Cardiovascular and cerebrovascular diseases in ankylosing spondylitis: current insights

Exploring the common mechanisms and biomarker ST8SIA4 of atherosclerosis and ankylosing spondylitis through bioinformatics analysis and machine learning

Background

Atherosclerosis (AS) is a major contributor to cerebrovascular and cardiovascular events. There is growing evidence that ankylosing spondylitis is closely linked to AS, often co-occurring with it; however, the shared pathogenic mechanisms between the two conditions are not well understood. This study employs bioinformatics approaches to identify common biomarkers and pathways between AS and ankylosing spondylitis.

Methods

Gene expression datasets for AS (GSE100927, GSE28829, GSE155512) and ankylosing spondylitis (GSE73754, GSE25101) were obtained from the Gene Expression Omnibus (GEO). Differential expression genes (DEGs) and module genes for AS and ankylosing spondylitis were identified using the Limma R package and weighted gene co-expression network analysis (WGCNA) techniques, respectively. The machine learning algorithm SVM-RFE was applied to pinpoint promising biomarkers, which were then validated in terms of their expression levels and diagnostic efficacy in AS and ankylosing spondylitis, using two separate GEO datasets. Furthermore, the interaction of the key biomarker with the immune microenvironment was investigated via the CIBERSORT algorithm, single-cell analysis was used to identify the locations of common diagnostic markers.

Results

The dataset GSE100927 contains 524 DEGs associated with AS, whereas dataset GSE73754 includes 1,384 genes categorized into modules specific to ankylosing spondylitis. Analysis of these datasets revealed an overlap of 71 genes between the DEGs of AS and the modular genes of ankylosing spondylitis. Utilizing the SVM-RFE algorithm, 15 and 24 central diagnostic genes were identified in datasets GSE100927 and GSE73754, respectively. Further validation of six key genes using external datasets confirmed ST8SIA4 as a common diagnostic marker for both conditions. Notably, ST8SIA4 is upregulated in samples from both diseases. Additionally, ROC analysis confirmed the robust diagnostic utility of ST8SIA4. Moreover, analysis through CIBERSORT suggested an association of the ST8SIA4 gene with the immune microenvironment in both disease contexts. Single-cell analysis revealed that ST8SIA4 is primarily expressed in Macrophages, Monocytes, T cells, and CMPs.

Conclusion

This study investigates the role of ST8SIA4 as a common diagnostic gene and the involvement of the lysosomal pathway in both AS and ankylosing spondylitis. The findings may yield potential diagnostic biomarkers and offer new insights into the shared pathogenic mechanisms underlying these conditions.

Identification of key biomarkers for predicting CAD progression in inflammatory bowel disease via machine-learning and bioinformatics strategies

The study aimed to identify the biomarkers for predicting coronary atherosclerotic lesions progression in patients with inflammatory bowel disease (IBD). Related transcriptome datasets were seized from Gene Expression Omnibus database. IBD-related modules were identified via Weighted Gene Co-expression Network Analysis. The 'Limma' was applied to screen differentially expressed genes between stable coronary artery disease (CAD) and acute myocardial infarction (AMI). Subsequently, we employed protein-protein interaction (PPI) network and three machine-learning strategies to further screen for candidate hub genes. Application of the receiver operating characteristics curve to quantitatively evaluate candidates to determine key diagnostic biomarkers, followed by a nomogram construction. Ultimately, we performed immune landscape analysis, single-gene GSEA and prediction of target-drugs. 3227 IBD-related module genes and 570 DEGs accounting for AMI were recognized. Intersection yielded 85 shared genes and mostly enriched in immune and inflammatory pathways. After filtering through PPI network and multi-machine learning algorithms, five candidate genes generated. Upon validation, CTSD, CEBPD, CYP27A1 were identified as key diagnostic biomarkers with a superior sensitivity and specificity (AUC > 0.8). Furthermore, all three genes were negatively correlated with CD4+ T cells and positively correlated with neutrophils. Single-gene GSEA highlighted the importance of pathogen invasion, metabolism, immune and inflammation responses during the pathogenesis of AMI. Ten target-drugs were predicted. The discovery of three peripheral blood biomarkers capable of predicting the risk of CAD proceeding into AMI in IBD patients. These identified biomarkers were negatively correlated with CD4+ T cells and positively correlated with neutrophils, indicating a latent therapeutic target.

Impact of Endophthalmitis on the Risk of Acute Myocardial Infarction in Ankylosing Spondylitis Patients: A Population-Based Retrospective Cohort Study

Many studies have demonstrated an increased cardiovascular (CV) risk in ankylosing spondylitis (AS) patients. Nevertheless, the influence of an endophthalmitis episode toward the future risks of acute myocardial infarction (AMI) in AS patients has been unclear. The objective of this study was to explore the impact of endophthalmitis on AMI risk in this particular patient population by a population-based retrospective cohort study with a follow-up period up to 16 years. Univariate and multivariate Cox regression analyses were used for the risk evaluation and the results were presented as crude and adjusted hazard ratios (HRs). Overall, we enrolled 557 AS patients with endophthalmitis as the study cohort and selected another 2228 matched AS patients without endophthalmitis as the comparison cohort. Comparing the comparison cohort, the study cohort showed a significantly higher overall AMI incidence rate with an adjusted HR of 1.631 (p < 0.001). In conclusion, endophthalmitis increased the risk of AMI in AS patients after adjusting for possible clinical confounders. Special attention and work-up are required for physicians when encountering a history of endophthalmitis in these special patient populations, especially when they are comorbid with other potential CV risk factors.

