflammation in ascending aorta, compatible with aortitis. The patient was treated with nonsteroidal anti-inflammatory drugs, prednisolone, and infliximab, and his signs and symptoms significantly improved. Our case reports a rare but substantial complication of AS, in a young patient without a history of prolonged disease presenting with unspecific manifestations. The implantation of a thorough examination of AS patients, including cardiac examinations, could contribute to faster and more efficient diagnosis and treatment.

Cardiovascular risk in axial spondyloarthritis-a systematic review

Cardiovascular manifestations are common in patients suffering axial spondyloarthritis and can result in substantial morbidity and disease burden. To give an overview of this important aspect of axial spondyloarthritis, we conducted a systematic literature search of all articles published between January 2000 and 25 May 2023 on cardiovascular manifestations. Using PubMed and SCOPUS, 123 out of 6792 articles were identified and included in this review. Non-radiographic axial spondyloarthritis seems to be underrepresented in studies; thus, more evidence for ankylosing spondylitis exists. All in all, we found some traditional risk factors that led to higher cardiovascular disease burden or major cardiovascular events. These specific risk factors seem to be more aggressive in patients with spondyloarthropathies and have a strong connection to high or long-standing disease activity. Since disease activity is a major driver of morbidity, diagnostic, therapeutic, and lifestyle interventions are crucial for better outcomes. Key Points • Several studies on axial spondyloarthritis and associated cardiovascular diseases have been conducted in the last few years addressing risk stratification of these patients including artificial intelligence. • Recent data suggest distinct manifestations of cardiovascular disease entities among men and women which the treating physician needs to be aware of. • Rheumatologists need to screen axial spondyloarthritis patients for emerging cardiovascular disease and should aim at reducing traditional risk factors like hyperlipidemia, hypertension, and smoking as well as disease activity.

Impact of ankylosing spondylitis on stroke limited to specific subtypes: Evidence from Mendelian randomization study

Background

The relationship between Ankylosing Spondylitis (AS) and the risk of stroke is complex. Therefore, we utilized Two-Sample Mendelian randomization to examine the probable causal link between these two features.

Methods

The genetic instruments linked to AS were chosen from a summary-level genetic data set from the FinnGen consortium in people of European ancestry (1462 cases and 164,682 controls). Stroke and its subtypes were selected as outcomes, and the MEGASTROKE consortium population was used to identify the genetic associations of AS on stroke (40,585 cases and 406,111 controls), ischemic stroke (IS) (34,217 cases and 406,111 controls), and its subtypes including large artery stroke (LAS) (4373 cases and 146,392 controls), small vessel stroke (SVS) (5386 cases and 192,662 controls), and cardioembolic stroke (CES) (7193 cases and 204,570 controls). Intracerebral hemorrhage (ICH) (1687 cases and 201,146 controls) data set from the FinnGen consortium was also used. To obtain the casual estimates, the inverse variant weighted (IVW) method was mainly used. By examining the heterogeneity and pleiotropy of particular single nucleotide polymorphisms (SNPs), the robustness of the results was also examined.

Results

There was no evidence found to prove the correlation between genetically predicted AS and stroke (odds ratio [OR] 1.014; 95% confidence interval [CI] 0.999-1.031; P = 0.063), ICH (OR 1.030; 95% CI 0.995-1.067; P = 0.090), and IS (OR 1.013; 95% CI 0. 998-1.030; P = 0.090). In terms of the different subtypes of IS, there was strong evidence of positive causal inferences on CES (OR 1.051; 95% CI 1.022-1.081; P = 0.001), and suggestive evidence of positive causal inferences on LAS (OR 1.042; 95% CI 1.003-1.082; P = 0.033), while it was not significant for SVS (OR 1.010; 95% CI 0.975-1.047; P = 0.563).

Conclusion

This study suggests that the possible causative impact of genetically predicted AS on stroke may be restricted to the CES and LAS subtypes.

Increased risks of aortic regurgitation and atrial fibrillation in radiographic axial spondyloarthritis patients: a 10-year nationwide cohort study

Background:

To compare the incidences of aortic regurgitation, atrial fibrillation (AF), and atrioventricular (AV) block II–III between radiographic axial spondyloarthritis (r-axSpA) patients and the general population (GP).

Methods:

National Health Insurance Services data were used. R-axSpA patients (N = 8877) and the age- and sex-matched GP (N = 26,631) were followed from August 2006 to December 2019. Incidence rates and standardized incidence ratios (SIRs) of aortic regurgitation, AF, and AV block II–III were compared between these groups. Ten-year incidence rates and hazard ratios (HRs) were calculated by the Kaplan–Meier method and Cox regression analysis.

Results:

Incidence rates of aortic regurgitation, AV block II–III, and AF in the r-axSpA group were 0.42, 0.21, and 4.0 per 1000 person-years (PYs), respectively. In the r-axSpA group, the SIR for aortic regurgitation was highest among 40- to 49-year-old men (4.11). Incidence rates of aortic regurgitation and AF were higher in the r-axSpA group than in the GP group (0.42 versus 0.18 per 1000 PYs 4.00 versus 3.13 per 1000 PYs, both p < 0.001, respectively), whereas the difference was insignificant for AV block II–III (0.21 versus 0.14 per 1000 PYs, p = 0.222). In multivariate analysis, r-axSpA was associated with a higher hazard (risk) for the development of aortic regurgitation and AF [HR (95% confidence interval) = 2.55 (1.49–4.37) and 1.20 (1.04–1.39), respectively], but the difference was insignificant for AV block II–III [HR (95% confidence interval) = 1.17 (0.59–2.31)].

Conclusions:

Compared with the GP, r-axSpA patients are at increased risk of aortic regurgitation and AF, but not AV block II–III. These patients should be carefully monitored for occurrence of aortic regurgitation and AF.

