Risk of coronary artery disease in patients with systemic sclerosis: a systematic review and meta-analysis

Can we define difficult-to-treat systemic sclerosis?

INTRODUCTION

Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by microvascular alterations, immunopathology, and widespread fibrosis involving various organs. It is considered difficult to treat due to several reasons: complex pathogenesis, heterogeneity, late diagnosis, limited treatment options for certain organ manifestations, lack of personalized medicine.

AREAS COVERED

This review presents the heterogeneity, survival and organ manifestations with their risk factors of systemic sclerosis and their current treatment options, while drawing attention to difficult-to-treat forms of the disease, based on literature indexed in PubMed.

EXPERT OPINION

Despite recent advances in the management of SSc over the last decades, the disease presents significant morbidity and mortality. Although available treatment protocols brought significant advancements in terms of survival in SSc-associated interstitial lung disease and pulmonary arterial hypertension, less success has been achieved in the treatment of Raynaud's phenomenon and digital ulcers and the results are modest in case of heart, gastrointestinal, and renal manifestations. There are patients who do not respond to treatment and deteriorate even with adequate therapy. They can be considered difficult-to treat (D2T) cases. We have created a possible score system based on the individual organ manifestations and highlighted treatment options for the D2T SSc category.

Systemic sclerosis is associated with increased in-patient mortality in patients hospitalized for heart failure

AIMS

We aimed to analyse the characteristics and in-hospital outcomes of patients hospitalized for heart failure (HF) with co-morbid systemic sclerosis (SSc) and compare them to those without SSc, using data from the National Inpatient Sample from years 2016 to 2019.

METHODS AND RESULTS

International Classification of Diseases, Tenth Revision diagnosis codes were used to identify hospitalized patients with a primary diagnosis of HF and secondary diagnoses of SSc from the National Inpatient Sample database from 2016 to 2019. Patients were divided into two groups: those with and without a secondary diagnosis of SSc. Baseline characteristics including demographics and co-morbidities, outcomes of mortality, length of stay (LOS), and costs were compared between the two groups. Multivariable logistic regression analysis was performed to adjust for confounders and assess the impact of SSc on in-hospital mortality, cost, and LOS. A total of 4 709 724 hospitalizations for HF were identified, with 8150 (0.17%) having a secondary diagnosis of SSc. These patients were predominantly female (82.3% vs. 47.8%; P = 0.01), younger (mean age of 67.4 vs. 71.4; P < 0.01), and had significantly lower rates of traditional cardiovascular risk factors such as coronary artery disease (35.8% vs. 50.6%; P < 0.01), hyperlipidaemia (39.1% vs. 52.9%; P < 0.01), diabetes (22.5% vs. 49.1%; P < 0.01), obesity (13.2% vs. 25.0%; P < 0.01), and hypertension (20.2% vs. 23.8%; P < 0.01). Higher rates of co-morbid pulmonary disease in the form of interstitial lung disease (23.1% vs. 2.0%; P < 0.01) and pulmonary hypertension (36.6% vs. 12.7%; P < 0.01) were noted in the SSc cohort. Unadjusted in-hospital mortality was significantly higher in the HF with SSc group [5.1% vs. 2.6%; odds ratio: 1.99; 95% confidence interval (CI): 1.60-2.48; P < 0.001]. Unadjusted mortality was also higher among female (86.7% vs. 47.0%; P < 0.01), Black (15.7% vs. 13.0%; P < 0.01), and Hispanic (13.3% vs. 6.9%; P < 0.01) patients in the SSc cohort. After adjusting for potential confounders, SSc remained independently associated with higher in-hospital mortality (adjusted odds ratio: 1.81; 95% CI: 1.44-2.28; P < 0.001). Patients with HF and SSc also had longer LOS (6.4 vs. 5.4; adjusted mean difference [AMD]: 0.37, 95% CI: 0.05-0.68; P = 0.02) and higher hospitalization costs ($67 363 vs. $57 128; AMD: 198.9; 95% CI: -4780 to 5178; P = 0.93).

CONCLUSIONS

In patients hospitalized for HF, those with SSc were noted to have higher odds of in-hospital mortality than those without SSc. Patients with HF and SSc were more likely to be younger, female, and have higher rates of co-morbid interstitial lung disease and pulmonary hypertension at baseline with fewer traditional cardiovascular risk factors.

Association between systemic sclerosis and risk of cerebrovascular and cardiovascular disease: a meta-analysis

We aimed to evaluate the association between systemic sclerosis (SSc) and major cerebrovascular/cardiovascular risks through a systematic approach. Databases were systematically searched from their inception to October 10, 2023 for studies comparing cerebrovascular/cardiovascular event rates between patients with SSc and controls. The primary outcome was the stroke risk in patients with SSc. Secondary outcomes included risk of myocardial infarction (MI), cardiovascular disease (CVD), peripheral vascular disease (PVD), and venous thromboembolism (VTE). Seventeen studies with 6,642,297 participants were included. SSc was associated with a significantly increased risk of stroke (HR, 1.64; 95% confidence interval [CI], 1.35-2.01), CVD (HR, 2.12; 95% CI, 1.36-3.3), MI (HR, 2.15; 95% CI, 1.23-3.77), VTE (HR, 2.75; 95% CI, 1.77-4.28), and PVD (HR, 5.23; 95% CI, 4.25-6.45). Subgroup analysis revealed a significantly increased stroke risk in the non-Asian group (HR, 1.55; 95% CI, 1.26-1.9), while the Asian group displayed a higher but not statistically significant risk (HR, 1.86; 95% CI, 0.97-3.55). The study found that SSc is associated with a significantly increased risk of cerebrovascular/cardiovascular events. These findings highlight the importance of vasculopathy in SSc and suggest the need for enhanced clinical monitoring and preventive measures in this high-risk population.

Accelerated Atherosclerosis and Management of Cardiovascular Risk in Autoimmune Rheumatic Diseases: An Updated Review

Even though diagnosis and management pathways have been substantially improved over the last years, autoimmune rheumatic diseases (AIRDs) such as rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren's syndrome, and systemic vasculitides have been linked to elevated rates of cardiovascular morbidity and mortality, primarily secondary to accelerated atherosclerosis. This phenomenon can be partially attributed to the presence of established cardiovascular risk factors but may also be a result of other inflammatory and autoimmune mechanisms that are enhanced in AIRDs. According to the current guidelines, the recommendations regarding cardiovascular disease prevention in patients with AIRDs are not significantly different from those applied to the general population. Herein, we present a review of the current literature on the risk of accelerated atherosclerosis in AIRDs and provide a summary of available recommendations for the management of cardiovascular risk in rheumatic diseases.