Spine Surgery and Ankylosing Spondylitis: Optimizing Perioperative Management

Ankylosing spondylitis (AS) is a common form of axial spondyloarthritis, characterized by inflammatory back pain, radiographic sacroiliitis, excess spinal bone formation, and a high prevalence of HLA-B27. Commonly, AS patients require spinal surgery for kyphotic deformities, spinal trauma, and spinal infections. For preoperative management, proper interruption considering each specific half-lives of disease-modifying antirheumatic drugs are necessary to avoid complications, such as infections. When feasible, bone quality assessment before surgery is mandatory. For intraoperative measurements, airway management should be carefully evaluated, especially in patients with severe cervical deformities. Cardiac, renal, and pulmonary assessment should be made considering specific pathologic characteristics involved in AS patients, such as pulmonary restrictive disease and chronic anti-inflammatory drugs use. Multimodal neurophysiological intraoperative monitoring is recommended once these patients had a high risk for neurological deterioration. At the postoperative period, early oral intake, early mobilization, and aggressive pain control may decrease complications and enhance recovery. AS presents several unique challenges that require specific attention around spine surgery. This includes handling preoperative and postoperative pharmacotherapeutics, intraoperative airway management, and the mitigation of postoperative complications. In this paper, we provide a literature review of optimal strategies for the perioperative management for patients with AS.

Time Trends of Cardiovascular Disease in the General Population and Inflammatory Arthritis

Cardiovascular diseases (CVDs) are the leading causes of death in the world, but declining trends for cardiovascular (CV) mortality and morbidity have been observed during the last decades. Reports on secular trends regarding the excess CV mortality and morbidity in rheumatoid arthritis show diverging results. Data support that also patients with inflammatory arthritis have benefited from improved treatment and prevention for CVD, which can be observed, for example, in decreased case fatality after CV event. However, several recent studies indicate a remaining excess CV risk in patients with inflammatory arthritis.

Ankylosing spondylitis and glaucoma in European population: A Mendelian randomization study

Background

The relationship between ankylosing spondylitis (AS) and glaucoma in the European population remains unclear. In the present study, we applied a two-sample Mendelian randomization (MR) method to investigate their causal relationship.

Methods

MR analysis was conducted to validate the causal associations between AS with glaucoma using summary statistics from the genome-wide association studies of AS (9,069 cases and 13,578 control subjects) and glaucoma (8,591 cases and 210,201 control subjects). The inverse variance weighting method was performed to evaluate the causal relationship. The MR-Egger regression approach was applied to assess pleiotropy, while Cochran's Q test was used to analyze heterogeneity. Subgroup analysis was performed according to primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

Results

The results of the MR study reveal a risk-increasing causal relationship between AS and glaucoma among European populations (OR = 1.35, 95%CI = 1.16-1.57, P = 8.81 × 10^-5). Pleiotropy and heterogeneity were not found in our study. In the subgroup analysis, AS was also causal with POAG (OR = 1.48, 95%CI = 1.17-1.86, P = 8.80 × 10^-4) and PACG (OR = 1.91, 95%CI = 1.03-3.51, P = 3.88 × 10^-2).

Conclusion

The results of the MR analysis suggested a causal relationship between AS and glaucoma in the European population. Further studies are needed to identify the specific mechanism between these two diseases.

Comparison of Application Effects of Different Hemostasis Methods After Ischemic Cerebrovascular Intervention

Objective

To explore the effects of two different hemostasis methods, namely, arterial compression devices and vascular closure devices, in the ischemic cerebrovascular intervention to provide a theoretical basis for clinical selection of hemostasis methods.

Methods

A total of 302 patients who underwent ischemic cerebrovascular intervention in our hospital from January 2016 to December 2020 were selected as the research subjects and randomly divided into the control group (n = 151) and the observation group (n = 151). The patients in both groups underwent cerebrovascular intervention. The patients in the control group were treated with an artery compressor for hemostasis after the operation, while those in the observation group were treated with vascular closure devices for hemostasis. The hemostatic indexes and vascular parameters at the puncture site before and after the operation were compared between the two groups. The comfort level of the patients was assessed at 6, 12, and 24 h after the operation with the Kolcaba Comfort Scale score, and the postoperative complications were recorded.

Results

There was no significant difference in the success rate of hemostasis between the two groups (p > 0.05). The hemostatic time and immobilization time of (2.69 ± 0.62) min and (4.82 ± 0.93) h in the observation group were lower than those in the control group with (16.24 ± 3.58) min and (7.94 ± 1.86) h (p < 0.05). The differences in the minimum inner diameter of the puncture site and its nearby vessels and the peak velocity of blood flow between the two groups before and after the operation were not statistically significant within or between groups (p > 0.05). The scores of the Kolcaba comfort scale in the observation group (80.16 ± 8.49) and (93.65 ± 9.26) at 6 and 12 h, respectively, after the operation, were higher than those in the control groups (72.08 ± 7.54) and (85.49 ± 8.63) (p < 0.05). The 24 h postoperative Kolcaba comfort scale score was (97.54 ± 9.86) in the observation group and (96.82 ± 9.64) in the control group, and the difference was not statistically significant (p > 0.05). In the control group, there were 7 cases of dysuria, 12 cases of low back pain, 14 cases of sleep disorder, 20 cases of mental stress, and 5 cases of wound bleeding, and the total incidence of complications was 38.41% (58/151). In the observation group, there were 4 cases of dysuria, 8 cases of low back pain, 10 cases of sleep disorder, 14 cases of mental stress, and 3 cases of wound bleeding, and the total incidence of complications was 25.83% (39/151). The total incidence of complications in the observation group was lower than that in the control group (p < 0.05).

Conclusion

For patients with ischemic cerebrovascular disease undergoing femoral artery puncture intervention, the use of vascular closure devices can stop the bleeding quickly, which can significantly shorten the bleeding time, and the postoperative braking time of patients is short, with high comfort and fewer complications.

The Risk of Cardiovascular Diseases in Axial Spondyloarthritis. Current Insights

There is an increased cardiovascular (CV) risk in axial spondyloarthritis (axSpA), leading to increased CV mortality and morbidity in these patients. The factors that may explain this enhanced CV risk in axSpA are multiple, including traditional CV risk factors such as smoking, but also the inflammatory process and probably the use of non-steroidal anti-inflammatory drugs (NSAIDs). The CV involvement of axSpA may be detected at an early and pre-clinical stage, using non-invasive techniques. While NSAIDs play a deleterious role in the CV risk of axSpA, TNF inhibitors seem to have a beneficial impact, but this remains to be demonstrated in specific clinical studies. More data are needed to determine the potential effects of IL-17 inhibitors on the CV risk of axSpA. CV comorbidity has been mainly assessed in the radiographic form of axSpA, while limited data are available in patients with the non-radiographic form. The current management of axSpA must consider this CV comorbidity according to the EULAR recommendations. Rheumatologists play a determinant role in the detection of CV risk and current management of these patients is focused on the control of disease activity, suppression of inflammation, screening for and management of traditional CV risk factors, as well as the restriction of NSAID use.