The Prevalence of Cardiac Diseases in a Contemporary Large Cohort of Dutch Elderly Ankylosing Spondylitis Patients-The CARDAS Study

Objectives: The aim of the present study was to determine the prevalence of specific cardiac manifestations, i.e., conduction disorders, valvular disease and diastolic left ventricular (LV) dysfunction, in a large cross-sectional controlled cohort of elderly ankylosing spondylitis (AS) patients. Methods: This cross-sectional study assessed the prevalence of valvular disease, conduction disorders and LV dysfunction in 193 randomly selected AS patients compared with 74 osteoarthritis (OA) controls aged 50–75 years. Patients underwent conventional and tissue Doppler echocardiography in combination with clinical and laboratory assessments. Multivariate regression analyses were performed to compare the odds of mitral valve regurgitation (MVR) and aortic valve regurgitation (AVR) between AS patients and OA controls. Results: The prevalence of diastolic dysfunction was trivial and comparable in AS patients compared to controls (respectively, 4% and 3%) and had no further clinical relevance. In addition, the prevalence of conduction disturbances was similar in both groups, with little clinical relevance, respectively 23% vs. 24%. The prevalence of AVR was significantly higher in AS patients compared to the controls, respectively 23% (9% trace, 12% mild, 1% moderate, 1% severe, 1% prosthesis) vs. 11%, p = 0.04. After correcting for age, sex and CV risk factors, AS patients had an odds ratio of 4.5 (95% CI 1.1–13.6) for AVR compared to the controls. In contrast, the prevalence values of MVR were similar and mostly not clinically relevant in AS patients and controls, respectively 36% and 32% and p = 0.46. Conclusion: The prevalence of diastolic LV dysfunction and conduction disorders was mostly not clinically relevant, and similar in AS patients and controls. However, AS patients had an up to five times increased odds to develop AVR compared to controls. Therefore, echocardiographic screening of elderly (50–75 years) AS patients should be considered.

Valve Abnormalities, Risk Factors for Heart Valve Disease and Valve Replacement Surgery in Spondyloarthritis. A Systematic Review of the Literature

Objective: Evaluate the evidence on the abnormalities of the aortic root and heart valves, risk and prognostic factors for heart valve disease and valve replacement surgery in spondyloarthritis.

Methods: A systematic literature review was performed using Medline, EMBASE and Cochrane databases until July 2021. Prevalence, incidence, risk and prognostic factors for heart valve disease; dimension, morphology, and pathological abnormalities of the valves were analyzed. Patient characteristics (younger age, history of cardiac disease or longer disease duration) and period of realization were considered for the analysis. The SIGN Approach was used for rating the quality of the evidence of the studies.

Results: In total, 37 out of 555 studies were included. Overall, the level of evidence was low. The incidence of aortic insufficiency was 2.5–3.9‰. Hazard Ratio for aortic insufficiency was 1.8–2.0. Relative risk for aortic valve replacement surgery in ankylosing spondylitis patients was 1.22–1.46. Odds ratio for aortic insufficiency was 1.07 for age and 1.05 for disease duration. Mitral valve abnormalities described were mitral valve prolapse, calcification, and thickening. Aortic valve abnormalities described were calcification, thickening and an echocardiographic “subaortic bump.” Abnormalities of the aorta described were thickening of the wall and aortic root dilatation. The most common microscopic findings were scarring of the adventitia, lymphocytic infiltration, and intimal proliferation.

Conclusions: A higher prevalence and risk of aortic valve disease is observed in patients with ankylosing spondylitis. Studies were heterogeneous and analysis was not adjusted by potential confounders. Most studies did not define accurate outcomes and may have detected small effects as being statistically significant.

Heart Involvement in a Moroccan Population with Spondyloarthritis: A Cross-sectional Study

Objectives

The aim of this study was to investigate the prevalence of cardiac manifestations and their predictive factors in Moroccan patients with spondyloarthritis (SpA).

Methods

We have conducted a cross-sectional study over four months at the Department of Rheumatology in Mohammed VI University Hospital of Oujda, Morocco. All SpA patients fulfilled the 2009 Assessment SpondyloArthritis international Society (ASAS) criteria. Every patient had a cardiac check up including clinical examination, 12-lead electrocardiogram (ECG) and transthoracic echocardiography (TTE). Multiple logistic regression was used to analyze the associated factors with cardiac manifestations.

Results

We included 64 men and 30 women with a mean age of 37.32 ± 12.65 years old. The mean disease duration was 10.60 ± 7.61 years. Patients had a mean Ankylosing Spondylitis Disease Activity Score (ASDAS) CRP of 2.25 ± 1.38, a mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 2.88 ± 2.26 and a mean Bath Ankylosing Spondylitis Functional Index (BASFI) of 33.52 ± 30.49. Traditional cardiovascular risk factors (CVRF) included dyslipidemia in 14.9%, hypertension in 9.6% and type 2 diabetes in 7.4% of the cases. Eight patients (8.5%) smoked and 3 patients (3.2%) used alcohol whereas 20 patients (21.3%) had a history of smoking and 5 patients (6.3%) a history of alcohol. Cardiac manifestations were found in 12 patients (13.3%): 3.3% had aortic regurgitation (AR), 1.1% had aortic dilatation, 1.1% had aortic valve thickening (AVT), 2.2% had mitral thickening, 1.1% had mitral regurgitation (MR), 1.1% had mitral stenosis (MS), 3.3 had pericarditis and 2.2% had complete right bundle branch block (RBBB). In multivariate analysis, cardiac involvement was significantly associated with extra-articular manifestations (OR = 6.05; 95% CI: 1.197-30.607, p = 0.029).

Conclusion

Based on these results, cardiac involvement was common and associated with the severity of the disease; hence, early detection of cardiac abnormalities and targeted treatment strategies of SpA and comorbidities are necessary to control the systemic inflammation and improve the excess of cardiovascular mortality in this group of patients.

Data to be collected for an optimal management of axial spondyloarthritis in daily practice: Proposal from evidence-based and consensual approaches

OBJECTIVE

To propose a list of variables to be collected right after the diagnosis has been made and during the follow-up of patients with axial spondyloarthritis (ax-SpA) for an optimal management in daily practice.

METHODS

The process comprised (1) the evaluation of the interest of 51 variables proposed for the assessment of ax-SpA by means of a systematic literature research; (2) a consensus process involving 78 hospital-based or office-based rheumatologists, considering the collection of each variable in a 4 grade scale from "not very useful/useless" to "mandatory"; (3) a consensus on the minimum interval of time for periodic assessment of the selected variables on a 5 grade scale from "at each visit" to "never to be re-collected".

RESULTS

The systematic literature research retrieved a total of 14,133 abstracts, of which 213 were included in the final qualitative synthesis. Data to be collected at the initial systematic review comprised 5 patient's self-administered questionnaires, 3 variables of the physician's interview, 2 variables of the physical examination, 2 variables of the specific ax-SpA imaging and 2 other investigations. Two variables were recommended to be systematically collected at each visit, 1 variable twice a year, 6 variables yearly and 1 variable every 2 years.

CONCLUSIONS

Using an evidence-based and an expert consensus approaches, this initiative defined a core set of variables to be collected and reported right after the diagnosis and during follow-up of patients with ax-SpA in daily practice.

