Factors associated with accelerated subclinical atherosclerosis in patients with spondyloarthritis without overt cardiovascular disease

Spinal radiographic progression is correlated with preclinical atherosclerosis in spondyloarthritis

BACKGROUND

A higher prevalence of cardiovascular risk was observed in spondyloarthritis (SpA). The relationship between disease-related factors structural damage and subclinical atherosclerosis is still unknown.

OBJECTIVE

The aim of our study was to evaluate the association of subclinical atherosclerosis with radiographic structural damage in patients with SpA.

METHODS

Forty-seven SpA patients who fulfilled the ASAS criteria were enrolled in a case-control study conducted over 12 months and compared with 47 age and sex-matched healthy controls. None of the subjects had a previous history of cardiovascular diseases or cardiovascular risk factors. Demographic and disease characteristics were recorded. Structural lesions were evaluated using plain radiography, and two scoring tools were used to spine (BASRI and mSASSS). Subclinical atherosclerosis was assessed using ultrasound measurements of flow-mediated dilation (FMD) and carotid intima-media thickness (cIMT).

RESULTS

The median age of patients was 36 years. The sex ratio was 2.35. The median BASRI total score was 3 (IQR 2-4), median mSASSS score was 10 (IQR 415). cIMT was significantly increased in SpA patients compared to controls (p< 0.0001), and FMD was significantly lower in patients than in healthy subjects (p= 0.008). cIMT was significantly associated with ankylosis of the facet joints (p= 0.035) and Romanus spondylitis (p= 005). FMD was negatively associated with vertebral squaring (p= 0049), bridging syndesmophytes (p= 0031) and mSASSS score (p= 0.047).

CONCLUSION

Our result supports the association of radiographic structural damage and subclinical atherosclerosis assessed using cIMT and FMD. This finding highlights the importance of earlier treatment in order to prevent radiographic damage progression and atherosclerotic events.

Association of blood pressure and hypertension with radiographic damage among the patients with ankyloing spondylitis

To investigate the association of blood pressure and hypertension with disease severity among the patients with ankyloing spondylitis (AS). There were 167 AS patients enrolled in the cross-sectional study. Blood pressure was measured and the presence of hypertension was recorded. Patient's disease severity, including disease activity, functional ability, patient's global assessments, physical mobility and radiographic damage were evaluated. ESR and CRP levels were tested. We recorded patient's medication use of NSAIDs, DMARDs and TNF-α blockers. Smoking, exercise habit, diabetes mellitus, hypercholesterolemia and obesity indices were assessed. Multivariate linear regression showed that systolic blood pressure was associated with TNF-α blocker [standard coefficient (β) = 0.194, P = .007], DMARDs (β = 0.142, P = .046), age (β = 0.211, P = .003), male gender (β = 0.242, P = .001) and body mass index (BMI) (β = 0.245, P = .001). Diastolic blood pressure was associated with cervical rotation (β = -0.174, P = .037), lateral lumbar flexion (β = -0.178, P = .019), m-SASSS (β = 0.198, P = .038) and BMI (β = 0.248, P = .003). Notably, multivariate logistic regression showed that hypertension was associated with m-SASSS (OR = 1.033, P = .033), age (OR = 1.098, P = .0010) and BMI (OR = 1.210, P = .003). Using ROC cure analyses, age, BASMI, BASRI-Total, m-SASSS, waist circumference, BMI and waist-to-height ratio were useful in predicting hypertension, and m-SASSS is the best (AUC = 0.784, P < .001). Advanced radiographic damage is an independent risk factor of hypertension in AS, and m-SASSS is the most useful disease severity parameter in predicting the presence of hypertension. Advanced radiographic damage, poor cervical rotation, lateral lumbar flexion, older age, male gender, TNF-α blocker, DMARDs use and obesity are associated with increased blood pressure.

Cardiovascular and disease-related features associated with extra-articular manifestations in axial spondyloarthritis. A multicenter study of 888 patients

OBJECTIVES

To determine the potential impact of extra-articular manifestations (EAMs) on disease characteristics and cardiovascular (CV) risk in patients with axial spondylarthritis (axSpA).