Adalimumab and sulfasalazine in alleviating sacroiliac and aortic inflammation detected in PET/CT in patients with axial spondyloarthritis: PETSPA

Aim

Inflammatory signals in the sacroiliac (SI) joints and the aorta of patients with axial spondyloarthritis (axSpA) were graded by positron emission tomography/computed tomography (PET/CT) imaging before and after treatment with sulfasalazine (SSZ) or adalimumab (ADA).

Methods

Patients with axSpA, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4, were recruited. Disease‐modifying antirheumatic drug‐naïve patients started SSZ for 12 weeks, whereas those with prestudy treatment with or contraindication to SSZ commenced ADA for 16 weeks. In addition, those patients in the SSZ group with insufficient response commenced ADA for 16 weeks. 18F‐fluorodeoxyglucose PET/CT was performed after inclusion and after treatment with SSZ and ADA. Maximum standardized uptake value (SUVmax) was assessed for the aorta and the SI joints, and maximal target‐to‐blood‐pool ratio (TBRmax) only for the aorta.

Results

Among five SSZ patients, mean ± SD BASDAI was 4.7 ± 1.6 before and 3.5 ± 1.4 after treatment (p = .101). In 13 ADA patients, the BASDAI decreased from 5.4 ± 1.6 to 2.8 ± 2.2 (p < .001). Among the SSZ patients, SUVmax in SI joints decreased from 2.35 ± 0.55 to 1.51 ± 0.22 (−35.8%, p = .029). Aortic TBRmax decreased from 1.59 ± 0.43 to 1.26 ± 0.26 (−33.2%, p = .087). In the ADA patients, SUVmax in the SI joints was 1.92 ± 0.65 before and 1.88 ± 0.54 after treatment (−1.8%, p = .808) and TBRmax in the aorta 1.50 ± 0.60 before and 1.40 ± 0.26 after treatment (−6.7%, p = .485).

Conclusions

Our small open‐label study showed that SSZ may reduce PET‐CT‐detectable inflammation in the SI joints, with a trend towards a reduction in the aorta.

Dysregulation of ribosome-related genes in ankylosing spondylitis: a systems biology approach and experimental method

Background

Ankylosing spondylitis (AS) is an autoimmune rheumatic disease. Few candidate gene associations have been reported for AS and the current understanding of its pathogenesis remains still poor. Thus, the exact mechanism of AS is needed to urgently be disclosed. The purpose of this study was to identify candidate genes involving in AS disease.

Methods and results

GSE25101 publicly available microarray and GSE117769 RNA-seq datasets of AS patients were obtained for bioinformatics analyses. Gene set enrichment analysis showed that in the microarray dataset, the ribosome pathway was significantly up-regulated in AS compared with controls. Furthermore, some ribosomal components demonstrated overexpression in patients in the RNA-seq dataset. To confirm the findings, 20 AS patients and 20 matching controls were selected from the Rheumatology Research Center clinic, Shariati Hospital. PBMCs were separated from whole blood and RNA contents were extracted. Following the results of datasets analysis, the expression level of rRNA5.8S pseudogene, rRNA18S pseudogene, RPL23, RPL7, and RPL17 genes were measured through real-time PCR. Our findings showed dysregulation of rRNA5.8S and rRNA18S pseudogenes, and also the RPL17 gene in patients.

Conclusion

Considering that genes involved in ribosome biogenesis contributed to some AS-associated biological processes as well as diseases that have comorbidities with AS, our results might advance our understanding of the pathological mechanisms of ankylosing spondylitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04662-2.

Exercise capacity in axial spondyloarthritis and associated factors: A cross-sectional controlled study

OBJECTIVE

To examine the associations between exercise capacity (EC), cardiovascular (CV) risk factors and disease-related variables in axial spondyloarthritis (AxSpA) patients.

METHODS

In this cross-sectional controlled study, CV risk profile data, physical activity, 10-year CV event risk estimated by the Framingham model and Ankylosing Spondylitis Disease Activity Score - C-reactive protein were recorded. A maximal treadmill exercise test by Bruce protocol was administered. Analyses of covariance were performed with adjustments for age, smoking status and physical activity level. Linear regression analysis was performed to study the association between EC and related CV risk factors.

RESULTS

Thirty-eight patients and 38 age-gender matched controls were recruited between May and October 2014. Patients had significantly lower EC than controls (MD 2.2; metabolic equivalents 0.91-3.49; P = .001). The difference remained significant after adjustments (P = .001). There were significant correlations between EC and age, 10-year CV event risk, body mass index (BMI) and waist circumference for patients and controls (P < .001 and P < .05, respectively). There was a significant relationship between EC and total cholesterol, triglycerides and heart rate recovery (HRR) in patients (P = .04, P < .001 and P = .006, respectively). High-density lipoprotein - cholesterol was significantly higher, and BMI was significantly lower in nonradiographic AxSpA patients (P = .026 and P = .03 respectively). Age and triglyceride levels were found as the significant predictors for EC in the AxSpa group (for age β = -.105, P = .003; for triglycerides β = -.016 P = .003).

CONCLUSION

Exercise capacity was significantly lower and attenuated HRR was significantly associated with low EC and high 10-year CV event risk in AxSpA patients.

Unexpected increase of aortic stiffness in juvenile Spondyloarthropathies

Juvenile spondyloarthropathy is an umbrella term for a group of childhood rheumatic diseases that can cause chronic arthritis extending to the axial skeleton before the age of 16. Although ankylosing spondylitis has aortic involvement as one of its most important effects, this relationship has not been extensively studied in children with juvenile spondyloarthropathy. Here, a cross-sectional study of the elastic properties of the aorta of 43 patients with juvenile spondyloarthropathy and 19 healthy controls is reported. Aortic stiffness assessed by echocardiography was used to predict the presence of aortitis, supplemented by pulsed-wave tissue Doppler indices. The right ventricular fractional area change was found to be significantly lower in the patients with juvenile spondyloarthropathy than in the healthy controls; aortic strain and distensibility were also significantly lower, and aortic stiffness index β was significantly higher; and the aortic root diameter change was significantly lower. According to HLA-B27 positivity, there was no difference in the stiffness parameters between the two groups. There was a significant correlation between juvenile Ankylosing Spondylitis Disease Activity Index and aortic diameter change, between juvenile Ankylosing Spondylitis Disease Activity Index and aortic stiffness. Thus, juvenile spondyloarthropathy is linked to high aortic stiffness parameters.