Cardiovascular risk in ankylosing spondylitis and the effect of anti-TNF drugs: a narrative review

Introduction: Cardiovascular (CV) mortality is increased in patients with ankylosing spondylitis (AS), but little is known about CV morbidity beyond the fact that they have a two-fold higher prevalence of ischemic heart disease than controls due to the inflammatory pattern of the disease itself, and a higher prevalence of traditional CV risk factors than the general population. Anti-TNF drugs reduce inflammation and a number of studies have reported a reduction in sub-clinical atherosclerosis in AS patients treated with anti-TNF drugs, thus suggesting that inflammation contributes to their higher CV risk. Anti-TNF drugs also alter the lipid profiles of AS patients, although these changes may reflect their normalization secondary to inflammation control, and improve their other myocardial alterations.Areas covered: This review concentrates on the risk of cardiovascular morbidity and mortality among AS patients and the effect of anti-TNF drugs on this risk, with particular emphasis on the putative causes involved and the aspects that are relevant in clinical practice.Expert opinion: The growing evidence of CV disease in AS means that all clinicians need to know how to prevent it and treat patients appropriately. It is important to bear in mind the EULAR guidelines, which state that a rheumatologist is responsible for monitoring all AS patients for signs of CV involvement because this is essential in order to ensure that they are treated properly. As there is little clinical evidence concerning the effects of biological drugs other than anti-TNF agents, treatment should be decided on the basis of the clinical aspects of the type of AS and the CV co-morbidity: for example, patients who are hypertensive or dyslipidemic should immediately start treatment with an anti-hypertensive agent and/or a statin. All of the patients should be educated to prevent CV events by keeping to a balanced healthy diet, avoiding tobacco smoking, and maintaining normal blood pressure, LDL-cholesterol and glucose levels. Finally, all clinicians (but particularly rheumatologists) should always bear in mind CV complications in order to guarantee that the quality of life of AS patients is as good as possible.

Cardiac conduction disturbances in patients with ankylosing spondylitis: results from a 5-year follow-up cohort study

Objectives

To describe electrocardiographic (ECG) development in patients with ankylosing spondylitis (AS) and identify associations between baseline characteristics and cardiac conduction disturbances (CCD) at 5-year follow-up.

Methods

In a longitudinal cohort study, 172 patients (54% men, mean age (SD) of 50 (13) years at baseline) with AS underwent ECG, physical examination, questionnaires and laboratory testing at baseline and at 5-year follow-up. Descriptive statistics and univariate and age- and sex-adjusted logistic regression analyses were used. CCD included both atrioventricular and intraventricular blocks.

Results

Twenty-three of the 172 patients (13.4%) had a CCD at follow-up. Eight patients had developed a new CCD and eight had normalised their ECG. In the age- and sex-adjusted analyses, CCD at baseline (OR 24.8, 95% CI 7.3 to 84.5), male sex (OR 6.4, 95% CI 2.0 to 20.8), history of anterior uveitis (OR 4.4, 95% CI 1.3 to 14.5), higher ASDAS-CRP (OR 2.3, 95% CI 1.3 to 4.0), greater waist circumference (OR 1.3, 95% CI 1.1 to 1.6, per 5 cm), and medication with antiplatelets (OR 7.0, 95% CI 1.5 to 31.8) and beta-blockers (OR 3.4, 95% CI 1.0 to 11.5) were associated with a CCD at follow-up. Higher age and longer symptom duration were highly correlated and were both associated with a CCD at follow-up.

Conclusions

The presence of CCD in AS is in part dynamic and associated with both AS and non-AS characteristics. Our results suggest that patients especially prone to present with CCDs are older men with a previous CCD, longer symptom duration, higher AS disease activity, a history of anterior uveitis and medication reflecting cardiovascular disease.

Lifetime Risks of Valvular Heart Disease and Pacemaker Use in Patients With Ankylosing Spondylitis

Background The likelihoods of valvular heart disease ( VHD ) and conduction abnormalities in patients with ankylosing spondylitis ( AS p) are poorly defined. Knowing their lifetime risks of VHD and pacemaker use would help inform whether cardiac screening should be done. Methods and Results Patients with AS p and a comparison group without AS p were identified among US Medicare beneficiaries in 1999 to 2013. Frequencies of VHD and pacemaker use were compared in 4 age groups: 65 to 69 years, 70 to 74 years, 75 to 79 years, and 80 years or older, as were rates of valve surgeries, a measure of VHD severity, and new pacemaker insertions. Outcomes were compared between 42 327 patients with AS p and 19 211 703 patients without AS p. The prevalence of aortic valve disease in patients with AS p increased with age (2.6%, 6.7%, 10.9%, and 17.1%), as did the prevalence of mitral valve disease. Risks of VHD were slightly but significantly higher in patients with AS p (adjusted odds ratios 1.06-1.51). Rates of aortic valve replacement/repair were also higher in patients with AS p than in the comparison group (125 versus 93; 183 versus 149; 261 versus 208; 279 versus 191 per 100 000 patient-years in the 4 age groups). Rates of mitral valve surgery did not differ between groups. Among patients with AS p, pacemaker use ranged from 1.0% to 7.6% across age groups, and was slightly higher than in controls (odds ratio range 1.11-1.32). Conclusions Lifetime risks of VHD and pacemaker use in AS p increase markedly with age, but are only slightly higher than in elderly people without AS p.

Association of High-Sensitivity Troponin T With Left Ventricular Dysfunction in Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a systemic inflammatory disease, and cardiac dysfunction has not been clearly described clinically. High-sensitivity cardiac troponin T (hs-cTnT) is a noninvasive marker for subclinical myocardial injury.

OBJECTIVE

In this study, we aimed to investigate any relationship between hs-cTnT and left ventricular (LV) function evaluated via tissue Doppler imaging in AS patients with no known cardiac risk factor.

METHODS

Our study used a cross-sectional case protocol design and was conducted between January 2016 and June 2016. In total, 40 AS patients (17 females and 23 males) were age and sex matched with healthy volunteers (20 females and 20 males) and enlisted for this study. Detailed transthoracic echocardiography was performed, and tissue Doppler imaging was used to assess systolic and diastolic functions. High-sensitivity cardiac troponin T levels were measured and compared between 2 groups.

RESULTS

Compared with control subjects, AS patients had lower early (Em)/late (Am) diastolic myocardial velocities, mitral annular plane systolic excursion, and end-diastolic distance from the mitral annulus to the LV apex. Conversely, they had greater systolic myocardial velocity (Sm), isovolumetric relaxation time, and displacement index (p < 0.001, for all). Higher hs-cTnT levels were measured in AS patients (0.45 ± 0.22 vs. 1.11 ± 0.27, p < 0.001), and multivariate logistic regression analyses revealed that hs-cTnT was an independent predictor of LV diastolic dysfunction in AS patients.

CONCLUSIONS

These data show that AS patients had impaired LV functions and increased hs-cTnT levels. Tissue Doppler imaging may be a useful tool for detection of early functional LV abnormalities, and hs-cTnT may be valuable biomarker of diastolic LV dysfunction in AS patients.