Sudden cardiac death, arrhythmias and abnormal electrocardiography in systemic sclerosis: A systematic review and meta-analysis

OBJECTIVE

To calculate the frequency of sudden cardiac death(SCD), arrhythmia and conduction defects in SSc.

METHODS

MEDLINE/EMBASE were searched to January 2023. English-language studies reporting the incidence/frequency of SCD, arrhythmia and electrocardiography(ECG) abnormalities in SSc were included. Odds ratios(OR), estimations of annual incidence or pooled frequencies were calculated.

RESULTS

Seventy-nine studies(n = 13,609 participants with SSc) were included in the meta-analysis. Methodology and outcomes were heterogeneous. Ten studies included cohorts with known/suspected SSc-associated heart involvement(SHI), generally defined as clinically-manifest cardiac disease/abnormal cardiac investigations. The incidence of SCD in SHI was estimated to be 3.3% annually(n = 4 studies, 301PY follow-up). On ambulatory ECG, 18% of SHI cohorts had non-sustained ventricular tachycardia(NSVT; n = 4, 95%CI3.2-39.3%), 70% frequent premature ventricular complexes (PVCs; n = 1, 95%CI34.8-93.3%), and 8% atrial fibrillation (AF; n = 1, 95%CI4.2-13.6%). Nineteen studies included participants without SHI, defined as normal cardiac investigations/absence of cardiac disease. The estimated incidence of SCD was approximately 2.9% annually (n = 1, 67.5PY). Compared to healthy controls, individuals without SHI demonstrated NSVT 13.3-times more frequently (n = 2, 95%CI2-102), and paroxysmal supraventricular tachycardia 7-times more frequently (n = 4, 95%CI3-15). Other ambulatory ECG abnormalities included NSVT in 9% (n = 7, 95%CI6-14%), >1000 PVCs/24 h in 6% (n = 2, 95%CI1-13%), and AF in 7% (n = 5, 0-21%). Fifty studies included general SSc cohorts unselected for cardiac disease. The incidence of SCD was estimated to be 2.0% annually(n = 4 studies, 1646PY). Unselected SSc cohorts were 10.5-times more likely to demonstrate frequent PVCs (n = 2, 95%CI 2-59) and 2.5-times more likely to have an abnormal electrocardiography (n = 2, 95%CI1-4).

CONCLUSIONS

The incidence of SCD in SSc is estimated to be 1.0-3.3% annually, at least 10-fold higher than general population estimates. Arrhythmias including NSVT and frequent PVCs appear common, including amongst those without known/suspected SHI.

Understanding and managing cardiac involvement in systemic sclerosis

INTRODUCTION

Cardiac involvement is common in systemic sclerosis occurring in up to 80% of patients. Primary myocardial dysfunction results from impairment of coronary microvascular circulation, myocardial inflammation and fibrosis with the prevalence of atherosclerosis remaining contradictory.

AREAS COVERED

This review presents the various aspects of cardiac involvement in SSc from a pathophysiological, clinical, diagnostic and therapeutic standpoint. Imaging modalities with emerging role in the understanding of mechanisms and prompt diagnosis of myocardial fibrosis namely cardiac magnetic resonance are also discussed.

EXPERT OPINION

Cardiac involvement in SSc - and particularly primary myocardial disease - remains a challenge as clinical symptoms manifest in advanced stages of heart failure and convey poor prognosis. Over the last years the introduction of sophisticated imaging methods of myocardial function has resulted in a better understanding of the underlying pathophysiological processes of myocardial damage such as microvasculopathy, inflammation, diffuse or focal fibrosis. Such developments could contribute to the identification of patients at higher risk for subclinical heart involvement for whom diligent surveillance and prompt initiation of therapy with cardioprotective and/or immunosuppressive drugs coupled with invasive interventions namely radiofrequency ablation, implantable cardioverter-defibrillator when indicated, may improve long-term outcomes.

Management and long-term outcomes of patients with chronic inflammatory diseases experiencing ST-segment elevation myocardial infarction: The SCALIM registry

BACKGROUND

Patients with chronic inflammatory diseases (CIDs) are at increased risk of cardiovascular events. However, the prognostic impact of CID after an acute coronary event has been poorly studied.

AIMS

To examine the effect of history of CID on long-term outcome in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We analysed data from SCALIM, a regional registry that prospectively enrolled patients with STEMI between June 2011 and May 2019. The presence of CID (including inflammatory bowel diseases, rheumatic conditions, inflammatory skin diseases, multiple sclerosis, vasculitis and autoimmune diseases) was identified. The primary outcome was all-cause death. Secondary outcomes were cardiovascular death, myocardial infarction, ischaemic stroke, peripheral vascular events and rehospitalization for cardiovascular conditions.

RESULTS

Data from 1941 patients with STEMI (mean age 64.8±14.1 years, 75.1% men) were analyzed. The prevalence of any CID was 4.6% (n=89). After a mean follow-up of 3.4±2.6 years, the overall death rate was 16.2%, with similar 5-year survival between patients with and without CID (74.2% vs. 81.9%, respectively; P=0.121), with no significant mortality excess (hazard ratio: 1.15, 95% confidence interval: 0.73-1.82; P=0.55). However, among CID patients, 35 (39.3%) were on corticosteroid therapy and showed decreased 5-year survival (52.8% vs. 89.5% without corticosteroids; P=0.001). We found no increased rate of secondary endpoints, except for peripheral vascular events (5-year survival free of peripheral events: 93.3% vs. 98.6% in those without CID; P=0.005).

CONCLUSIONS

Approximately 1 in 20 patients with STEMI has CID. We found no effect of CID on long-term survival. However, patients on corticosteroid therapy appeared to have higher rates of death during follow-up. Whether this finding is related to the use of corticosteroids or to the more progressive nature of their condition warrants further investigation.

Mechanisms shared between cancer, heart failure, and targeted anti-cancer therapies

Heart failure (HF) and cancer are the leading causes of death worldwide and accumulating evidence demonstrates that HF and cancer affect one another in a bidirectional way. Patients with HF are at increased risk for developing cancer, and HF is associated with accelerated tumour growth. The presence of malignancy may induce systemic metabolic, inflammatory, and microbial alterations resulting in impaired cardiac function. In addition to pathophysiologic mechanisms that are shared between cancer and HF, overlaps also exist between pathways required for normal cardiac physiology and for tumour growth. Therefore, these overlaps may also explain the increased risk for cardiotoxicity and HF as a result of targeted anti-cancer therapies. This review provides an overview of mechanisms involved in the bidirectional connection between HF and cancer, specifically focusing upon current 'hot-topics' in these shared mechanisms. It subsequently describes targeted anti-cancer therapies with cardiotoxic potential as a result of overlap between their anti-cancer targets and pathways required for normal cardiac function.