Microvascular changes of the retina in ankylosing spondylitis, and the association with cardiovascular disease - the eye for a heart study

OBJECTIVE

Ankylosing spondylitis (AS) is associated with an increased risk of cardiovascular disease (CVD). Microvasculature changes can precede overt CVD, but have been studied poorly in AS. The retinal vasculature is easily accessible and changes are associated with CVD (e.g. arteriolar narrowing, venular widening, loss of tortuosity). This proof of concept study compared the retinal microvasculature of AS patients with healthy controls, and the influence of gender.

METHODS

Cross-sectional case-control study comparing AS patients with healthy controls. Main inclusion criteria were: age 50-75 years, no diabetes mellitus and, for AS, fulfillment of the modified New York criteria. All subjects underwent fundus photography, analyzed with Singapore I Vessel Assessment software, and Optical Coherence Tomography Angiography (OCTA). Subjects were compared with generalized estimating equations (GEE). Multivariable analyses were adjusted for demographics and cardiovascular risk, and stratified for gender.

RESULTS

Fifty-nine AS patients and 105 controls were included (50% women). Controls were significantly older than patients (68 versus 60, p<0.01), but did not differ in cardiovascular profile. Patients had a lower retinal arteriolar tortuosity (β ̶-0.1, 95%CI [-0.2; -0.01], p = 0.02), and higher vessel density (β 0.5, 95% CI [0.1; 0.9], p = 0.02). In addition, male AS patients showed a lower arteriovenular ratio compared to male controls (β -0.03, p = 0.04, 95%CI [-0.05; -0.001]). There were no differences found between women with and without AS.

CONCLUSION

This study detected several retinal microvascular changes, in AS patients compared to controls, which have been associated with CVD. Retinal imaging might be an interesting tool for future CVD screening.

Biomechanical Properties of Common Carotid Arteries Assessed by Circumferential 2D Strain and β Stiffness Index in Patients With Ankylosing Spondylitis

OBJECTIVE

Ankylosing spondylitis (AS) is associated with an elevated risk of cardiovascular disease (CVD) related to atherosclerosis, preceded by arterial stiffness. We aimed to examine common carotid artery (CCA) biomechanical properties using ultrasound to calculate β stiffness index (indicating arterial stiffness) and, a more recently developed technique, 2-dimensional (2D) speckle tracking strain (indicating arterial motion and deformation, strain) to (1) compare with age- and sex-matched controls, and (2) analyze relationships between strain and stiffness with disease characteristics and traditional risk factors for CVD in patients with AS.

METHODS

In this cross-sectional study, a cohort of 149 patients with AS, mean age 55.3 ± 11.2 years, 102 (68.5%) men, and 146 (98%) HLA-B27-positive, were examined. Bilateral CCA were examined for circumferential 2D strain and β stiffness index. A subgroup of 46 patients was compared with 46 age- and sex-matched controls, both groups without hypertensive disease, diabetes, myocardial infarction, or stroke.

RESULTS

Mean bilateral circumferential 2D strain was lower in AS patients compared with controls (7.9 ± 2.6% vs 10.3 ± 1.9%, P < 0.001), whereas mean bilateral β stiffness index was higher (13.1 ± 1.7 mmHg/mm vs 12.3 ± 1.3 mmHg/mm, P = 0.02). In multivariable linear regression analyses, strain was associated with age, erythrocyte sedimentation rate, history of anterior uveitis, and treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARD) and/or biological DMARD (R² 0.33), while stiffness was associated with age (R² 0.19).

CONCLUSION

Both CCA circumferential 2D strain and β stiffness index differed between patients with AS and controls. Strain was associated with AS-related factors and age, whereas only age was associated with stiffness, suggesting that the obtained results reflect different pathogenic vascular processes.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Impact of ankylosing spondylitis on depression: a nationwide cohort study

The aim of this study is to determine the relationship between AS and subsequent depression. This study was conducted using a nationwide dataset available in Korean National Health Insurance System (KNHIS). We identified 11,465 newly diagnosed AS patients and 57,325 patients without AS in the ratio of 1:5 matched by sex, age, and index date, between 2010 and 2014. We investigated any latent characteristics in the patients’ demographic information and chronic comorbidities that could trigger a depression when diagnosed with AS. By comparing the cohort data, the hazard ratio of developing subsequent depression in AS patients was calculated and adjusted based on several risk factors. Despite the adjustment of demographic variables and chronic comorbidities, the risk of depression was 2.21 times higher in the AS cohort than in the control group. Multivariate analysis showed that AS patients with female gender, old age and low-income status showed higher risks of developing depression. Additionally, the presence of chronic comorbidities including diabetes mellitus, hypertension, hyperlipidemia, cancer, stroke, and chronic kidney disease increased the patients’ risk of depression. The AS patients with stroke were reported to have the highest risk of depression. This population-based cohort study showed that AS significantly increased the subsequent risk of developing depression. Moreover, the development of a depression is influenced by certain demographic variables and different chronic comorbidities.

Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis

The cardiovascular burden in inflammatory rheumatic diseases is well recognized. Recently, this burden has been highlighted in ankylosing spondylitis (also known as radiographic axial spondyloarthritis) and psoriatic arthritis. We review the cardiovascular morbidity and mortality in these diseases, as well as the prevalence and incidence of traditional cardiovascular risk factors. We examine the contribution of anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and TNF inhibitors on the cardiovascular risk profile. Finally, we examine the available recommendations for the management of cardiovascular comorbidity, as they apply to the spondyloarthritis population.