Ankylosing spondylitis: A novel risk factor for atrial fibrillation - A nationwide population-based study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease, associated with a number of cardiovascular diseases. We sought to investigate whether AS increases the risk of atrial fibrillation (AF) in a nationwide population-based study.

METHODS

A total of 14,129 patients newly diagnosed with AS (mean age 41.8 ± 15.3 years, 72% male) were recruited from the Korean National Health Insurance Service database between 2010 and 2014 and followed up for new onset AF. Age- and sex-matched non-AS subjects (1:5, n = 70,645) were selected and compared with the AS patients.

RESULTS

During a mean follow-up of 3.5 years, AF was newly diagnosed in 486 patients (114 patients of the AS group). The AS patients developed AF more frequently than the non-AS subjects (2.32 vs. 1.51 per 1000 person-years). In multivariate Cox regression analysis, AS was an independent risk factor for AF (Hazard ratio [HR] 1.28, 95% confidence interval [1.03-1.58]). The AS with tumor necrosis factor inhibitor (TNFi) therapy group showed higher risk for AF (HR 1.60 [1.02-2.39]). In younger patients of the AS group (patients <40 years old), the risk for AF was three times higher than patients at same age in the non-AS group. AS was an independent risk factor for AF in men, but not in women (HR 1.53 [1.18-1.95]; HR 1.42 [0.94-2.08], respectively).

CONCLUSIONS

AS was an independent risk factor for AF, especially in those under 40 years of age and those administered TNFi. It would be reasonable to screen for AF and stroke prevention in these high-risk patients.

Burden of severe spondyloarthritis in France: A nationwide assessment of prevalence, associated comorbidities and cost

OBJECTIVES

To estimate the number of patients with severe spondyloarthritis (SpA) in France, describe their comorbidities and document and value their healthcare resource consumption.

METHODS

Data were retrieved from an insurance claims database covering a 1/97 random sample of the French population. All patients benefiting from full insurance coverage ("ALD") for severe SpA in 2012 (including cases with structural damage and/or frequent flares) were identified, together with a control group frequency-matched by age and gender. Severe comorbidities were documented through ALD categories. Healthcare resource consumption was documented and valued from the payer's perspective. Rates of comorbidities and costs were compared in SpA patients versus controls using non-parametric testing.

RESULTS

Overall, 827 patients with ALD status for severe SpA were identified (control group: n=2.481), corresponding to a prevalence rate of 0.18% [0.17-0.19] for SpA with ALD in the general population. Severe comorbidities more frequent in patients with SpA than in controls included inflammatory bowel disorders (odds ratio: 15.0 [6.2-36.2]), hypertension (2.5 [1.6-3.9]), atrial fibrillation (4.3 [1.9-9.6]) and major depressive disorder (2.1 [1.3-3.6]). Mean per capita annual direct healthcare expenditure was 3.6 [3.2-4.1]-fold higher in SpA patients (€6,122 [€5,838-€6,406]) than in controls (€1,682 [€1,566-€1,798]). Extrapolating to all patients in France, total healthcare cost attributable to severe SpA patients was €391 [€355-€426] million, with medication accounting for 53.8% of this cost.

CONCLUSIONS

The burden of severe SpA in France is substantial, due to the high prevalence, high direct costs and associated comorbidities.

Risk of cardiac rhythm disturbances and aortic regurgitation in different spondyloarthritis subtypes in comparison with general population: a register-based study from Sweden

Objectives

To describe the incidence of atrioventricular (AV) block II–III, atrial fibrillation (AF), pacemaker implantation (PM) and aortic regurgitation in patients with ankylosing spondylitis (AS), undifferentiated spondyloarthritis (uSpA) and psoriatic arthritis (PsA) compared with the general population (GP) and with each other.

Methods

A prospective nationwide study with cohorts of patients with AS (n=6448), PsA (n=16 063) and uSpA (n=5190) and a GP (n=2 66 435) cohort, identified in 2001–2009 in the Swedish National Patient and Population registers. Follow-up began on 1 January 2006 and ended at event, death, emigration or 31 December 2012. Age-standardised and sex-standardised incidence rates and hazard ratios (HRs) were calculated.

Results

The highest incidence rates were noted for AF (5.5–7.4 events per 1000 person-years), followed by PM (1.0–2.0 events per 1000 person-years). HRs for AV block, AF, PM and aortic regurgitation were significantly increased in AS (HRs 2.3, 1.3, 2.1 and 1.9), uSpA (HRs 2.9, 1.3, 1.9 and 2.0) and PsA (HRs 1.5, 1.5, 1.6 and 1.8) compared with the GP cohort. The highest HRs were seen for AV block in male uSpA (HR 4.2) and AS (HR 2.5) compared with GP. Compared with PsA, significantly increased HRs were noted for PM (HR 1.5) in AS and for AV block (HR 1.8) in uSpA.

Conclusions

Patients with SpA are at increased risk of aortic regurgitation, cardiac rhythm disturbances and, as a probable consequence, also PM. Particularly for AF, the most common arrhythmia, increased caution is warranted, whereas AV block should be looked for especially in men with AS or uSpA.

Evaluation of Atrial Conduction Times, Epicardial Fat Thickness and Carotid Intima-Media Thickness in Patients With Ankylosing Spondylitis

Objectives

This study aims to determine the relationship between atrial electromechanical delay (EMD), carotid intima-media thickness (CIMT), and epicardial fat thickness (EFT) in ankylosing spondylitis (AS), which has a complicated inflammatory nature.

Patients and methods

The study population included 42 consecutive patients with AS (28 males, 14 females; mean age 39.3±8.5 years; range 22 to 60 years) and 40 healthy subjects as controls (24 males, 16 females; mean age 37.2±8.7 years; range 22 to 60 years) (p>0.05). All patients underwent a standard tissue Doppler echocardiography to assess the left ventricular diastolic dysfunction, atrial EMD, CIMT, and EFT. All values were compared between the groups.

Results

Interatrial (29.5±5.8 ms vs. 17.9±5.3 ms) left and right intraatrial EMD (18.2±4.6 ms and 11.7±3.5 ms vs. 11.9±3.2 ms and 7.1±3.2 ms, respectively) intervals were longer in AS patients than in healthy controls (all p<0.001). Left and right CIMT (0.50±0.11 mm and 0.44±0.06 mm vs. 0.51±0.11 mm and 0.43±0.04 mm, respectively) and EFT (0.73±0.15 cm and 0.63±0.07 cm) values were higher in AS patients than in healthy controls (all p<0.01).

Conclusion

To our best knowledge, this is the first report evaluating the atrial EMD, CIMT, and EFT values together in AS patients. As indicators of cardiovascular involvement, all parameters were higher in AS patients.