Endothelial Dysfunction in Systemic Lupus Erythematosus and Systemic Sclerosis: A Common Trigger for Different Microvascular Diseases

This review describes the complex interplay between inflammation, vasculopathy and fibrosis that involve the heart and peripheral small vessels, leading to endothelial stiffness, vascular damage, and early aging in patients with systemic lupus erythematosus and systemic sclerosis, which represents two different models of vascular dysfunction among systemic autoimmune diseases. In fact, despite the fact that diagnostic methods and therapies have been significantly improved in the last years, affected patients show an excess of cardiovascular mortality if compared with the general population. In addition, we provide a complete overview on the new techniques which are used for the evaluation of endothelial dysfunction in a preclinical phase, which could represent a new approach in the assessment of cardiovascular risk in these patients.

Coronary Heart Disease and Cardiovascular Risk Factors in Patients With Idiopathic Inflammatory Myopathies: A Systemic Review and Meta-Analysis

Objectives:

It is well-established that the association between atherosclerotic cardiovascular diseases (ASCVD) and connective tissue diseases (CTDs), but the relationship between coronary heart disease (CHD) and idiopathic inflammatory myopathies (IIMs) remains controversial yet. The aim of this meta-analysis is to systematically evaluate the risk of CHD in IIMs patients. In addition, we explore differences in traditional cardiovascular risk factors between IIMs patients and controls.

Methods:

We searched Pubmed, EMBASE and Cochrane databases to identify relevant observational studies published in English up to August 2021. Pooled relative risk (RR) and 95% confidence interval (CI) was calculated using the generic inverse variance method for the risk of CHD. A meta-proportion analysis was conducted to assess differences in cardiovascular risk factors between two groups.

Results:

A total of 15 studies met inclusion criteria: seven studies focused on CHD and nine studies focused on traditional cardiovascular risk factors. The results demonstrated that IIMs patients had a higher risk of CHD (RR = 2.19, 95% CI: 1.40–3.42). Hypertension (OR = 1.44, 95% CI: 1.28–1.61), diabetes mellitus (OR = 1.67, 95% CI: 1.55–1.81) and dyslipidemia (OR = 1.48, 95% CI: 1.19–1.84) were more prevalent in IIMs patients compared with controls. However, there was a significant heterogeneity among studies assessing the risk of CHD and hypertension. Subgroup analysis demonstrated that definition of CHD, country and sample size may be potential sources of heterogeneity.

Conclusions:

IIMs patients were at increased risk of CHD, and traditional cardiovascular risk factors appeared more prevalent in IIMs patients. This systemic review offers the proof that early appropriate interventions could reduce cardiovascular-associated morbidity and mortality in IIMs patients.

Systemic Sclerosis Is Associated With Increased Inpatient Mortality in Patients Admitted for Acute Coronary Syndrome: Analysis of the National Inpatient Sample

OBJECTIVE

This study aims to compare the outcomes of patients primarily admitted for acute coronary syndrome (ACS) with and without systemic sclerosis (SSc). The primary outcome was odds of inpatient mortality. Hospital length of stay, total hospital charges, rates of cardiovascular procedures, and treatments were secondary outcomes of interest.

METHODS

Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 Database. The NIS was searched for hospitalizations for adult patients with ACS (ST-segment elevation myocardial infarction [STEMI], non-ST-segment elevation myocardial infarction [NSTEMI], and unstable angina) as principal diagnosis with and without SSc as secondary diagnosis using International Classification of Diseases, Tenth Revision codes. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders.

RESULTS

There were more than 71 million discharges included in the combined 2016 and 2017 NIS database. There were 1,319,464 hospitalizations for adult patients with a principal International Classification of Diseases, Tenth Revision code for ACS. There were 1155 (0.09%) of these hospitalizations that had SSc. The adjusted odds ratios for inpatient mortality for ACS, STEMI, and NSTEMI hospitalizations with coexisting SSc compared with those without SSc were 2.02 (95% confidence interval [CI], 1.19-3.43; p = 0.009), 2.47 (95% CI, 1.05-5.79; p = 0.038), and 2.19 (95% CI, 1.14-4.23; p = 0.019), respectively.

CONCLUSIONS

Acute coronary syndrome hospitalizations with SSc have increased inpatient mortality compared with those without SSc. ST-segment elevation myocardial infarction and NSTEMI hospitalizations with SSc have increased inpatient mortality compared with STEMI and NSTEMI hospitalizations without SSc, respectively. Acute coronary syndrome hospitalizations with SSc have similar hospital length of stay, total hospital charges, rates of revascularization strategies (percutaneous coronary intervention, coronary artery bypass surgery, and thrombolytics), and other interventions (such as percutaneous external assist device and intra-aortic balloon pump) compared with those without SSc.

A Case of Localized Prostate Cancer Associated with Polymyalgia Rheumatica with Marked Symptomatic Improvement after Robot-Assisted Radical Prostatectomy

A 73-year-old man visited our hospital with chief complaints of fever of unknown origin and bilateral shoulder and hip joint pain. He was initially diagnosed with polymyalgia rheumatica (PMR). Although the patient was treated with prednisolone 15 mg/day, his PMR-related symptoms did not improve. Further examination was performed as the patient was suspected of having paraneoplastic syndrome. Assessment results showed prostate cancer without metastases. After undergoing robot-assisted radical prostatectomy, the patient's PMR-related symptoms dramatically improved. Hence, the prednisolone dose was decreased to 4 mg/day. PCa may have triggered the development of PMR through the activation of immune-mediated systemic inflammatory responses.

Sudden Cardiac Death in Systemic Sclerosis: Diagnostics to Assess Risk and Inform Management

Cardiac disease is a leading cause of death in systemic sclerosis (SSc) and sudden cardiac death (SCD) is thought to occur more commonly in SSc than in the general population. Diffuse myocardial fibrosis, myocarditis and ischaemic heart disease are all prevalent in SSc and can be reasonably hypothesised to contribute to an increased risk of SCD. Despite this, SCD remains a relatively understudied area of SSc with little understood about SSc-specific risk factors and opportunities for primary prevention. In this review, we present an overview of the possible mechanisms of SCD in SSc and our current understanding of how each of these mechanisms may contribute to cardiac death. This review highlights the need for a future research agenda that addresses the underlying epidemiology of SCD in SSc and identifies opportunities for intervention to modify the disease course of heart disease in SSc.