Evaluation of subclinical atherosclerosis using ultrasound radiofrequency data technology in patients diagnosed with ankylosing spondylitis

OBJECTIVE

The present study aims to identify the cardiovascular risk associated with chronic inflammation and disease activity in patients with ankylosing spondylitis (AS) using noninvasive ultrasonographic radiofrequency data technology.

METHODS

In this study, a total of 87 participants, 38 patients with AS and 49 healthy controls, were evaluated by Doppler ultrasonography. Intima-media thickness (IMT) and arterial stiffness were measured from the bilateral common carotid artery using the radiofrequency method.

RESULTS

No statistically significant difference was found between the AS patients and healthy controls concerning the right common carotid artery, left common carotid artery, IMT, distensibility coefficient, elasticity coefficient, α and β stiffness indexes, and pulse wave velocities (P > .05). The symptom duration of the AS patients had a positive correlation that was moderate and was detected with the α stiffness index and pulse wave velocity (P < .05). The duration of diagnosis and treatment of the AS patients had a positive correlation that was moderate, was detected with the α stiffness index, the β stiffness index, and pulse wave velocity (P < .05). The mean IMT and elasticity coefficient values of the AS patients whose Bath Ankylosing Spondylitis Disease Activity Index score was 4 and above, were substantially higher than the values in the patients with scores lower than 4 (P = .038 and P = .33, respectively).

CONCLUSIONS

Subclinical atherosclerosis is not accelerated in AS patients with low disease activity, although insufficiently controlled disease activity may result in increased carotid IMT and atheromatosis. Radiofrequency data technology provides a noninvasive method for accurately and quantitatively demonstrating CCA-IMT elevation and the decrease in vascular elasticity in patients with AS.

Relationship between dementia and ankylosing spondylitis: A nationwide, population-based, retrospective longitudinal cohort study

Among a variety of comorbidities of ankylosing spondylitis (AS), the association between dementia and AS by using an extensive dataset from the Korean National Health Insurance System was evaluated in this study. We extracted 15,547 newly diagnosed AS subjects among the entire Korean population and excluded wash-out patients (n = 162) and patients that were inappropriate for cohort match (n = 1192). Finally, 14,193 subjects were chosen as the AS group, and through 1:5 age- and sex-stratified matching, 70,965 subjects were chosen as the control group. We evaluated patient demographics, household incomes, and comorbidities, including hypertension, diabetes, and dyslipidemia. The prevalence of overall dementia (1.37%) and Alzheimer’s dementia (AD) (0.99%) in the AS group was significantly higher than in the control group (0.87% and 0.63%), respectively. The adjusted hazard ratio of the AS group for overall dementia (1.758) and AD (1.782) showed statistical significance also. On the other hand, the prevalence of vascular dementia did not differ significantly between the two groups. Subgroup analyses revealed the following risk factors for dementia in the AS group: male gender, greater than 65 years in age, fair income (household income greater than 20% of the median), urban residency, no diabetes, and no hypertension. From the nationwide, population-based, retrospective, longitudinal cohort study, AS patients showed a significantly higher prevalence of overall dementia and Alzheimer’s dementia. Comprehensive patient assessment using our subgroup analysis could help to prevent dementia in patients suffering from AS.

The effects of golimumab treatment on systolic and diastolic left ventricular function in ankylosing spondylitis

Background

Diastolic left ventricular (LV) dysfunction appears more prevalent in ankylosing spondylitis (AS). The effects of tumor necrosis factor alpha (TNF-α) blocking therapy, a strong and effective anti-inflammatory drug, on diastolic LV function in AS are unknown. The objective of the study was to find the effects of 1-year treatment with golimumab 50 mg subcutaneously once per month on systolic and diastolic LV dysfunction in AS patients.

Methods

Forty consecutive AS patients were treated with TNF-α blocking therapy for 1 year. Transthoracic echocardiography was performed in all patients at baseline and after 1 year of treatment.

Results

Diastolic LV function improved after treatment in four out of six (67%) AS patients who completed follow-up (P=0.125), and did not develop or worsen in any of the other patients. Treatment with TNF-α blocking therapy had no effect on systolic LV function.

Conclusion

These findings give support to the hypothesis that diastolic LV dysfunction improves during treatment with TNF-α blocking therapy.

Subclinical cardiac disease in ankylosing spondylitis

OBJECTIVES

To investigate aortic stiffness and subclinical left ventricular systolic dysfunction in ankylosing spondylitis (AS) patients.

METHODS

A cross-sectional study of 55 AS patients being treated with antitumor necrosis factor alpha (anti-TNF-α) biological agents, conventional synthetic disease-modifying antirheumatic drugs (csDMARDS), and non steroidal anti-inflammatory drugs (NSAIDs) and 20 controls matched for conventional cardiovascular risk factors. Aortic stiffness, ejection fraction, and left ventricular global longitudinal strain (LVGLS) were evaluated using transthoracic echocardiography and 2D Doppler echocardiography.

RESULTS

Aortic stiffness was higher in AS patients when compared to controls (P = 0.009). Stiffness increased in those being treated with csDMARDs when compared to the control group and those on anti-TNF-α biologics (P ˂0.001). AS patients' LVGLS values were worse than those of the control group (P < 0.001) and also worse in patients on csDMARDs and anti-TNF-α biologics when compared to those being treated with NSAIDs (P < 0.001).

CONCLUSIONS

Subclinical cardiac dysfunction occurs in AS patients despite well controlled musculoskeletal disease. Aortic stiffness and LVGLS increases in AS patients. Anti-TNF biological agents may somewhat protect arterial compliance. We believe that all AS patients should be investigated for cardiac dysfunction and followed up accordingly.