Ankylosing spondylitis: A state of the art factual backbone

Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects 1% of the general population. As one of the most severe types of spondyloarthropathy, AS affects the spinal vertebrae and sacroiliac joints, causing debilitating pain and loss of mobility. The goal of this review is to provide an overview of AS, from the pathophysiological changes that occur as the disease progresses, to genetic factors that are involved with its onset. Considering the high prevalence in the population, and the debilitating life changes that occur as a result of the disease, a strong emphasis is placed on the diagnostic imaging methods that are used to detect this condition, as well as several treatment methods that could improve the health of individuals diagnosed with AS.

Frequency of fragmented QRS in ankylosing spondylitis : a prospective controlled study

OBJECTIVES

Since inflammatory diseases may also cause fibrosis, we hypothesized that patients with ankylosing spondylitis (AS) may have frequent fragmented QRS complexes (fQRS) when compared to a control group.

PATIENTS AND METHODS

In this prospective study, 71 patients with AS (group 1) were compared with 42 age- and gender-matched individuals without rheumatic disease (group 2, control). fQRS was described as the presence of an additional R wave (R') or R or S wave bridging, or the presence of fragmentation on two consecutive derivations that correspond to the major coronary artery regions.

RESULTS

The mean ages of groups 1 and 2 were 37.67 ± 9.17 and 40.43 ± 11.09 years, respectively (p = 0.270). fQRS was detected in 23 AS patients (32.4%), whereas 3 patients in the control group had fQRS (7.14%). Age, gender, medication, and echocardiography results were comparable. The disease duration score was 101.37 ± 59.96 months in fQRS(+) patients; in contrast, it was 57.93 ± 30.95 months in fQRS(-) patients. This difference was of statistical significance (p = 0.046). A statistically significant difference was not determined between the fQRS(+) and fQRS(-) groups when evaluated in terms of HLAB27 (p = 0.739). In the fQRS(+) group, the mean lumbar Schober score was 2.91 ± 1.52; in patients without fQRS, it was 4.10 ± 1.40. The mean thoracic expansion test scores in the fQRS(+) and fQRS(-) groups were 1.44 ± 0.66 and 2.69 ± 1.22, respectively.

CONCLUSION

Given the higher frequency of fQRS detected in electrocardiography studies in AS patients than in the control group, cardiac fibrosis is thought to be more likely to occur in AS patients without cardiovascular disease. The presence of fQRS may be a simple and cost-effective method for predicting cardiac fibrosis in AS patients. fQRS can be a predictive marker for fibrosis in patients with AS.

Large vessel vasculitis and spondyloarthritis: coincidence or associated diseases?

INTRODUCTION

Although cardiac complications have been reported in established spondyloarthritis (SpA), little is known about peripheral axial SpA in large vessel vasculitis (LVV). The aim of this study was to assess the prevalence of SpA in patients with newly diagnosed LVV.

METHOD

Retrospective single-centre analysis of all newly diagnosed LVV patients was performed between January 2011 and December 2012. Vasculitides were confirmed on thoracic magnetic resonance imaging (MRI) or 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). Patients completed a standardized questionnaire incorporating the Berlin criteria to assess inflammatory back pain. Existing scans were reassessed for sacroiliitis and ferritin antibodies measured in all patients.

RESULTS

Fifteen patients exhibiting new LVV were identified. Diagnosis was confirmed using MRI in nine patients and FDG-PET/CT in six. Six patients (40%) fulfilled American College of Rheumatology (ACR) criteria for giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), and nine PMR only. Four patients fulfilled the Berlin criteria for inflammatory back pain, with three demonstrating sacroiliitis on imaging. All remaining patients demonstrated no sacroiliitis. One further patient with LVV lacking features of inflammatory back pain had known psoriatic arthritis (PsA). Patients with coexisting SpA were younger (mean age 57 years vs. 66 years) and had higher C-reactive protein (CRP) levels (200 mg/L vs. 85 mg/L) at presentation. Four SpA patients and seven out of nine patients with isolated LVV had ferritin antibodies.

CONCLUSIONS

We have demonstrated a higher than anticipated prevalence of SpA in LVV, given the reported 0.5-1% prevalence in the general population. Coexisting SpA should be considered in LVV patients exhibiting inflammatory back pain despite steroid initiation. Ferritin antibodies demonstrated a similarly high prevalence in aortitis and SpA as reported previously in untreated GCA and PMR.

Abnormal heart rate recovery on exercise in ankylosing spondylitis

OBJECTIVES

This study evaluated the heart rate recovery response in ankylosing spondylitis (AS) patients and control subjects.

BACKGROUND

Delayed heart rate recovery after exercise reflects AD and independently predicts adverse cardiac outcome.

METHODS

Fifty-one patients with AS and 50 age- and matched controls received electrocardiography, echocardiography, and treadmill exercise testing. The heart rate recovery (HRR) index was calculated as the reduction in heart rate from the rate at peak exercise to the rate at the 1st (HRR1), 2nd (HRR2), 3rd (HRR3) and 5th (HRR5) minute after the cessation of exercise stress testing.

RESULTS

There were significant differences in HRR1 and HRR2 indices between patients and controls (24.8 ± 12.1 vs 34.9 ± 11.0; p<0.001 and 41.2 ± 14.2 vs 54.3 ± 11.8; p<0.001, beats/min, respectively). Similarly, HRR3 and HRR5 indices were lower in patients than controls (51.3 ± 15.1 vs 65.2 ± 14.0; p<0.001 and 61.0 ± 14.2 vs 76.1 ± 14.8; p<0.001). In addition, exercise capacity was markedly lower (8.1 ± 2.0 vs 10.5 ± 2.5 METs; p<0.001) in AS than controls.

CONCLUSION

The HRR index is impaired in AS patients, implying the occurrence of autonomic dysfunction even without active joint disease or frank cardiac involvement.

Increased risk of cardiovascular and cerebrovascular diseases in individuals with ankylosing spondylitis: a population-based study

OBJECTIVE

To estimate the excess risk of cardiovascular and cerebrovascular diseases among individuals with ankylosing spondylitis (AS) in Quebec compared with the general population of Quebec.

METHODS

A retrospective cohort study was conducted using population-based administrative data from Quebec. The cohort included all adult individuals with at least 1 AS diagnosis on physician billing or hospital discharge records between 1996 and 2006. A comparison cohort was generated using a 1% random sample of individuals without AS. Cardiovascular and cerebrovascular diseases, and associated hospitalizations, were classified into 1 of 6 subcategories: congestive heart failure, valvular (aortic or nonaortic) heart disease, ischemic heart disease, cerebrovascular disease, or "other" cardiovascular disease. The age- and sex-stratified prevalence estimates, and standardized prevalence ratios, of cardiovascular or cerebrovascular disease in patients with AS, compared to that in the general population, were calculated.