Systemic sclerosis and risk of cardiovascular disease: A PRISMA-compliant systemic review and meta-analysis of cohort studies

BACKGROUND

Systemic sclerosis (SSc) is an autoimmune disorder leading to extensive fibrosis and microvascular injury. Macrovascular disease is well documented in other autoimmune rheumatic diseases such as systemic lupus erythematosus and rheumatoid arthritis. However, the link is unclear between SSc and macrovascular disease, particularly atherosclerotic cardiovascular disease (CVD). This meta-analysis aimed to investigate the association between SSc and CVD.

METHODS

A thorough literature search was conducted in the Cochrane, Embase, Medline, and PubMed to identify all cohort studies comparing the risk of CVD with and without SSc. The pooled hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular end points were calculated. The risk of bias of included studies was assessed by the Newcastle-Ottawa scale.

RESULTS

Seven cohort studies with a total of 14,813 study participants were included. In a comparison of SSc patients versus non-SSc controls, the pooled HR for cardiovascular disease was 2.36 (95% CI 1.97-2.81); for peripheral vascular disease was 5.27 (95%CI 4.27-6.51); for myocardial infarction was 2.36 (95% CI 1.71-3.25); and for stroke was 1.52 (95% CI 1.18-1.96).

CONCLUSION

This meta-analysis revealed that SSc was associated with an increased risk of CVD. Clinicians who manage patients with SSc should be aware of the increased cardiovascular burden and undertake preventive measures.

Outcomes of acute cardiovascular events in rheumatoid arthritis and systemic lupus erythematosus: a population-based study

OBJECTIVES

Patients with RA and SLE have an excess cardiovascular risk. We aimed to evaluate outcomes of acute cardiovascular events in these patients.

METHODS

Using a nationwide database of Taiwan, we identified adult patients who experienced first-time acute myocardial infarction (n = 191 008), intracranial haemorrhage (n = 169 923) and ischaemic stroke (n = 486 890) over a 13-year period. Odds ratios (ORs) of in-hospital mortality and hazard ratios (HRs) of overall mortality and adverse outcomes during long-term follow-up in relation to RA and SLE were estimated with adjustment for potential confounders.

RESULTS

In each cohort, 748, 410 and 1419 patients had established RA; 256, 292 and 622 patients had SLE. Among acute myocardial infarction patients, RA and SLE were associated with in-hospital mortality (RA: OR 1.61, 95% CI 1.33, 1.95; SLE: OR 2.31, 95% CI 1.62, 3.28) and overall mortality. Additionally, RA (HR 1.28, 95% CI 1.18, 1.38) and SLE (HR 1.46, 95% CI 1.27, 1.69) increased the risk of major adverse cardiac events. After intracranial haemorrhage, patients with RA and SLE had higher risks of in-hospital mortality (RA: OR 1.61, 95% CI 1.26, 2.06; SLE: OR 3.00, 95% CI 2.33, 3.86) and overall mortality. After ischaemic stroke, RA and SLE increased in-hospital mortality (RA: OR 1.45, 95% CI 1.15, 1.83; SLE: OR 2.18, 95% CI 1.57, 3.02), overall mortality and recurrent cerebrovascular events (RA: HR 1.10, 95% CI 1.002, 1.21; SLE: HR 1.31, 95% CI 1.14, 1.51), among which ischaemic stroke (HR 1.39, 95% CI 1.19, 1.62) was more likely to recur in SLE patients.

CONCLUSION

Both RA and SLE are consistently associated with adverse outcomes following acute cardiovascular events, highlighting the necessity of integrated care for affected patients.

Cardiovascular Risk Factors and Atherosclerotic Cardiovascular Events Among Incident Cases of Systemic Sclerosis: Results From a Population-Based Cohort (1980-2016)

OBJECTIVE

To characterize cardiovascular (CV) risk factors and outcomes among incident cases of systemic sclerosis (SSc) in a population-based cohort.

METHODS

Medical records of patients with SSc diagnosed in Olmsted County, Minnesota, between January 1, 1980, and December 31, 2016, were reviewed to identify 78 incident SSc cases. The comparators were 156 sex- and age-matched individuals from the same population. Data for SSc characteristics, traditional CV risk factors, and CV events were collected. Cumulative incidence was adjusted for the competing risk for death.

RESULTS

During a median follow-up of 9.8 (SSc) and 9.2 years (non-SSc), 21 patients with SSc and 17 patients without SSc developed CV events, corresponding to 10-year cumulative incidence of 24.4% and 15.2%, respectively. The risk for incident CV disease was increased by 2-fold (hazard ratio, 2.38; 95% CI, 1.28-4.43) in patients with SSc vs comparators, predominately due to coronary artery disease (hazard ratio, 2.35; 95% CI, 1.17-4.71). Mean body mass index and prevalence of diabetes mellitus were lower in SSc vs non-SSc. There was no significant difference in smoking, hypertension, or hyperlipidemia. Observed CV events were increased compared with CV events predicted by the Framingham Risk Score and American College of Cardiology/American Heart Association score with standardized incident ratios of 4.16 (95% CI, 2.16-7.99) and 5.69 (95% CI, 2.71-11.94), respectively.

CONCLUSION

Patients with SSc are at >2-fold increased risk for experiencing a CV event compared with persons without SSc. Framingham Risk Score and American College of Cardiology/American Heart Association score dramatically underestimate CV risk in SSc.

Chronic inflammatory diseases, myocardial function and cardioprotection

The association between chronic inflammatory diseases (CIDs) and increased cardiovascular (CV) risk is well documented and can be a most threatening complication in these patients. However, the pathogenetic mechanisms underlying increased CV risk remain elusive, especially in their cellular and biochemical pathways. Using animal models to understand mechanisms underlying cardiac involvement are limited. Additionally, treatments may influence cardiovascular events through different outcomes. Some drugs used to treat CIDs can negatively affect cardiac function by a direct toxicity, whereas others may protect the myocardium. In the present article, we focus on the cardiac manifestations and risk factors, the pathogenetic mechanisms, and the effect of treatments on myocardial function and cardioprotection for five common worldwide CIDs (rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, psoriasis and inflammatory bowel disease). We also give recommendations in order to evaluate common targets between CID and CV disease (CVD) and to design therapies to alleviate CID-related CVD. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc.