Systemic Inflammatory Response and Atherosclerosis: The Paradigm of Chronic Inflammatory Rheumatic Diseases

Patients with Chronic Inflammatory Rheumatic diseases (CIRD) are at increased risk of cardiovascular disease (CVD), ascribed not only to classical risk factors, but also to the presence of chronic systemic inflammatory response. Αtherosclerosis, the cornerstone of CVD, is known to be accelerated in CIRD; rheumatoid arthritis promotes atheromatosis and associates with preclinical atherosclerosis equivalent to Diabetes Mellitus, which also seems to apply for systemic lupus erythematosus. Data on ankylosing spondylitis and psoriatic arthritis, albeit more limited, also support an increased CV risk in these patients. The association between inflammation and atherosclerosis, has been thoroughly investigated in the last three decades and the role of inflammation in the pathogenesis and progression of atherogenesis has been well established. Endothelial dysfunction, oxidative stress in vascular endothelial cells and macrophage accumulation, toll-like receptor signaling, NLPR-3 formation and subsequent pro-inflammatory cytokine production, such as TNFa, IL-1β, IL-6, and TNF-like cytokine 1A, are few of the mechanisms implicated in the atherogenic process. Moreover, there is evidence that anti-inflammatory biologic drugs, such as anti-TNF and anti-IL1β agents, can decelerate the atherogenic process, thus setting new therapeutic targets for early and effective disease control and suppression of inflammation, in addition to aggressive management of classical CV risk factors.

[Becoming older with axial spondyloarthritis]

The combination of physiological age-related changes (e. g. reduction in muscle mass and function, reduction in organ function and degenerative changes in joints) and disease-specific changes of ankylosing spondylitis (AS), make older AS patients vulnerable for additional diseases. In this patient population various processes lead to a reduction in physical function, changes in posture, osteoporosis and sarcopenia, which then can result in falls and fractures, especially vertebral fractures. Mortality is increased in patients with AS, particularly in men due to an increase in cardiovascular mortality. Although the standardized assessment of cardiovascular risk factors in patients with inflammatory rheumatic diseases (independent of age) has been recommended for years, it is rarely done in clinical practice. Overall, data on comorbidities and risk factors are only available for AS patients and are lacking for other forms of spondyloarthritides.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Muscle wasting in male TNF-α blocker naïve ankylosing spondylitis patients: a comparison of gender differences in body composition

Objective

To assess gender differences in body composition (BC) in a cohort of AS patients naïve to TNF-α blockers.

Methods

Patients included fulfilled the Modified New York criteria for AS. Demographic information and disease activity measures (ASDAS and BASDAI) were reported. BC was measured by whole body DXA. Body fat percentage (BF%), fat mass index (FMI), fat free mass index (FFMI) and android/gynoid fat ratio were reported and compared between men and women and with the reference population (percentiles).

Results

Seventy consecutive patients were included; 60% were men. Demographic variables were similar, except for dyslipidaemia (57.1% of men; 14.3% of women). Women had significantly more fat (BF%, FMI), and less muscle (FFMI) than men, but below the median of the reference population. Male AS patients had a markedly low FFMI (31.7th percentile) compared with the reference population. In the whole group, after multivariate analysis, an ASDAS CRP >3.5 was related to lower fat free mass content. In men, a significant relationship between having a high disease activity (ASDAS, BASDAI) and lower BF% or FMI percentile was found, but in women it was the opposite.

Conclusion

Muscle wasting, measured as low FFMI compared with the reference population, was found in male TNF-α blocker naïve AS patients, especially in those with active disease. Women had higher volumes of body fat than men, but near the median of the reference population. The relationships between fat content and disease activity support the complex association between adipose tissue and inflammation.

An ultrasound automated method for non-invasive assessment of carotid artery pulse wave velocity

To validate the clinical applicability and feasibility of an automated ultrasound (US) method in measuring the arterial stiffness of patients with chronic inflammatory rheumatic diseases, comparing automated measurements performed by a rheumatologist without experience in vascular sonography with those obtained by a sonographer experienced in vascular US, using a standardized manual method. Twenty subjects affected by different chronic inflammatory rheumatic disorders were consecutively recruited. For each patient, the arterial stiffness of both common carotids was manually calculated. Subsequently, the measure of the pulse wave velocity (PWV) was obtained using an US device called Radio Frequency - Quality Arterial Stiffness (RF-QAS), provided by the same US system (ie, My Lab 70 XVG, Esaote SpA, Genoa, Italy) equipped with a 4-13 MHz linear probe. The reliability comparison between the two US methods was calculated using the intraclass correlation coefficient (ICC). ICC between the values obtained with the two methods for calculating the arterial stiffness resulted 0.789. A significant positive correlation between the two methods was also established with Pearson's (r=0.62, p<0.0001) and Spearman's analysis (r=0.66, p=0.001). A significant performance comparison was seen using Bland-Altman plot. The acquisition of the arterial stiffness parameter with the automated method required about 2 min for each patient. Clinical applicability of this US automated method to assess PWV at common carotid level by a rheumatologist is reliable and feasible in comparison with a conventional manual method.

Insights into cardiac involvement in ankylosing spondylitis from cardiovascular magnetic resonance

OBJECTIVE

To evaluate cardiac involvement in patients with ankylosing spondylitis using cardiac magnetic resonance (CMR).

METHODS

Patients with ankylosing spondylitis without cardiovascular symptoms or known cardiovascular disease were screened by transthoracic echocardiography (TTE) for participation in this exploratory CMR study. We prospectively enrolled 15 ankylosing spondylitis patients with an abnormal TTE for further tissue characterisation using late gadolinium enhancement (LGE) and T1 mapping. T1 mapping was used to calculate myocardial extracellular volume (ECV). Disease activity was assessed by C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) measurements.

RESULTS

In the total of 15 included patients, 14 had a complete CMR exam (mean age 62 years, 93% male and mean disease duration 21 years). Left ventricular (LV) diastolic dysfunction was the most common finding on TTE (79%), followed by aortic root dilatation (14%), right ventricular (RV) dilatation (7%) and RV dysfunction (7%). CMR revealed focal hyperenhancement in three patients (21%), all with a particular pattern of enhancement. LV dysfunction, as defined by a LV ejection fraction below 55%, was observed in five patients (36%). Myocardial ECV was correlated with the CRP concentration (R=0.78, p<0.01) and ESR level (R_S=0.73, p<0.01).

CONCLUSIONS

In patients with ankylosing spondylitis, CMR with cine imaging and LGE identified global LV dysfunction and focal areas of hyperenhancement. Myocardial ECV, quantified by CMR T1 mapping, was associated with the degree of disease activity. These results may suggest the presence of cardiac involvement in ankylosing spondylitis and may show the potential of ECV as a marker for disease monitoring.