RESULTS

The AS cohort included 8,616 individuals diagnosed over the period 1996-2006. The prevalence of cardiovascular and cerebrovascular diseases increased with increasing age for all cardiovascular disease subgroups, and was similar for individuals of both sexes. Age- and sex-stratified prevalence ratios were highest in younger individuals with AS. The age- and sex-standardized prevalence ratios comparing the risk among those with AS to the risk in the general population were as follows: for aortic valvular heart disease 1.58 (95% confidence interval [95% CI] 1.31-1.91), for nonaortic valvular heart disease 1.58 (95% CI 1.43-1.74), for ischemic heart disease 1.37 (95% CI 1.31-1.44), for congestive heart failure 1.34 (95% CI 1.26-1.42), for "other" cardiovascular disease 1.36 (95% CI 1.29-1.44), for cerebrovascular disease 1.25 (95% CI 1.15-1.35), and for any hospitalization for a cardiovascular or cerebrovascular disease 1.31 (95% CI 1.22-1.41).

CONCLUSION

Compared with the general population, patients with AS are at increased risk for many types of cardiovascular and cerebrovascular diseases, and are more likely to be hospitalized for these diseases. The excess risk is greatest in younger patients with AS.

Cardiovascular and cerebrovascular diseases in ankylosing spondylitis: current insights

Patients with ankylosing spondylitis (AS) suffer from an increased cardiovascular (CV) risk. The evidence for increased atherosclerotic disease is nowadays convincing, while the precise contribution of the so-called AS-specific (related) cardiac manifestations toward the increased CV risk still needs to be determined. Such studies should be performed in the near future, since they might have clinical consequences-for example, mandatory echocardiographic screening of AS patients. There appears to be a clear contribution of the "traditional" CV risk factors, as well as the underlying chronic inflammatory process, to the increased atherosclerotic risk in AS. Furthermore, there is accumulating evidence for an etiological role of inflammation in the AS-related cardiac manifestations. Nowadays, CV risk management appears necessary for AS patients, and this should consist of, on the one hand, assessment and treatment, if necessary, of the "traditional" CV risk factors, and, on the other hand, effective suppression of the inflammatory process.

Subclinical cardiovascular target organ damage manifestations of ankylosing spondylitis in young adult patients

AIM

Although it is known that ankylosing spondylitis (AS) is associated with cardiovascular complications, the extent of these complications has not been clearly demonstrated in young adult patients. We have therefore investigated myocardial diastolic functions, carotid intima-media thickness (CIMT), and aortic elastic properties of young adult patients diagnosed with AS.

METHOD

Sixty-six AS patients and 21 age/gender-matched healthy subjects were enrolled in the study. Spectral and tissue Doppler echocardiography, CIMT, aortic strain and distensibility, and serum B-type natriuretic peptide values were compared with disease activity indexes of AS, including the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the role of other variables, such as anti-tumor necrosis factor-alpha (anti-TNF-α) treatment, lipid parameters, erythrocyte sedimentation rate, and C-reactive protein.

RESULTS

Both mitral early diastolic flow speed (mE) and late diastolic flow speed (mA) scores were lower among patients than among the control subjects (p = 0.015 and p = 0.035, respectively). The Em ratio of the patients was remarkably lower than that of the control subjects (p = 0.044). BASDAI scores of >4 were used to identify patients with more active disease. The mA and mE/mA ratios were significantly different between patients with a BASDAI score of >4 and those with a BASDAI score of <4 (p = 0.026 and p = 0.021, respectively). While aortic elasticity were not significantly different between the groups, AS patients treated with anti-TNF-α had significantly improved aortic strain and distensibility values (p = 0.022 and p = 0.014, respectively) compared to those treated with non-steroidal anti-inflammatory drugs (NSAIDs).

CONCLUSION

Myocardial diastolic functions were significantly deteriorated in the AS patients, and disease activity and myocardial diastolic functions were associated. An interesting finding was that patients receiving anti-TNF-α had better aortic elasticity than those treated with NSAIDs.

Cardiac manifestations of rheumatological conditions: a narrative review

Cardiovascular diseases are common in systemic rheumatologic diseases. They can be presented at the time of diagnosis or after diagnosis. The cardiac involvements can be the first presentation of rheumatologic conditions. It means that a patient with rheumatologic disease may go to a cardiologist when attacked by this disease at first. These manifestations are very different and involve different structures of the heart, and they can cause mortality and morbidity of patients with rheumatologic diseases. Cardiac involvements in these patients vary from subclinical to severe manifestations. They may need aggressive immunosuppressive therapy. The diagnosis of these conditions is very important for choosing the best treatment. Premature atherosclerosis and ischemic heart disease are increased in rheumatoid arthritis and systemic lupus erythematosus, and may be causes of mortality among them. The aggressive control of systemic inflammation in these diseases can reduce the risk of cardiovascular disease especially ischemic heart disease. Although aggressive treatment of primary rheumatologic diseases can decrease mortality rate and improve them, at this time, there are no specific guidelines and recommendations, to include aggressive control and prevention of traditional risk factors, for them.

Early cardiac valvular changes in ankylosing spondylitis: a transesophageal echocardiography study

BACKGROUND

This study was conducted to determine the early cardiac valvular changes in young male ankylosing spondylitis (AS) patients.

METHODS

A total of 70 AS patients on treatment without clinical cardiac symptoms were divided into group I (< 10 years, n = 50) and group II (≥ 10 years, n = 20) depending on their disease duration after first diagnosis. Twenty-five healthy volunteers were selected as control subjects. All the subjects underwent transthoracic and transesophageal echocardiography, electrocardiography, and rheumatologic evaluation for AS patients.

RESULTS

The thickness of both the aortic and mitral valve was more increased in AS patients than in controls. Aortic valve thickness over 1.3 mm could predict AS with a sensitivity of 73% and specificity of 76%. The prevalence of aortic valve thickening was higher in the AS group compared to the controls. The prevalence of aortic and mitral regurgitation was very low and there was no difference between the controls and the patients. The aortic valve thickening was related to longer disease duration, high blood pressure, disease activity and inflammatory markers.

CONCLUSION

Thickening of the aortic and mitral valve was observed without regurgitation in male AS patients early in the course of their disease without clinical cardiac manifestations. This subclinical change of aorto-mitral valve in early AS should be considered and followed up to determine its prognostic implication and evolution.