Comorbidity burden in systemic sclerosis: beyond disease-specific complications

Systemic sclerosis (SSc) is a chronic, systemic disease characterized by fibrosis of the skin and internal organs, vasculopathy, and auto-immune activation. On the top of severe organ involvement such as interstitial lung and myocardial fibrosis, pulmonary hypertension, and renal crisis, individuals diagnosed with SSc may suffer from a number of comorbidities. This is a narrative review according to published recommendations and we searched the online databases MEDLINE and EMBASE using as key words the following terms: systemic sclerosis, scleroderma, myocardial fibrosis in combination with micro- and macro-vascular disease, cardiac involvement, atherosclerosis, cardiovascular disease and coronary arteries, infections, cancer, depression, osteoporosis, and dyslipidemia. Although data are usually inconclusive it appears that comorbidities with significant impact on life expectancy, namely cardiovascular disease, infections, and cancer as well as phycological disorders affecting emotional and mental health are highly prevalent in SSc population. Thereafter, the aim of this review is to summarize the occurrence and the clinical significance of such comorbidities in SSc population and to discuss how rheumatologists can incorporate the management of these conditions in daily clinical practice.

Epicardial adipose tissue thickness in systemic sclerosis patients without overt cardiac disease

Systemic sclerosis is associated with an increased prevalence/incidence of coronary artery disease. The aim of this study was to investigate epicardial adipose tissue (EAT) thickness which may contribute to cardio-metabolic risk in systemic sclerosis (SSc) patients without overt cardiac disease. EAT thickness was measured by transthoracic conventional Doppler echocardiography and compared in SSc patients (n = 47) and age- and sex-matched healthy controls (n = 36). The relationships between EAT thickness and markers of cardio-metabolic risk in SSc were examined. EAT thickness was significantly greater in patients with SSc compared to healthy controls (6 [7-5] vs 5 [6.75-3.25], p = 0.041). Compared to controls, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), leukocyte, neutrophil, B-type natriuretic protein (BNP), fasting plasma insulin and HOMA-IR were elevated (18 [31-10] vs 8.5 [18-4], p < 0.001; 0.4 [0.67-0.18] vs 0.21 [0.48-0.09], p = 0.012; 7510 [8731-5990] vs 6435 [7360-5195], p = 0.002; 4350 [5440-3570] vs 3390 [4168-2903], p < 0.001; 111 [185-74] vs 70 [127-70], p = 0.010; 6.7 [10.5-4.7] vs 4.7 [6.8-4.1], p = 0.008; 1.7 [2.6-1] vs 1.1 [1.7-0.9], p = 0.015, respectively). The total and low-density lipoprotein (LDL)-cholesterol were decreased in SSc patients (197 ± 45 vs 284 ± 36, p = 0.005; 118 [148-84] vs 140 [180-115], p = 0.003, respectively). In patients with SSc, the EAT thickness correlated positively with age, ESR, CRP, insulin, hemoglobin A1c and total and LDL-cholesterol (r = 0.574, p < 0.001; r = 0.352, p = 0.015; r = 0.334, p = 0.022; r = 0.290, p = 0.048; r = 0.317, p = 0.030; r = 0.396, p = 0.006 and r = 0.349, p = 0.016, respectively). Our study confirms that EAT thickness is greater in SSc patients compared to healthy controls using echocardiographic measurements. The results of our study suggest that EAT thickness is a candidate for atherosclerotic risk assessment in SSc.

[Unusual cause of acute coronary syndrome: Horton's disease]

The pathophysiology of acute coronary syndromes is in most cases due to the erosion or rupture of a plaque with consequent thrombotic obstruction of coronary artery. In a few cases, the mechanism is different, this not modifying the initial management but imposing special techniques for diagnosis and therapeutic management. We report a clinical case of a patient supported for an acute coronary syndrome, in a context of impaired general condition and biological inflammatory syndrome revealing a Horton's disease.

Autoimmune Diseases May Increase Adverse Cardiovascular Events After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

BACKGROUND

Outcomes of patients with autoimmune diseases after percutaneous coronary intervention (PCI), as compared to those without autoimmune disease, remain unclear.

METHODS

We searched Medline, EMBASE, and the Cochrane Library from their inception to 1 April 2017. All studies comparing the following outcomes of patients with and without autoimmune diseases after PCI were included: long-term mortality, major adverse cardiovascular events (MACE), repeat revascularisation, myocardial ischaemia or myocardial infarction (MI), restenosis, and in-hospital mortality. The Newcastle-Ottawa Quality Assessment Scale (NOS) and the quality assessment form of the Agency for Healthcare Research and Quality (USA) (AHRQ) were used for assessing the risk of bias, and the certainty of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

A total of 11 studies were included in our analysis. Compared with patients without autoimmune diseases, those with autoimmune diseases carried an increased risk of MACEs (relative risk (RR): 2.24, 95% confidence interval (CI): 1.20-4.16; heterogeneity: p=0.128, I²=56.9%), repeat revascularisation (RR: 1.66, 95% CI 95%: 1.01-2.72; heterogeneity: p=0.057, I²=65.1%), ischaemia or MI (RR: 2.80, 95% CI: 1.38-5.65; heterogeneity: p=0.871, I²=0.0%), and restenosis (RR: 2.06, 95% CI: 1.39-3.07; heterogeneity: p=0.665, I²=0.0%) during the one-year follow-up after PCI, and carried an increased risk of MACEs (RR: 1.10, 95% CI: 1.04-1.17) and death (RR: 1.38, 95% CI: 1.25-1.51) during the 11-year follow-up after PCI.

CONCLUSIONS

Evidence of very low quality showed that during the one-year follow-up period, patients with autoimmune diseases after PCI were more likely to experience MACEs, repeat revascularisation, myocardial ischaemia or MI, and restenosis. During the 11-year follow-up period, patients with autoimmune diseases after PCI were more likely to die. It is therefore important to watch for restenosis, repeat ischaemia or MI and other adverse events more carefully in patients with autoimmune diseases after PCI.

Diagnostic criteria, severity classification and guidelines of systemic sclerosis

Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.

