Evaluation of cardiac autonomic nervous system in patients with ankylosing spondylitis using 12-lead electrocardiography and Holter monitoring

Heart Rate Variability in Patients of Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

Patients with ankylosing spondylitis (AS) have a significantly higher risk of cardiovascular morbidities. The participation of the autonomic nervous system (ANS) in AS is still unknown and inconclusive. Heart rate variability (HRV) is defined as the variability of the time interval between two consecutive heartbeats. This meta-analysis aims to detect the association of HRV and its various parameters with AS patients by comparing them to healthy controls. Research literature was searched in PubMed, Embase, and Cochrane Library databases from inception to April 2022. The Review Manager 5 (RevMan) Version 5.4 software was used to analyze the data. In addition, the protocol of systematic review is registered in the PROSPERO database with ID CRD42022336484. This study includes a total of nine case-control studies with a total of 923 patients; 409 with AS and 514 healthy controls. The root mean square of successive differences between normal heartbeats (RMSSD) [standardized mean difference (SMD); -0.47, 95% CI: -0.69 to -0.25, p < 0.0001], proportion of NN50 (pNN50) (SMD; -0.89, 95% CI: -1.74 to -0.04, p = 0.04) and HRV (SMD; -1.11, 95% CI: -1.53 to 0.69, P < 0.00001) were significantly low in AS cases compared to healthy controls. The HRV value was also significantly low in patients with high Bath ankylosing spondylitis disease activity (BASDAI) index (SMD: -1.45, 95% CI: -2.45 to -0.36, p < 0.009). HRV (parasympathetic activity) was significantly lowered in AS patients compared to healthy controls.

Cardiovascular risk in axial spondyloarthritis-a systematic review

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

Autonomic responses to aerobic and resistance exercise in patients with chronic musculoskeletal pain: A systematic review

BACKGROUND

It is unknown whether patients with chronic musculoskeletal pain (CMP) show autonomic dysregulation after exercise, and the interventional effects of exercise on the autonomic dysregulation have not been elucidated. The objectives of this study were to reveal acute autonomic responses after aerobic and resistance exercises and the interventional effects of both exercises on autonomic dysregulation in patients with CMP.

METHODS

A systematic search using nine electronic databases was performed based on three key search terms: "chronic musculoskeletal pain," "autonomic nervous system," and "exercise." Data were extracted from measurements of the autonomic nervous system and pain.

RESULTS

We found a total of 1170 articles; 17 were finally included, incorporating 12 observational and five interventional studies. Although a comparator has not been specified, healthy controls were compared to patients with CMP in observational studies. Three of five interventional studies were pre-post study with healthy controls as a comparator or no controls. The other two interventional studies were randomized controlled trial with a different treatment e.g., stretching. There were four good, 10 fair, and three poor-quality articles. The total number of participants was 617, of which 551 were female. There was high heterogeneity among the five disease conditions and nine outcome measures. Following one-time exposure to aerobic and resistance exercises, abnormal autonomic responses (sympathetic activation and parasympathetic withdrawal), which were absent in healthy controls, were observed in patients with CMP. The effects of aerobic and resistance exercise as long-term interventions were unclear since we identified both positive effects and no change in the autonomic activities in patients with CMP.

CONCLUSIONS

This study indicates dysfunctional autonomic responses following one-time exposure to exercise and inconsistent interventional effects in the autonomic activities in patients with CMP. Appropriate therapeutic dose is necessary for studying the management of autonomic regulation and pain after exercise.

Evaluation of Tp-e interval and Tp-e/QTc ratio in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), a multisystemic inflammatory disorder, has been associated with increased risk of cardiovascular problems, including complications such as conduction defects and arrhythmias. Therefore, the early assessment of the risk factors predisposing to ventricular arrhythmias is crucial, since it can improve clinical outcomes. The objective of the present study is to evaluate ventricular repolarization by using Tp‑e interval and Tp-e/QTc ratio as candidate markers of ventricular arrhythmias in patients with IBD.

METHODS

The presented study was designed as a single-center prospective cohort study. The study population consisted of 175 patients with IBD and 175 healthy volunteers. The Tp‑e interval, corrected QT (QTc), and Tp-e/QTc ratio were measured from the 12-lead electrocardiogram. These parameters were compared between groups.

RESULTS

The groups were similar in terms of electrocardiographic findings such as heart rate, QRS interval, and QTc interval. However, Tp‑e interval (87.0 ms, interquartile range, IQR 81.0-105.0 ms vs. 84.0 ms, IQR 74.0-92.0 ms; p < 0.001) and Tp-e/QTc ratio (0.21 ± 0.04 vs. 0.19 ± 0.05; p < 0.001) were significantly increased in IBD patient group compared to control group. Notably, a positive correlation was demonstrated between Tp‑e interval, Tp-e/QTc ratio and disease duration (Spearman's Rho = 0.36, p < 0.001 for Tp‑e; Spearman's Rho = 0.28, p < 0.001 for Tp-e/QTc).

