Metabolic syndrome in patients with ankylosing spondylitis receiving anti-TNFα therapy: association with predictors of cardiovascular risk

Cardiovascular Disease and Cardiac Imaging in Inflammatory Arthritis

Cardiovascular morbidity and mortality are more prevalent in inflammatory arthritis (IA) compared to the general population. Recognizing the importance of addressing this issue, the European League Against Rheumatism (EULAR) published guidelines on cardiovascular disease (CVD) risk management in IA in 2016, with plans to update going forward based on the latest emerging evidence. Herein we review the latest evidence on cardiovascular disease in IA, taking a focus on rheumatoid arthritis, psoriatic arthritis, and axial spondylarthritis, reflecting on the scale of the problem and imaging modalities to identify disease. Evidence demonstrates that both traditional CVD factors and inflammation contribute to the higher CVD burden. Whereas CVD has decreased with the newer anti-rheumatic treatments currently available, CVD continues to remain an important comorbidity in IA patients calling for prompt screening and management of CVD and related risk factors. Non-invasive cardiovascular imaging has been attracting much attention in view of the possibility of detecting cardiovascular lesions in IA accurately and promptly, even at the pre-clinical stage. We reflect on imaging modalities to screen for CVD in IA and on the important role of rheumatologists and cardiologists working closely together.

Increased risk of stroke among patients with ankylosing spondylitis: A systematic review and meta-analysis

BACKGROUND

Ankylosing spondylitis is a chronic inflammatory disease that is associated with adverse cardiovascular events. This study aimed to determine the relationship between ankylosing spondylitis and the risk of stroke.

METHODS

A systematic literature search in PubMed/MEDLINE, Scopus, and Web of Science were conducted from inception to December 2021 to identify relevant articles investigating the risk of stroke in patients with ankylosing spondylitis. A random-effects model (DerSimonian and Laird) was used to estimate a pooled hazard ratio (HR) and 95% confidence intervals (CI). Meta-regression based on the length of follow-up and subgroup analysis based on the type of stroke, study location, and year of publication to investigate the source of heterogeneity.

RESULTS

A total of eleven studies comprising 1.7 million participants were included in this study. Pooled analysis showed a significantly increased stroke risk (56%) among patients with ankylosing spondylitis (HR: 1.56, 95% CI 1.33-1.79). Subgroup analysis revealed a higher risk of ischemic stroke among patients with ankylosing spondylitis (HR: 1.46, 95% CI: 1.23-1.68). However, meta-regression analysis showed no association between the duration of ankylosing spondylitis and stroke incidence (Coef=-0.0010, P=0.951).

CONCLUSION

This study reveals that ankylosing spondylitis was associated with an increased risk of suffering a stroke. Management of cerebrovascular risk factors and the control of systemic inflammation should be considered in patients with ankylosing spondylitis.

Benefits of tumor necrosis factor inhibitors for cardiovascular disease in ankylosing spondylitis

Ankylosing spondylitis (AS) has been associated with an increased cardiovascular disease (CVD) risk, with current guidelines recommending multiple CVD-related risk assessment strategies. CVD risk prediction using a scoring model with lipids might be another promising alternative, for which ultrasound screening for subclinical atherosclerosis may be considered together with surrogate markers. Theoretically, tumor necrosis factor inhibitors (TNFi), which are known to inhibit endothelial activation and inflammation caused by the disease and underlying metabolic dysfunction, might prevent microvascular events. In this narrative review, we summarized the evidence of TNFi effects on CVD in AS. Although early case reports revealed that CVD occurred during TNFi treatment, more recent evidence shows that it could be successfully treated. Studies of TNFi on lipid changes and subclinical atherosclerosis have shown controversial results, possibly due to genetic predisposition, differences in affinity for membrane-bound TNF leading to insufficient inhibition of inflammation or primary failure response to TNFi, and not enough follow-up time to identify potential significance. Overall, patients vulnerable to CVD could benefit from long-term administration of TNFi when inflammation is under control. Besides healthy lifestyle modification, traditional CVD risk factors and metabolic syndrome-related diseases should be further assessed and treated if necessary.

Athrogenic indexes: Useful markers for predicting metabolic syndrome in axial spondyloarthritis

INTRODUCTION

Metabolic syndrome is a pathological entity associated with a high risk of cardiovascular disease. Data regarding the frequency of this syndrome, lipid profile, and atherogenic index of plasma in patients with radiographic axial spondyloarthritis are scarce. We aim to determine the prevalence of metabolic syndrome in patients with spondyloarthritis. We also aim to determine discriminative values of atherogenic indexes between patients with and without metabolic syndrome.