Reliability of Cardiovascular Risk Calculators to Estimate Accurately the Risk of Cardiovascular Disease in Patients With Sarcoidosis

Chronic inflammation is an independent risk factor for cardiovascular disease (CVD), but most risk calculators, including the Framingham risk score (FRS) and the American College of Cardiology (ACC)/American Heart Association (AHA) risk score do not account for it. These calculators underestimate cardiovascular risk in patients with rheumatoid arthritis and systemic lupus erythematosus. To date, how these scores perform in the estimation of CVD risk in patients with sarcoidosis has not been assessed. In this study, the FRS and the ACC/AHA risk score were calculated for a previously identified cohort of patients with incident cases of sarcoidosis in Olmsted County, Minnesota, United States, from 1989 to 2013 as well as their gender- and age-matched comparators. The standardized incidence ratio (SIR) was estimated as the ratio of the predicted and observed numbers of CVD events. All CVD events were identified by diagnosis codes and were verified by individual medical record reviews. The predicted number of CVD events among 188 cases by FRS was 11.8 and the observed number of CVD events was 34, which corresponded to an SIR of 2.88 (95% confidence interval 2.06 to 4.04). FRS underestimated the risk of CVD events in patients with sarcoidosis by gender, age and severity of sarcoidosis. The predicted number of CVD events among cases by ACC/AHA risk score was 4.6 and the observed number of CVD events was 19, corresponding to an SIR of 4.11 (95% confidence interval 2.62 to 6.44). In conclusion, the FRS and the ACC/AHA risk score underestimate the risk of CVD in patients with sarcoidosis.

Metabolic regulation of inflammation

Immune cells constantly patrol the body via the bloodstream and migrate into multiple tissues where they face variable and sometimes demanding environmental conditions. Nutrient and oxygen availability can vary during homeostasis, and especially during the course of an immune response, creating a demand for immune cells that are highly metabolically dynamic. As an evolutionary response, immune cells have developed different metabolic programmes to supply them with cellular energy and biomolecules, enabling them to cope with changing and challenging metabolic conditions. In the past 5 years, it has become clear that cellular metabolism affects immune cell function and differentiation, and that disease-specific metabolic configurations might provide an explanation for the dysfunctional immune responses seen in rheumatic diseases. This Review outlines the metabolic challenges faced by immune cells in states of homeostasis and inflammation, as well as the variety of metabolic configurations utilized by immune cells during differentiation and activation. Changes in cellular metabolism that contribute towards the dysfunctional immune responses seen in rheumatic diseases are also briefly discussed.

Polymyalgia rheumatica and risk of coronary artery disease: a systematic review and meta-analysis of observational studies

Several chronic inflammatory disorders, such as rheumatoid arthritis and systemic lupus erythematosus, are associated with an increased risk of coronary artery disease (CAD) as a result of accelerated atherosclerosis. However, the data on CAD risk of polymyalgia rheumatica (PMR), one of the most common chronic inflammatory disorders in older adults, remain unclear due to limited number of epidemiological studies. To further investigate this possible association, this systematic review and meta-analysis of observational studies was performed to compare the risk of CAD in patients with PMR versus subjects without it. Published studies indexed in MEDLINE and EMBASE were searched from inception to April 2016 using the terms "polymyalgia rheumatica" combined with the terms for CAD. The inclusion criteria were: (1) observational studies published as original studies to evaluate the risk of CAD among patients with PMR; (2) published odds ratios, relative risk or hazard ratio or standardized incidence ratio with 95 % confidence intervals (CI) in the studies; and (3) subjects without PMR were used as comparators in cohort studies and cross-sectional studies, while subjects without CAD were used as comparators in case-control studies. Point estimates and standard errors were extracted from individual studies and were combined by the generic inverse variance method of DerSimonian and Laird. Four studies with 34,569 patients with PMR were identified and included in this meta-analysis. The pooled risk ratio of CAD in patients with PMR was 1.72 (95 % CI 1.21-2.45). The statistical heterogeneity of this meta-analysis was high with an I ² of 97 %.

Cerebrovascular accident in patients with giant cell arteritis: A systematic review and meta-analysis of cohort studies

OBJECTIVES

To investigate the risk of cerebrovascular accident (CVA) among patients with giant cell arteritis (GCA).

METHODS

We conducted a systematic review and meta-analysis of cohort studies that reported relative risks, hazard ratios, or standardized incidence ratios comparing CVA risk in patients with GCA versus non-GCA comparators. Pooled risk ratio and 95% confidence interval were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Eight studies with 17,919 patients with GCA were identified and included in our data analysis. The pooled risk ratio of CVA in patients with GCA versus non-GCA controls was 1.40 (95% CI: 1.27-1.56). The statistical heterogeneity was low with an I² of 31%.

CONCLUSIONS

Our study indicates a significantly increased risk of CVA among patients with GCA.

Risk of Parkinson's Disease Among Patients with Psoriasis: A Systematic Review and Meta-analysis

Background:

Patients with psoriasis might be at a higher risk of developing Parkinson's disease (PD) as a result of the detrimental effect of chronic inflammation on the neuronal tissue. This meta-analysis aimed to investigate this risk by comprehensively reviewing all available data.

Methods:

We conducted a systematic review and meta-analysis of cohort and case–control studies that reported relative risk, hazard ratio, odds ratio, or standardized incidence ratio comparing the risk of PD in patients with psoriasis versus subjects without psoriasis. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect, generic inverse variance methods of DerSimonian and Laird.

Results:

Three retrospective studies and one case–control study met our eligibility criteria and were included in this meta-analysis. The pooled risk ratio of PD in patients with psoriasis versus participants without psoriasis was 1.38 (95% CI, 1.15–1.66). The statistical heterogeneity was low with an I² of 35%.

Conclusions:

Our meta-analysis demonstrated a statistically significant increased risk of PD among patients with psoriasis.

The heart and pulmonary arterial hypertension in systemic sclerosis

Systemic sclerosis (SSc) is an autoimmune connective tissue disease characterized by vasculopathy and progressive fibrosis of the skin and visceral organs (gastrointestinal tract, heart, kidneys and lungs). Although the prevalence is low, SSc is a disease with high morbidity and mortality. Since pulmonary arterial hypertension (PAH) associated with SSc (SSc-PAH) and clinically evident cardiac involvement is associated with increased mortality, the cardiac complications and PAH in SSc are reviewed. Both diffuse cutaneous (DcSSc) and limited cutaneous (LcSSc) subgroups are at risk for cardiac involvement and SSc-PAH. Cardiac involvement can be divided in pericardial involvement, myocardial involvement and rhythm disturbances and mostly occurs asymptomatically. However, when symptomatic, it is associated with a poor prognosis. Screening for asymptomatic cardiac involvement should be considered in SSc in order to initiate treatment in an early stage. However, there are no randomized controlled trials on treatment options for cardiac involvement in SSc. SSc-PAH is a devastating complication of SSc, which can develop early in DcSSc and LcSSc. Screening for PAH should be performed since screening leads to earlier diagnosis and earlier treatment is associated with a better prognosis. Today, screening is performed by clinical judgement and echocardiography. Recently the DETECT algorithm, a 2-step screening algorithm is proposed in a SSc-subgroup at increased risk for PAH, but further validation is needed. Despite current treatment options with prostacyclins, endothelin-1 receptor antagonists and phosphodiesterase type-5 inhibitors, mortality remains high. Several promising new treatment options for PAH are evaluated in phase II and III clinical trials.