Prevalence and characteristics of lung involvement on high resolution computed tomography in patients with ankylosing spondylitis: a systematic review

To determine the prevalence of lung involvement and the spectrum of abnormalities revealed on HRCT in patients with AS, a systematic literature review was conducted in the Medline database up to May 2009 and in the abstracts of rheumatology scientific meetings (2006–2008). A hand search of references was also performed. Among the 264 selected articles, 10 articles (303 patients) allowed a calculation of the prevalence of lung abnormalities on thoracic HRCT in AS. A total of 185 patients (61%) had an abnormal thoracic HRCT: upper lobe fibrosis in 21 (6.9%), emphysema in 55 (18.1%), bronchiectasis in 33 (10.8%), and ground glass attenuation in 34 (11.2%). Non specific interstitial abnormalities were observed in 101 (33%) patients. The most common observed abnormalities were pleural thickening (52%), parenchymal bands (45%) and interlobular septal thickening (30%). Only the prevalence of upper lobe fibrosis increased significantly with disease duration (3 studies). Mild and non-specific interstitial abnormalities on thoracic HRCT are common in patients with AS, even in patients with early disease and without respiratory symptoms.

Extra-articular manifestations of ankylosing spondylitis: prevalence, characteristics and therapeutic implications

Ankylosing spondylitis (AS) is the most frequent and most severe subtype of spondyloarthritis and can be an outcome of any of the other spondyloarthritis subtypes. It primarily affects the axial joints, most notably the sacroiliac joints. Other sites of involvement include the spine, peripheral joints, and entheses (capsules, ligaments, and tendons). Inflammatory enthesopathy progressing to ossification and ankylosis is the pathologic basis for the disease. Extra-articular manifestations vary widely in terms of both frequency and severity. The most common extra-articular manifestations are represented by uveitis, bowel disease, heart, lung, skin, bone and kidney involvement. This review focuses on prevalence and clinical characteristics of the most common extra-articular manifestations in AS, and discuss the diagnosis and therapeutic difficulties that rheumatologists faces when dealing with such manifestations. The advantages of treatment with non-steroidal anti-inflammatory drugs (NSAIDs), especially if continuous use is envisaged, should be weighted against possible gastrointestinal and cardiovascular disadvantages. In the presence of history of gastrointestinal complaints or a high cardiovascular risk, NSAIDs should be used with caution. TNF inhibition has demonstrated effectiveness in the treatment of AS symptoms and all currently available anti-TNF agents appear to have similar efficacy. However, the efficacy of anti-TNF agents varies in the presence of extra-articular manifestations. Etanercept appears to have very little effect on inflammatory bowel disease and limited efficacy on the course of uveitis probably inferior to the monoclonal antibodies infliximab and adalimumab.

[Cardiovascular disorders and rheumatic disease]

Cardiovascular disease is a common and under-recognized problem in patients with systemic rheumatic conditions. Patients may present with disease associated heart involvement at the time of diagnosis or later in the course of the illness. The manifestations vary by disease, and all structures in the heart can be affected and may result in significant morbidity and mortality. Manifestations of cardiac disease in these patients range from subclinical to severe and may require aggressive immunosuppressive therapy. Early recognition is important for prompt institution of appropriate therapy. Treatment of disease associated cardiac involvement is based on severity of disease with more severe manifestations often requiring a combination of corticosteroid and cytotoxic agent. Premature atherosclerosis has been increasingly recognized in patients with systemic lupus erythematosus and rheumatoid arthritis and may result in premature coronary death when compared to the general population. Aggressive control of systemic inflammation in these diseases may result in a reduction in the risk of ischemic heart disease. Although aggressive treatment of the primary rheumatic disease has been associated with an improvement in mortality rates, specific guidelines for prevention of ischemic heart disease in this group of patients have not been formulated and recommendations at this time include aggressive control and monitoring of traditional risk factors.

Cardiopulmonary manifestations of ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory condition that usually affects young men. Cardiac dysfunction and pulmonary disease are well-known and commonly reported extra-articular manifestation, associated with ankylosing spondylitis (AS). AS has also been reported to be specifically associated with aortitis, aortic valve diseases, conduction disturbances, cardiomyopathy and ischemic heart disease. The pulmonary manifestations of the disease include fibrosis of the upper lobes, interstitial lung disease, ventilatory impairment due to chest wall restriction, sleep apnea, and spontaneous pneumothorax. They are many reports detailing pathophysiology, hypothesized mechanisms leading to these derangements, and estimated prevalence of such findings in the AS populations. At this time, there are no clear guidelines regarding a stepwise approach to screen these patients for cardiovascular and pulmonary complications.

Aortitis and periaortitis in ankylosing spondylitis

Aortic involvement is a potential life-threatening complication of ankylosing spondylitis, usually occurring late in the course of this frequent disease. Inflammatory lesions evolving to fibrosis are primarily localized in the aortic root causing regurgitation, but this process can extend into the left atrium (subaortic bump) involving the mitral valve and the heart conduction system. First, second and third degree atrioventricular blocks are the most common conduction alterations described and they can be temporary. Chronic periaortitis has been described in ankylosing spondylitis patients. This disease is characterized by inflammation evolving to fibrosis and it is localized in the periaortic and peri-iliac retroperitoneum. It causes compressive effects on ureters and venous, arterial and lymphatic vessels. Its treatment employs endoscopic and/or surgical procedures and administration of corticosteroids, even in association with immunosuppressive agents. Both aortitis (with conduction system alterations) and periaortitis should be kept in mind by the physicians because they can significantly influence the prognosis of ankylosing spondylitis patients and they can need a rapid treatment.

Usefulness of routine electrocardiography for heart disease screening in patients with spondyloarthropathy or rheumatoid arthritis

OBJECTIVE

To assess the usefulness of routine electrocardiography for heart disease screening in patients with spondyloarthropathy (SpA) or rheumatoid arthritis (RA).

METHODS

We included consecutive patients with SpA or RA or with degenerative joint disease (control group) admitted over a 6-month period and free of cardiovascular events. A 12-lead electrocardiogram (ECG) was obtained and was interpreted by a cardiologist who was unaware of the diagnosis.

RESULTS

We included 108 patients with SpA (mean duration, 11+/-10 years), 106 with RA (mean duration, 12+/-9 years), and 74 with degenerative joint disease (controls). No patient had cardiovascular symptoms or a prior history of cardiovascular disease. The only difference in cardiovascular risk factors across the three populations was a higher prevalence of diabetes in the RA and control groups. We found no differences between the SpA or RA groups and the control group regarding the rates of the following ECG findings: premature beats, atrioventricular block (2.8% in the SpA group, 1.9% in the RA group, and 2.7% in the control group), complete or incomplete left bundle branch block (0.9%, 0.9%, and 2.7%, respectively), complete right bundle branch bloc or left bundle branch block (0.9%, 4.7%, and 4.1%, respectively); and abnormalities suggesting myocardial ischemia (10.2%, 19.8%, and 17.6%, respectively).