Multimorbidity in rheumatic conditions

In recent years, multimorbidity in rheumatic conditions has gained increasing attention. Rheumatologist care for an aging patient population with multiple diseases, therefore multimorbidity is the rule, not the exception. Owing to the high prevalence and the potential interaction of coexisting diseases, multimorbidity needs to be taken into account when treating patients with chronic inflammatory conditions. In this review we address the most prevalent comorbidities in patients with rheumatic conditions and their impact on important outcomes, such as physical function, quality of life, and mortality.

Relationship of serum osteoprotegerin with arterial stiffness, preclinical atherosclerosis, and disease activity in patients with ankylosing spondylitis

Patients with ankylosing spondylitis (AS) reportedly have a higher mortality and morbidity risk. Osteoprotegerin (OPG) was recently defined as an important cardiovascular (CV) marker in the general population. We aimed to assess the relationship of serum OPG levels with arterial stiffness, carotid intima media thickness (CIMT), and clinical and laboratory data in AS patients. We examined 60 AS patients without CV disease or risk factors and 50 healthy controls. Disease activity was evaluated using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS), whereas functional capacity was evaluated using the Bath Ankylosing Spondylitis Functional Index (BASFI). Serum OPG levels were measured with the enzyme-linked immunosorbent assay. Carotid-femoral pulse wave velocity (PWV) was used as an indicator of arterial stiffness, whereas CIMT (examined via carotid ultrasonography) was used to evaluate preclinical atherosclerosis. The mean serum OPG level, PWV, and CIMT were significantly higher in AS patients than in controls (106.7 ± 50.9 vs. 58.1 ± 12.7 pg/mL; 7.4 ± 1.8 vs. 6.2 ± 1.2 m/s; 0.72 ± 0.13 vs. 0.57 ± 0.07 mm, respectively; P < 0.001 for all). In AS patients, the serum OPG levels were not significantly correlated with PWV and CIMT but were significantly correlated with erthrocyte sedimentation rate, BASFI, and ASDAS. AS patients without CV disease or risk exhibited high OPG levels and increased PWV and CIMT values. Although OPG levels were not significantly correlated with PWV or CIMT, future long-term follow-up studies will help define the predictive value of OPG in these patients.

Evolution of traumatic spinal cord injury in patients with ankylosing spondylitis, in a Romanian rehabilitation clinic

The ankylosing spondylitis (AS) is a systemic, multi-factorial, chronic rheumatic disease. Patients are highly susceptible to vertebral fractures with or without spinal cord injury (AS-SCI), even after a minor trauma. The study is a retrospective descriptive survey of post-acute, traumatic AS-SCI patients, transferred from the neurosurgical department and admitted in a Romanian Neurorehabilitation Clinic, during 2010-2014. There were 11 males associating AS-SCI (0.90% of all consecutive SCI admitted cases), with an average age of 54.6 years (median 56, limits 42-73 years). The average duration between the medically diagnosed AS and the actual associated spinal fracture(-s) moment was 21.4 years (median 23; limits 10-34 years). Low-energy trauma was incriminated in 54.5% cases. The spinal level of fracture was: cervical (four cases), thoracic (three), lumbar (four), assessed at admission as: American Spinal Injury Association (ASIA) Impairment Scale (AIS) A (four subjects), C (five) and D (two). By the time of discharge, neither patient has neurologically deteriorated; five patients (45.5%) improved of at least grade 1 (AIS). The overall complications were mainly infections: symptomatic urinary tract infections (seven patients; 63.6%), pulmonary (three subjects; 27.3%) and spondylodiscitis (one case; 9%). The average follow-up period was 15.3 months (median 12; limits 1-48 months) after discharge; three subjects gained functional improvement to AIS-E. The clinical profile (different risk factors, mechanisms, types and levels of spinal fractures, additional encephalic and/or cord lesions, co-morbidities), different post-surgical and/or general complications acquired during admission in our rehabilitation ward, served us for future prevention strategies and a better therapeutic management.

Risk of Psychiatric Disorders following Ankylosing Spondylitis: A Nationwide Population-based Retrospective Cohort Study

OBJECTIVE

Ankylosing spondylitis (AS) is a common inflammatory rheumatic disease. A higher prevalence of psychiatric comorbidities, including depressive disorder, has been proven in patients with AS. However, a clear temporal causal relationship between AS and psychiatric disorders has not been well established. We performed a nationwide population-based retrospective cohort study to analyze the relationship between AS and the subsequent development of psychiatric disorders, including schizophrenia, bipolar disorder, depressive disorders, anxiety disorders, and sleep disorders.

METHODS

We identified subjects who were newly diagnosed with AS between January 1, 2000, and December 31, 2008, in the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed of patients without AS who were matched according to age and sex. All patients with AS and control patients were observed until diagnosed with psychiatric disorders, or until death or withdrawal from the NHI system, or until December 31, 2009.

RESULTS

The AS cohort consisted of 2331 patients and the comparison cohort consisted of 9324 matched control patients without AS. The adjusted HR for depressive disorders, anxiety disorders, and sleep disorders in subjects with AS were higher than those of the controls during followup (HR 1.718, 95% CI 1.303-2.265; HR 1.848, 95% CI 1.369-2.494; and HR 1.494, 95% CI 1.031-2.162, respectively).

CONCLUSION

AS might increase the risk of a subsequent newly diagnosed depressive disorder, anxiety disorder, or sleep disorder, but not schizophrenia or bipolar disorder. These observations highlight the need for psychiatric evaluation and intervention for patients with AS.

Cardiovascular comorbidity in rheumatic diseases

Patients with rheumatoid arthritis (RA) and other inflammatory joint diseases (IJDs) have an increased risk of premature death compared with the general population, mainly because of the risk of cardiovascular disease, which is similar in patients with RA and in those with diabetes mellitus. Pathogenic mechanisms and clinical expression of cardiovascular comorbidities vary greatly between different rheumatic diseases, but atherosclerosis seems to be associated with all IJDs. Traditional risk factors such as age, gender, dyslipidaemia, hypertension, smoking, obesity and diabetes mellitus, together with inflammation, are the main contributors to the increased cardiovascular risk in patients with IJDs. Although cardiovascular risk assessment should be part of routine care in such patients, no disease-specific models are currently available for this purpose. The main pillars of cardiovascular risk reduction are pharmacological and nonpharmacological management of cardiovascular risk factors, as well as tight control of disease activity.