The Assessment of Tp-e Interval and Tp-e/QT Ratio in Patients With Systemic Sclerosis

Objectives

This study aims to investigate ventricular repolarization using T-peak to T-end (Tp-e) intervals and Tp-e/QT ratios in patients with systemic sclerosis (SSc).

Patients and methods

Totally 65 patients (8 males, 57 females; mean age 49.8 years; range 20 to 77 years) with SSc and 63 control subjects (8 males, 55 females; mean age 49.3 years; range 20 to 77 years) were enrolled. Tp-e intervals, Tp-e/QT, and Tp-e/corrected QT (QTc) ratios were measured from the 12-lead electrocardiogram.

Results

Tp-e intervals, QT intervals, QTc intervals, Tp-e/QT, and Tp-e/QTc ratios were significantly higher in patients with SSc than control subjects (all p<0.01). There was no difference between patients with diffuse and limited cutaneous SSc in terms of electrocardiogram and echocardiographic findings. Correlation analysis revealed no correlation between Tp-e intervals, Tp-e/QT, and Tp-e/QTc ratios with disease duration and anti-Sjögren's syndrome antigen A antibody levels in patients with SSc (all p>0.05).

Conclusion

Our study showed that Tp-e intervals, Tp-e/QT, and Tp-e/QTc ratios were increased in patients with SSc than control subjects. The increased frequency of ventricular arrhythmias can be clarified by increased indexes of ventricular repolarization parameters in patients with SSc.

Treatment of Rapidly Progressive Systemic Sclerosis: Current and Futures Perspectives

INTRODUCTION

Systemic Sclerosis (SSc) is a systemic autoimmune disease characterized by severe and often progressive cutaneous, pulmonary, cardiac and gastrointestinal tract fibrosis, cellular and humoral immunologic alterations, and pronounced fibroproliferative vasculopathy. There is no effective SSc disease modifying therapy. Patients with rapidly progressive SSc have poor prognosis with frequent disability and very high mortality.

AREAS COVERED

This paper reviews currently available therapeutic approaches for rapidly progressive SSc and discuss novel drugs under study for SSc disease modification.

EXPERT OPINION

The extent, severity, and rate of progression of SSc skin and internal organ involvement determines the optimal therapeutic interventions for SSc. Cyclophosphamide for progressive SSc-associated interstitial lung disease and mycophenolate for rapidly progressive cutaneous involvement have shown effectiveness. Methotrexate has been used for less severe skin progression and for patients unable to tolerate mycophenolate. Rituximab was shown to induce improvement in SSc-cutaneous and lung involvement. Autologous bone marrow transplantation is reserved for selected cases in whom poor survival risk outweighs the high mortality rate of the procedure. Novel agents capable of modulating fibrotic and inflammatory pathways involved in SSc pathogenesis, including tocilizumab, pirfenidone, tyrosine kinase inhibitors, lipid lysophosphatidic acid 1, and NOX4 inhibitors are currently under development for the treatment of rapidly progressive SSc.

Coronary artery disease in primary biliary cirrhosis: A systematic review and meta-analysis of observational studies

AIM

To investigate the association between primary biliary cirrhosis (PBC) and risk of coronary artery disease (CAD).

METHODS

We conducted a systematic review and meta-analysis of published observational studies that reported relative risks, odd ratios, hazard ratios or standardized incidence ratios with 95% confidence intervals (CI) comparing CAD risk in patients with PBC versus non-PBC controls. Pooled risk ratios and 95% confidence intervals were combined using a random-effect model and generic inverse variance of DerSimonian and Laird methods.

RESULT

Four studies with 3362 patients with PBC were identified and included in our data analysis. The pooled risk ratio of CAD in patients with PBC was 1.57 (95% CI, 1.21-2.06). The statistical heterogeneity was low with an I(2) of 38%.

CONCLUSION

Our study demonstrated a statistically significant increased risk of CAD among patients with PBC.

Patients with giant cell arteritis have a lower prevalence of diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

The aim of this study is to compare the prevalence of diabetes mellitus (DM) in patients who are recently diagnosed with giant cell arteritis (GCA) with age- and sex-matched controls.

METHODS

We conducted a systematic review and meta-analysis of observational studies that (1) consisted of GCA cohort and non-GCA cohort that was randomly selected from the same population and (2) provided prevalences of DM at the time of diagnosis for patients with GCA and at the index date for controls. Pooled odds ratios and 95% confidence intervals (CIs) were calculated using a random-effect, Mantel-Haenszel analysis.

RESULTS

Five studies with 903 patients with GCA and 1064 controls were identified and included in our data analysis. We demonstrated a statistically significant lower prevalence of DM among patients with GCA with the pooled OR of 0.74 (95% CI, 0.57-0.97).

CONCLUSION

At diagnosis, patients with GCA had a lower prevalence of DM. Whether DM could be a protective factor against the development of GCA needs further investigations.

Risk of ischemic stroke in patients with systemic sclerosis: A systematic review and meta-analysis

BACKGROUND

Several chronic inflammatory disorders, such as rheumatoid arthritis and idiopathic inflammatory myositis, have been shown to increase risk of ischemic stroke but the data on systemic sclerosis (SSc) remains unclear.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of ischemic stroke in patients with SSc versus non-SSc participants. Pooled risk ratio and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Four retrospective cohort studies were identified and included in our data analysis. We found a statistically significant elevated ischemic stroke risk in patients with SSc with a pooled risk ratio of 1.68 (95% CI, 1.26-2.24). The statistical heterogeneity was moderate with an I(2) of 69%.

CONCLUSIONS

Our study demonstrated a statistically significant increased ischemic stroke risk among patients with SSc.

Peripheral arterial disease in patients with giant cell arteritis: a meta-analysis

AIM

To investigate the association between giant cell arteritis (GCA) and risk of peripheral arterial disease (PAD).

METHODS

We conducted a systematic review and meta-analysis of observational cohort studies that reported relative risks, hazard ratios or standardized incidence ratios with 95% confidence comparing PAD risk in patients with GCA versus non-GCA subjects. Pooled risk ratios and 95% confidence intervals were calculated using a random-effect, generic inverse variance of DerSimonian and Laird.

RESULTS

Four studies with 9789 patients with GCA and 236 728 controls were identified and included in our data analysis. The pooled risk ratio of PAD among patients with GCA compared with controls was 1.88 (95% CI 1.04-3.41). The statistical heterogeneity was high with an I(2) of 89%.