METHODS

This is a cross-sectional study from the AtheSpAin cohort, a Spanish multicenter cohort to study atherosclerosis in axSpA. Data on the history of CV events, subclinical carotid atherosclerosis, and disease-related features, including EAMs, were collected.

RESULTS

888 axSpA patients were recruited. Concomitant acute anterior uveitis (AAU), psoriasis (PSO), and inflammatory bowel disease (IBD) were present in 177 (19.9%), 96 (10.8%), and 57 (6.4%) patients, respectively. When compared with axSpA patients without EAMs, a significant increase in past CV events was observed in patients with PSO (9% versus 4%, p = 0.048) and in those with at least one EAM (7% versus 4%, p = 0.032) or with more than one EAM (11% versus 4%, p = 0.022). The frequency of carotid plaques and the values of cIMT were higher in patients with EAMs than in those without EAMs, although only the univariable analysis for carotid plaques in patients with PSO (39% versus 30%, p = 0.038) and for cIMT in patients with AAU (665 ± 156 µm versus 637 ± 139 µm, p = 0.042) and those with at least one EAM (661 ± 155 µm versus 637 ± 139 µm, p = 0.024) showed significant results. In addition, patients with PSO or IBD were found to have specific disease-related features, such as higher ESR at diagnosis, and more frequent use of glucocorticoids and TNF inhibitors than those without EAMs. Also, PSO patients had more commonly peripheral involvement and those with AAU more severe radiographic damage than those without EAMs. The frequency of HLA B27 was higher in patients with AAU and lower in those with PSO or IBD compared to those without EAMs.

CONCLUSION

Patients with axSpA and EAMs, in addition to displaying their own disease-related features, are likely to have an increased CV risk that appears proportional to the number of EAMs and could be related to proatherogenic factors other than traditional CV risk factors, such as the inflammatory load and the use of glucocorticoids.

Endothelial dysfunction and increased carotid intima-media thickness in patients with spondyloarthritis without traditional cardiovascular risk factors

Background

The aim of our study was to assess subclinical atherosclerosis in spondyloarthritis (SpA) by combining three ultrasound methods (flow-mediated dilation (FMD), carotid intima–media thickness (cIMT) and Ankle Brachial Index (ABI)) and to determine the predictive factors of theses parameters.

Methods

This was a case control study conducted over 12 months including 47 patients with SpA-free-cardiovascular (CV) disease in comparison with age and sex matched 47 healthy controls. Sociodemographic, clinical and biological features as well as therapeutic modalities were recorded in our patients. All subjects had Doppler ultrasound with measurement of cIMT, FMD and ABI. Ultrasound measurements were compared between patients and controls. Linear regression was performed and assessed by machine learning to determine the predictive models of markers of subclinical atherosclerosis.

Results

We found higher cIMT (p<0.0001), lower FMD (p=0.008) and higher left ABI (0.048) in patients with SpA compared with controls. cIMT was positively correlated to patient-related parameters (age, systolic blood pressure) and disease parameters (age at onset of SpA, disease duration and renal involvement). Biologically, cIMT was positively correlated with creatinine, blood-glocose, total cholesterol (CT) and CT/cholesterol-high density lipoprotein ratio. FMD was negatively correlated with male gender, age, systolic blood pressure, creatinine, blood glucose and Left Lequesne Index. ABI was significantly associated with diastolic blood pressure. Multiple regression analysis identified age, CT and creatinine as independents predictive factors for increased cIMT. Regarding endothelial dysfunction, blood glucose and Left Lequesne Index were the independents predictive factors of decreased FMD.

Conclusion

Our study supported the accelerated subclinical atherosclerosis in patients with SpA. This subclinical atherosclerosis was mainly mediated by traditional CV risk factors.