CONCLUSION

This study demonstrated that IBD patients are at increased risk of disrupted ventricular repolarization (increased Tpe, Tpe/QTc ratio). In addition, a positive correlation was demonstrated between Tp‑e interval, Tp-e/QTc ratio, and disease duration. Therefore, IBD patients, especially those with long-standing diseases, should be more closely screened for ventricular arrhythmias.

Ventricular repolarization heterogeneity in patients with COVID-19: Original data, systematic review, and meta-analysis

BACKGROUND

Coronavirus disease-2019 (COVID-19) has been associated with an increased risk of acute cardiac events. However, the effect of COVID-19 on repolarization heterogeneity is not yet established. In this study, we evaluated electrocardiogram (ECG) markers of repolarization heterogeneity in patients hospitalized with COVID-19. In addition, we performed a systematic review and meta-analysis of the published studies.

METHODS

QT dispersion (QTd), the interval between T wave peak to T wave end (TpTe), TpTe/QT (with and without correction), QRS width, and the index of cardio-electrophysiological balance (iCEB) were calculated in 101 hospitalized COVID-19 patients and it was compared with 101 non-COVID-19 matched controls. A systematic review was performed in four databases and meta-analysis was conducted using Stata software.

RESULTS

Tp-Te, TpTe/QT, QRS width, and iCEB were significantly increased in COVID-19 patients compared with controls (TpTe = 82.89 vs. 75.33 ms (ms), p-value = .005; TpTe/QT = 0.217 vs. 0.203 ms, p-value = .026). After a meta-analysis of 679 COVID-19 cases and 526 controls from 9 studies, TpTe interval, TpTe/QT, and TpTe/QTc ratios were significantly increased in COVID-19 patients. Meta-regression analysis moderated by age, gender, diabetes mellitus, hypertension, and smoking reduced the heterogeneity. QTd showed no significant correlation with COVID-19.

CONCLUSION

COVID-19 adversely influences the ECG markers of transmural heterogeneity of repolarization. Studies evaluating the predictive value of these ECG markers are warranted to determine their clinical utility.

Analysis of ambulatory blood pressure monitoring data in patients with ankylosing spondylitis without clinically evident cardiovascular disease

Ankylosing spondylitis (AS) is associated with an increased risk of cardiovascular morbidity and mortality. Parameters, such as non-dipper, average real variability (ARV), pulse pressure index (PPI), and ambulatory arterial stiffness index (AASI) obtained from ambulatory blood pressure monitoring (ABPM), provide information about adverse cardiovascular outcomes. In this study, these indexes were evaluated in patients with AS. Sixty-five patients with AS and 65 control subjects were included in this study. Non-dipper pattern, ARV, PPI, and AASI parameters were assessed using 24-h ABPM recordings. Twenty-four-hour systolic, diastolic, mean standard deviation, PPI, ARV, and AASI were higher in patients with AS (p < 0.05 all parameters). Non-dipper (43.1% vs. 21.5%, p = 0.007) and reverse dipper (10.8% vs. 0%, p = 0.013) patterns were more common in patients with AS. In addition, disease duration was moderately correlated with AASI and ARV (r = 0.36, p = 0.003; r = 0.31, p = 0.012, respectively). This study showed that PPI, AASI, ARV, and dipper pattern were impaired in patients with AS evaluated with ABPM.

Positive effects of music therapist's selected auditory stimulation on the autonomic nervous system of patients with disorder of consciousness: a randomized controlled trial

The current randomized controlled trial was performed at the China Rehabilitation Science Institute, China to test the hypothesis that musical auditory stimulation has positive effects on the autonomic nervous system of patients with disorder of consciousness. Although past studies have recommended that patients with disorder of consciousness listen to patient-preferred music, this practice is not universally accepted by researchers. Twenty patients with severe disorder of consciousness listened to either therapist-selected (n = 10, 6 males and 4 females; 43.33 ± 18.76 years old) or patient-preferred (n = 10, 5 males and 5 females, 48.83 ± 18.79 years old) musical therapy, 30 minutes/day, 5 times/week for 6 weeks. The results showed no obvious differences in heart rate variability-related parameters including heart rate, standard deviation of normal-to-normal R-R intervals, and the root-mean-square of successive heartbeat interval differences of successive heartbeat intervals between the two groups of patients. However, percentage of differences exceeding 50 ms between adjacent normal number of intervals, low-frequency power/high-frequency power, high-frequency power norm, low-frequency power norm, and total power were higher in patients receiving therapist-selected music than in patients receiving their own preferred music. In contrast, this relationship was reversed for the high-frequency power and very-low-frequency band. These results suggest that compared with preferred musical stimulation, therapist-selected musical stimulation resulted in higher interactive activity of the autonomic nervous system. Therefore, therapist-selected musical stimulation should be used to arouse the autonomic nervous system of patients with disorder of consciousness. This study was approved by the Institutional Ethics Committee of China Rehabilitation Research Center, China (approval No. 2018-022-1) on March 12, 2018 and registered with the Chinese Clinical Trial Registry (registration number ChiCTR1800017809) on August 15, 2018.