METHODS

We conducted a cross-sectional study including 51 patients meeting the ASAS 2009 criteria for radiographic axial spondyloarthritis. We measured the following parameters: triglyceride (TG), high-density lipoproteins (HDL_c), low-density lipoprotein cholesterol (LDL_c), and total cholesterol (TC). We calculated TC/HDL_c, TG/HDL_c, LDL_c/HDL_c ratios, and atherogenic index of plasma (LogTG/HDL_c).

RESULTS

Metabolic syndrome was noted in 33% of cases. Patients with active disease had a higher body mass index (26.89±5.88 versus 23.63±4.47kg/m², p=0.03), higher TG (1.41±0.64 versus 0.89±0.5mmol/L, p=0.05) and a lower HDL_c level (1±0.28 versus 1.31±0.22mmol/L, p=0.01). However, the LogTG/HDL_c and TG/HDL_c were higher in patients under TNFα inhibitors. The ability of the TG/HDL_c ratio and LogTG/HDL_c to distinguish patients with or without metabolic syndrome were good at cut-offs of 1.33 and 0.22, respectively (specificity: 91.2% and sensitivity 70.6% for both ratios).

CONCLUSION

Our study showed that metabolic syndrome is frequent in patients with axial spondyloarthritis. Atherogenic indexes can be used for predicting metabolic syndrome in these patients.

Metabolic syndrome is associated with increased cardiovascular risk and disease damage in patients with Takayasu arteritis

OBJECTIVE

Metabolic syndrome (MetS) is one of the preventable risk factors for cardiovascular disease (CVD). The aim of this study was to investigate the effect of MetS on CVD and cumulative organ damage in a multi-center, large cohort of patients with Takayasu arteritis (TAK).

METHODS

This is a cross-sectional study involving 192 consecutive TAK patients from seven tertiary rheumatology centers in Turkey. Clinical data of TAK patients fulfilling the 1990 American College of Rheumatology classification criteria were collected from medical records. They were evaluated for risk factors of CVD, disease activity, damage, and MetS at their last visits.

RESULTS

A total of 192 consecutive TAK patients were included in this study. One hundred and fifty-eight (82%) were female, the mean age was 43.3 ± 13 years, and mean disease duration was 13.5 ± 9.3 years. MetS was detected in 50 (26%) of the patients and CVD was detected in 28 (14.6%). The presence of MetS was detected as an independent risk factor for CVD (P < 0.001). In addition, the mean vasculitis damage index of the group with MetS was significantly higher than in the other patients (4.5 ± 3.3 vs 3.2 ± 2.2, respectively, P = 0.004).

CONCLUSION

The presence of MetS in TAK is associated with increased CVD and disease damage. Awareness and management of MetS can improve disease prognosis in patients with TAK.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Insulin resistance in non-diabetes patients with spondyloarthritis

Objectives: Insulin resistance (IR) constitutes a major underlying abnormality driving cardiovascular disease in the general population and has been linked to inflammatory diseases. In this study, we aimed to determine the prevalence of IR in patients with spondyloarthritis (SpA) and whether IR can be explained by disease-related features in such cases. Method: The study included 577 subjects: 306 patients diagnosed with SpA according to Assessment of SpondyloArthritis international Society criteria and 271 controls. Insulin and C-peptide serum levels, IR and β-cell function (%B) indices by homoeostatic model assessment (HOMA2), and lipid profiles were assessed in patients and controls. A multivariable regression analysis was performed to evaluate the differences in IR indices between patients and controls and to determine how IR is associated with disease-related characteristics in SpA patients. Results: HOMA2-%B and HOMA2-IR scores, both calculated with insulin or C-peptide, had significantly higher values in SpA patients compared to controls in multivariable analysis adjusted for age, gender, traditional IR-related factors, and glucocorticoid intake. Disease activity, functional status, and metrological SpA indices were positively related to IR, but only in univariable analysis. Disease duration and positivity for human leucocyte antigen-B27 were independently associated with a higher HOMA2-%B after multivariable analysis. Conclusion: Patients with SpA have an increased IR compared to controls. SpA disease-related data are independently associated with β-cell dysfunction.