Subclinical Atherosclerosis Measure by Carotid Ultrasound and Inflammatory Activity in Patients with Rheumatoid Arthritis and Spondylarthritis

Objective: To compare the effect of inflammation on subclinical atherosclerosis using carotid ultrasound in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods: Cross-sectional study including 347 participants (148 RA, 159 SpA, and 40 controls). We measured the carotid intima media thickness (cIMT) and detection of atheromatous plaques using carotid ultrasound. We recorded disease activity (DAS28-CRP/ASDAS-CRP) and traditional cardiovascular risk factors. We performed descriptive, bivariate, and linear multivariate analyses (dependent variable: cIMT) to evaluate the influence of diagnosis on cIMT in all patients. Two additional multivariate analyses were performed by stratifying patients according to their inflammatory activity. Results: cIMT correlated with the mean CRP during the previous 5 years in RA, but not with CRP at the cut-off date. We did not find such differences in patients with SpA. The first multivariate model revealed that increased cIMT was more common in patients with RA than in those with SpA (β coefficient, 0.045; 95% confidence interval (95% CI), 0.0002–0.09; p = 0.048) after adjusting for age, sex, disease course, and differential cardiovascular risk factors (arterial hypertension, smoking, statins, and corticosteroids). The second model revealed no differences in cIMT between the 2 groups of patients classified as remission–low activity (β coefficient, 0.020; 95% CI, −0.03 to 0.080; p = 0.500). However, when only patients with moderate–high disease activity were analysed, the cIMT was 0.112 mm greater in those with RA (95% CI, 0.013–0.212; p = 0.026) than in those with SpA after adjusting for the same variables. Conclusions: Subclinical atherosclerosis measured by carotid ultrasound in patients with RA and SpA is comparable when the disease is well controlled. However, when patients have moderate–high disease activity, cIMT is greater in patients with RA than in those with SpA after adjusting for age, sex, disease course, and cardiovascular risk factors. Our results point to greater involvement of disease activity in subclinical atherosclerosis in patients with RA than in those with SpA.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Higher Risk of Future Cardiovascular Events Among Patients with Psoriatic Arthritis Compared to Psoriatic Patients Between the Ages of 30-50

Introduction:

Psoriasis and Psoriatic Arthritis (PsA) are chronic diseases with a number of complications that, among others, may include alterations in the cardio-vascular system.

Methods:

The aim of this study was to evaluate the risk of Cardiovascular Diseases (CVD) in patients with psoriasis and psoriatic arthritis between the ages of 30-50. The research covered 95 outpatients and inpatients: 51 with plaque psoriasis (23 women and 28 men) and 44 with psoriasis and psoriatic arthritis (16 women and 28 men). The risk of cardio-vascular incident was evaluated with the use of the Framingham algorithm covering the age, total cholesterol, HDL cholesterol, blood pressure, the habit of smoking and diabetes. The 10-year risk of the occurrence of a cardio-vascular incident was higher in patients with psoriatic arthritis than in patients with plaque psoriasis (9,9% vs6,2%). A high risk of cardio-vascular events was observed in 35% men with psoriatic arthritis in comparison to 11% men with only psoriasis. In patients with plaque psoriasis, the increase in the risk of cardio-vascular incident was connected with the late beginning of psoriasis; whereas in the group of patients with psoriatic arthritis, the risk of cardio-vascular incident was connected with the intensification of psoriatic lesions.

Conclusion:

The patients with psoriasis, especially men with psoriatic arthritis, certainly require special medical care in terms of cardio-vascular diseases prevention.

The use of the tyrosine kinase inhibitor Nilotinib in Spondyloarthritis: does targeting inflammatory pathways with a treatment lead to vascular toxicity?

Spondylarthritis (SpA) is an inflammatory rheumatic disease associated with increased incidence of major adverse cardiovascular events (MACEs). Recently, Paramarta et al. proposed the use of the tyrosine kinase inhibitor Nilotinib in Spondyloarthritis to target certain inflammatory pathways. However, Nilotinib, which is highly effective for the treatment of patients with chronic myeloid leukaemia (CML), is also associated with an increased risk of MACEs. The authors suggest that Nilotinib may be effective in peripheral SpA by modulating inflammation, but not in axial SpA. Considering the vascular toxicity of Nilotinib and the acceleration of atherosclerosis in SpA patients, we suggest taking MACEs as an end-point in future trials.