CONCLUSION

In patients with SpA or RA who have no cardiovascular symptoms or history of cardiovascular disease, a routine ECG shows no increase in the cardiac abnormalities specifically associated with these joint diseases, compared to controls with degenerative joint disease.

Arrhythmias and conduction defects in rheumatological diseases--a comprehensive review

OBJECTIVES

To review the clinical aspects of cardiac arrhythmias and conduction disturbances in several common and less encountered adult rheumatic diseases and to underline the importance of prompt diagnosis and management in these patients.

METHODS

The PubMed database was searched for articles published between the years 1960 and 2008 for keywords referring to autoimmune diseases. All relevant English-written articles were reviewed. Most were uncontrolled series and case reports, due to the lack of prospective studies and randomized trials.

RESULTS

Rheumatologic conditions may affect the cardiovascular system and increase morbidity and mortality. Rhythm and conduction defects are usually mild but may be life-threatening; in certain diseases, such as in systemic lupus erythematosus they may resolve following therapy with corticosteroids. Conduction defects occur frequently in patients with spondyloarthropathies and in those with various forms of vasculitis. Enhanced variation of the QT interval may be a sensitive marker of a higher arrythmogenic tendency in patients with autoimmune conditions.

CONCLUSIONS

It is important to identify patients at high risk for cardiac arrhythmias. Treating such patients with arrhythmias should not differ fundamentally from other patients. Nevertheless, appropriate clinical attention and judgment should be applied to exclude the possibility that arrhythmias reflect uncontrolled myocardial inflammation.

Cardiovascular Involvement of Ankylosing Spondylitis: Report of Three Cases

Cardiovascular involvement is one of the extra-articular manifestations of ankylosing spondylitis. Of these, aortic disease and aortic regurgitation are the most commonly associated cardiovascular disorders. Since 2005, three male patients with ankylosing spondylitis were referred to The Chaim Sheba Medical Center for surgical treatment of cardiovascular associations. The diagnosis of ankylosing spondylitis was evidenced by radiography and/or laboratory tests of C-reactive protein or HLA-B27. Apart from the usual cardiac manifestations including heart block and left ventricular hypertrophy, usual associated disorders such as aortic aneurysmal dilation, bicuspid aortic valve, aortic root dilation and myocardial infarction, and solely bicuspid aortic valve that developed in these patients warranted a surgical intervention. Aortic aneurysmal dilation is a recognized rare association with ankylosing spondylitis, and bicuspid aortic valve or coronary artery disease is only occasionally present. Decreased aortic elasticity with impaired endothelial function could be responsible for the development of the aortic complication in ankylosing spondylitis patients. The underlying mechanisms of these associations are discussed.

Ventricular diastolic function of ankylosing spondylitis patients by using conventional pulsed wave Doppler, myocardial performance index and tissue Doppler imaging

OBJECTIVE

The aim of this study was to evaluate ventricular functions by using standard Doppler echocardiography (SDE), myocardial performance index (MPI), and pulsed wave tissue Doppler imaging (PW-TDI) in patients with ankylosing spondylitis (AS) and healthy controls.

METHODS

Forty-nine AS patients (38 +/- 11 years, 25 M/24 F) and 33 controls (36 +/- 9 years, 17 M/16 F) were studied. Two-dimensional, M-Mode, SDE, PW-TDI echocardiography examinations were performed. Spinal mobility was assessed by the Bath ankylosing spondylitis metrology index (BASMI) measurement. Patients were also evaluated using the Bath ankylosing spondylitis functional index (BASFI) and the Bath ankylosing spondylitis disease activity index (BASDAI).

RESULTS

Four control subjects and six AS patients met the left ventricular (LV) diastolic dysfunction (DD) criteria by using conventional Doppler echocardiography (p > 0.05). However, using PW-TDI method 22 patients in the AS group and six subjects in the control group were diagnosed to have LV DD (Em/Am < 1). Pseudonormalized pattern was present in 16 AS patients and two control subjects. Correlation analysis revealed significant moderate negative correlations between Em/Am and BASMI, age and body mass index (p < 0.05; r =-0.3, -0.6, and -0.4, respectively). No correlation was observed between Em/Am and disease duration, BASFI, BASDAI, CRP, and ESR. We could not detect any right ventricular function involvement either by conventional or by recently introduced echocardiography methods. The risk of developing LV DD was found to be 3.7 times higher in AS patients.

CONCLUSION

When sensitive echocardiographic Doppler techniques such as MPI, TDI-derived MPI, and PW-TDI are utilized, DD can be detected in a significant proportion of patients with AS without cardiovascular (CV) disease which may contribute CV mortality in these patients.

Cardiovascular disease in patients with spondyloarthropathies

Spondyloarthropathies are associated with a greater cardiovascular risk than expected based on the cardiac lesions known to occur in these diseases. The prevalence of several conventional risk factors is high in spondyloarthropathy patients, and chronic inflammation also contributes to premature plaque formation. In addition, susceptibility genes for spondyloarthropathies may be associated with an increased risk of cardiovascular disease. Finally, several drugs used to treat spondyloarthropathies may contribute to the occurrence of cardiovascular events. A careful evaluation of the cardiovascular risk profile is a key component of the management of patients with spondyloarthropathies.

Cardiovascular risks in spondyloarthritides

PURPOSE OF REVIEW

Spondyloarthritides are associated with increased cardiovascular risks, which can only partly be explained by traditional risk factors. It is likely that the chronic inflammatory state is involved. In this review, novel findings regarding cardiac and vascular pathologies and potential overlapping mechanisms will be discussed.

RECENT FINDINGS

Cardiac pathologies in spondyloarthritides are conduction disturbances and valvular heart diseases. Recent studies have also focused on vascular pathologies and showed impaired endothelial function, suggesting that atherosclerotic alterations could also be involved in increased cardiovascular mortality. Novel findings suggest that chronic systemic inflammation is involved in these cardiac and vascular pathologies. Thus, spondyloarthritides and ankylosing spondylitis are associated with increased levels of circulating inflammatory mediators such as C-reactive protein. Interestingly, ankylosing spondylitis patients may also have an atherogenic lipid profile and disturbances in their T-helper lymphocyte subsets, which may be involved in cardiovascular disease development. The beneficial effects of statin treatment on circulating inflammatory mediators and atherogenic lipid profiles may reveal new therapeutic options for patients with spondyloarthritides.

SUMMARY

Recent studies have highlighted that the chronic, systemic inflammatory condition of patients with spondyloarthritides may be involved in the development of cardiac and vascular pathologies.