Prevalence of Metabolic Syndrome Among Patients with Psoriasis Treated with TNF Inhibitors and the Effects of Anti-TNF Therapy on Their Lipid Profile: A Prospective Cohort Study

Background: Tumor necrosis factor (TNF) is an important inflammatory cytokine in the pathogenesis of psoriasis and metabolic syndrome (MS). Patients with psoriasis have higher rates of MS; therefore, some authors suggest an MS screening within this population. In addition, TNF inhibitor treatment often modifies the metabolic profiles of these patients. This study describes the epidemiological, clinical, and laboratory characteristics of patients with psoriasis undergoing anti-TNF treatment and evaluates whether anti-TNF treatments influence changes in their metabolic parameters. Methods: A prospective 6-month cohort study followed patients who underwent three consecutive consultations at 0, 3, and 6 months. The sample composed of 83 patients with psoriasis using anti-TNF. Results: The mean age and disease duration of the patients were 48 ± 11 and 16 ± 9 years, respectively. Most patients were men (61.5%). The prevalence of MS was 36%, and high rates of abdominal obesity (59%) and overweight (82%) were observed. Anti-TNF treatment significantly altered total cholesterol levels (195.5 ± 36.17 vs. 183.5 ± 41.23, P = 0.04) and low-density lipoprotein (LDL) cholesterol levels (128.5 ± 31.26 vs. 113 ± 36.31, P = 0.04). This study has some limitations, such as small sample size, brief follow-up period (6 months), patient recruitment from a tertiary-level referral center, and no control group. Conclusions: Patients with psoriasis have high rates of MS, overweight, and obesity, but anti-TNF treatment seems to improve the metabolic profile of these patients by decreasing their total and LDL cholesterol levels.

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.

Prevalence of metabolic syndrome and its associated factors in Chinese patients with ankylosing spondylitis

Purpose: We assessed the prevalence of metabolic syndrome (MetS) and associated factors in mainland Chinese patients with ankylosing spondylitis (AS). Patients and methods: A retrospective study was conducted in 117 AS patients and 117 age- and sex-matched healthy controls. Parameters of MetS based on the criteria established by the Chinese Diabetes Society in 2013 were tabulated. Demographic features, laboratory data, and clinical characteristics were also collected. Independent factors correlated with MetS in AS patients were identified by backward stepwise multivariate analysis. Results: The prevalence of MetS was higher in AS patients than in healthy controls (P= 0.026). AS patients also had higher blood pressure and fasting serum glucose levels, but generally lower serum lipid levels. AS patients with and without MetS had no distinct differences in disease duration, medication usage, disease activity, or biomarkers of inflammation. Multivariable logistic regression analysis showed that hyperuricemia (odds ratio [OR] = 2.385, 95% confidence interval [95% CI] = 1.019-5.582, P= 0.045) and high body mass index (BMI, OR = 5.165; 95% CI = 1.935-13.787, P=0.001) were independent factors for MetS in AS patients. Conclusion: Chinese AS patients living in the mainland have an increased risk of developing MetS. Hyperuricemia and high BMI are predictors of MetS in AS patients.

Atherogenic index of plasma: a useful marker for subclinical atherosclerosis in ankylosing spondylitis : AIP associate with cIMT in AS

Ankylosing spondylitis (AS) is associated with an increased risk of atherosclerotic cardiovascular disease (ACD). The atherogenic index of plasma (AIP), which is the logarithmic transformation of the plasma triglyceride (TG) level to the high-density lipoprotein level (HDL) ratio, has been suggested to be a novel marker in the identification of atherosclerosis risk. Therefore, this study aims to determine if the AIP can act as an accurate marker for the detection of subclinical atherosclerosis. Fifty-two male patients with AS and 52 age-, gender-, and body mass index (BMI)-matched healthy control subjects were included in the study. For each patient, AIP and total cholesterol (TC)/HDL values were calculated and carotid artery intima-media thickness (cIMT) was measured. The mean (SD) cIMT and median (range) AIP values for AS patients were higher than that of the healthy control subjects (0.60 ± 0.18 vs. 0.51 ± 0.10, p = 0.003 and 0.23 [- 0.32 to 0.85] vs. 0.09 [- 0.53 to 0.49], p = 0.007, respectively). A positive correlation was found between the patients' cIMT and AIP values (r = 0.307, p = 0.002) and TC/HDL values (r = 0.241, p = 0.014). Regression analysis revealed an independent association between the subclinical atherosclerosis and AIP (beta [β] = 0.309, p = 0.002). There were no independent correlations between subclinical atherosclerosis and TC (β = 0.245, p = 0.065), TG (β = 0.185, p = 0.515), HDL (β = 0.198, p = 0.231), TC/HDL (β = 0.032, p = 0.862), and low-density lipoprotein (LDL) (β = 0.151, p = 0.246). A strong and independent correlation exists between AIP and cIMT values. Therefore, the AIP could serve as a better marker than the TC/HDL ratio for the detection of subclinical atherosclerosis in AS patients.