CONCLUSION

Our study demonstrated a statistically significant increased risk of PAD among patients with GCA.

Systemic sclerosis and risk of venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Several chronic inflammatory disorders, such as rheumatoid arthritis, inflammatory myositis, and systemic vasculitides, have been linked to an increased risk of venous thromboembolism (VTE). However, the data on systemic sclerosis (SSc) remains unclear.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of VTE in patients with SSc versus non-SSc participants. Pooled risk ratio and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Out of 776 potentially relevant articles, five eligible studies were identified and included in the data analysis. The pooled risk ratio of VTE in patients with SSc was 2.51 (95% CI, 1.79-3.54). The statistical heterogeneity of this study was high with an I² of 90%.

CONCLUSIONS

Our study demonstrated a statistically significant increased VTE risk among patients with SSc.

Risk of coronary artery disease in patients with ankylosing spondylitis: a systematic review and meta-analysis

OBJECTIVE

To investigate the association between coronary artery disease (CAD) and ankylosing spondylitis (AS).

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported relative risks, hazard ratios, standardized prevalence ratio or standardized incidence ratios with 95% confidence comparing CAD risk in patients with AS versus non-AS controls. Pooled risk ratios and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance of DerSimonian and Laird.

RESULTS

Out of 229 potentially relevant articles, ten studies (five retrospective cohort studies and five cross-sectional studies) were identified and included in our data analysis. The overall pooled risk ratio of CAD in patients with AS was 1.41 (95% CI: 1.29-1.54). The pooled risk ratios for cross-sectional and cohort studies were 2.08 (95% CI: 1.28-3.40) and 1.36 (95% CI: 1.31-1.41), respectively. The statistical heterogeneity of this meta-analysis was moderate with an I(2) of 56%.

CONCLUSIONS

Our study demonstrated a statistically significant increased CAD risk among patients with AS with 41% excess risk.

Cardiovascular disease in systemic sclerosis

Cardiovascular (CV) system involvement is a frequent complication of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). It still remains unclear if a premature atherosclerosis (ATS) occurs even in systemic sclerosis (SSc). Although microvascular disease is a hallmark of SSc, in the last few years a number of studies highlighted a higher prevalence of macrovascular disease in SSc patients in comparison to healthy individuals and these data have been correlated with a poorer prognosis. The mechanisms promoting ATS in SSc are not fully understood, but it is believed to be secondary to multi-system organ inflammation, endothelial wall damage and vasculopathy. Both traditional risk factors and endothelial dysfunction have been proposed to participate to the onset and progression of ATS in such patients. In particular, endothelial cell injury induced by anti-endothelial antibodies, ischemia/reperfusion damage, immune-mediated cytotoxicity represent the main causes of vascular injury together with an impaired vascular repair mechanism that determine a defective vasculogenesis. Aim of this review is to analyse both causes and clinical manifestations of macrovascular involvement and ATS in SSc.

Cardiovascular disease in patients with chronic inflammation: mechanisms underlying premature cardiovascular events in rheumatologic conditions

A variety of systemic inflammatory rheumatic diseases associate with an increased risk of atherosclerotic events and premature cardiovascular (CV) disease. Although this recognition has stimulated intense basic science and clinical research, the precise nature of the relationship between local and systemic inflammation, their interactions with traditional CV risk factors, and their role in accelerating atherogenesis remains unresolved. The individual rheumatic diseases have both shared and unique attributes that might impact CV events. Understanding of the positive and negative influences of individual anti-inflammatory therapies remains rudimentary. Clinicians need to adopt an evidence-based approach to develop diagnostic techniques to identify those rheumatologic patients most at risk of CV disease and to develop effective treatment protocols. Development of optimal preventative and disease-modifying approaches for atherosclerosis in these patients will require close collaboration between basic scientists, CV specialists, and rheumatologists. This interface presents a complex, important, and exciting challenge.

Oral hydration for prevention of contrast-induced acute kidney injury in elective radiological procedures: a systematic review and meta-analysis of randomized controlled trials

Background:

The reports on efficacy of oral hydration treatment for the prevention of contrast-induced acute kidney injury (CIAKI) in elective radiological procedures and cardiac catheterization remain controversial.

Aims:

The objective of this meta-analysis was to assess the use of oral hydration regimen for prevention of CIAKI.

Materials and Methods:

Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews, and clinicaltrials.gov from inception until July 4^th, 2014. Primary outcome was the incidence of CIAKI.

Results:

Six prospective RCTs were included in our analysis. Of 513patients undergoing elective procedures with contrast exposures,45 patients (8.8%) had CIAKI. Of 241 patients with oral hydration regimen, 23 (9.5%) developed CIAKI. Of 272 patients with intravenous (IV) fluid regimen, 22 (8.1%) had CIAKI. Study populations in all included studies had relatively normal kidney function to chronic kidney disease (CKD) stage 3. There was no significant increased risk of CIAKI in oral fluid regimen group compared toIV fluid regimen group (RR = 0.94, 95% confidence interval, CI = 0.38-2.31).

Conclusions:

According to our analysis,there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients undergoing elective procedures with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen might be considered as a possible outpatient treatment option for CIAKI prevention in patients with normal to moderately reduced kidney function.

The Risk of Coronary Heart Disease in Patients with Kidney Stones: A Systematic Review and Meta-analysis

Background:

The reported risk of coronary heart disease (CHD) in patients with a history of kidney stones is conflicting.

Aims:

The objective of this meta-analysis was to assess the association between a history of kidney stones and CHD risk.

Materials and Methods:

A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception until April 04, 2014. Studies that reported odds ratios or hazard ratios comparing the risk of CHD in patients with a history of kidney stones versus those without a history of kidney stones were included. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

Results:

Seven study populations from four cohort studies and one cross-sectional study were identified and included in the data analysis. The pooled risk ratio (RR) of CHD in patients with kidney stones was 1.24 (95% CI, 1.10-1.40). This result remained significant (RR, 1.23 [95% CI, 1.08-1.41]) when the sensitivity analysis was restricted to only cohort studies. A history of kidney stones was associated with increased CHD risk in females (RR, 1.43 [95% CI, 1.12-1.82]), whereas the association was not significant in males (RR, 1.14 [95% CI, 0.94-1.38]).

Conclusions:

Our study demonstrates a statistically significant increased risk of CHD in female patients with prior kidney stones. This finding suggests that a history of kidney stones is a risk factor for CHD in females and may impact clinical management.