Lipid profile changes in patients with chronic inflammatory arthritis treated with biologic agents and tofacitinib in randomized clinical trials: a systematic review and meta-analysis

OBJECTIVE

To analyze lipid changes in patients with rheumatoid arthritis (RA) and patients with spondyloarthritis (SpA) treated with biologic agents or tofacitinib in randomized clinical trials (RCTs).

METHODS

A systematic literature search was performed, using the Medline, Embase, Cochrane Library, and Web of Knowledge databases. Meta-analyses were performed using random-effects models to assess changes in the percentage of patients with abnormal lipid values or in the mean percentage of increase in the cholesterol and triglycerides levels.

RESULTS

Twenty-five of 4,527 identified articles met the inclusion criteria. Compared with RA patients treated with placebo, those treated with tocilizumab were more likely to have hypercholesterolemia (odds ratio [OR] 4.64; 95% confidence interval [95% CI] 2.71, 7.95 [P < 0.001]), increased levels of high-density lipoprotein (HDL) cholesterol (OR 2.25; 95% CI 1.14, 4.44 [P = 0.020]), and increased levels of low-density lipoprotein (LDL) cholesterol (OR 4.80; 95% CI 3.27, 7.05 [P < 0.001]); this was not observed in patients treated with tumor necrosis factor (TNF) antagonists (OR 1.54; 95% CI 0.90, 2.66 [P = 0.119]) or tofacitinib (OR 3.4; 95% CI 0.62, 18.55 [P = 0.158]). Among patients receiving tofacitinib 5 mg twice daily, the mean percentage of increases in the HDL cholesterol level (weighted mean difference [WMD] 13.00 mg/dl; 95% CI 12.08, 13.93 [P < 0.001]) and the LDL cholesterol level (WMD 11.20 mg/dl; 95% CI 10.08, 12.32 [P < 0.001]) were higher than those in the comparator groups. Among patients treated with tofacitinib 10 mg twice daily, the mean percentage of increases in the HDL cholesterol level (WMD 15.21 mg/dl; 95% CI 13.28, 17.14 [P < 0.001]) and the LDL cholesterol level (WMD 15.42 mg/dl; 95% CI 11.77, 19.06 [P < 0.001]) were also higher than those in the comparator groups. No data were available for RA treated with other biologic agents or for SpA.

CONCLUSION

In patients with RA treated with tocilizumab or tofacitinib but not with TNF antagonists, moderate changes in lipids are observed. Whether these changes pertain to the control of inflammation or to the mechanism of action of the biologic agents or tofacitinib remains undetermined.

Extra-articular disease in patients with spondyloarthritis. Baseline characteristics of the spondyloarthritis cohort of the AQUILES study

OBJECTIVES

To describe the prevalence of extra-articular disease (uveitis, psoriasis and inflammatory bowel disease [IBD]), in a cohort of patients with spondyloarthritis (SpA).

PATIENTS AND METHODS

AQUILES is an observational, prospective and multicentric study of three cohorts of patients with one of the following immune-mediated inflammatory diseases (IMID): SpA, psoriasis, or IBD. In the present cohort, patients ≥18 years of age with SpA were enrolled from Rheumatology clinics. The main objective was to assess the coexistence of these diseases and of uveitis, based on the patients' clinical history up to the study entry.

RESULTS

A total of 601 patients with SpA (men: 63.1%; women: 36.9%) were enrolled. The specific diagnoses were: ankylosing spondylitis (55.1%), psoriatic arthritis (25.1%), undifferentiated spondyloarthritis (16.1%), enteropathic arthritis (2.5%), and others (1.3%). In 43.6% (95% CI: 39.7-47.6) of the patients, at least one of the three abovementioned diseases was encountered, predominantly psoriasis (prevalence 27.8%, 95% CI: 24.4-31.5), uveitis (13.6%, CI 95%: 11.1-16.6) and IBD (5.1%, 95% CI: 3.7-7.2). In patients with ankylosing spondylitis the proportion of other disease was 25.3% (IBD: 3.9%, psoriasis: 5.4%, uveitis: 19.0%) whilst it was 94.7% in psoriatic arthritis, due to the presence of psoriasis (94.0%). The coexistence of these diseases was associated with age, female gender and the presence of other extra-articular manifestations associated with SpA.

CONCLUSIONS

Extra-articular disease in patients with SpA is common and, in this study, it was associated to age, female gender and the presence of other SpA-related extra-articular manifestations.

Cardiovascular events in ankylosing spondylitis: an updated meta-analysis

OBJECTIVES

Rheumatoid arthritis is associated with increased cardiovascular risk. In the guidelines, ankylosing spondylitis (AS) is considered to have an equally high cardiovascular risk. The literature findings remain controversial. This study aims to assess the risk of myocardial infarction (MI) and stroke in AS patients.

METHODS

An updated meta-analysis with a new systematic literature review using PubMed was conducted up to January 2014. Incidence of MI or stroke was calculated by metaproportion.

RESULTS

In addition to the 11 previously included studies, six new studies assessed the occurrence of MI or stroke in AS patients. (1) MI. A total of 2131 MI were reported in AS patients (n = 27,532) over a mean follow-up of 15 years: incidence 5.3% (1.6%-11.0%), i.e., 0.36/100 pyrs. Seven studies revealed 17,410 MI [2.5% (95% CI: 1.8%-3.4%)] in the control group (n = 1,349,964). Meta-analysis of the seven longitudinal studies showed a significant increase in MI [OR = 1.60 (95% CI: 1.32-1.93)] in AS patients. (2) Stroke. In 11 longitudinal studies (n = 51,990), 1807 strokes were reported in AS patients over 17.6 years of follow-up: incidence 3.6% (1.5%-6.5%), i.e., 0.24/100 pyrs. Three studies reported 22,899 strokes in controls (n = 1,239,041), giving an incidence of 1.78% (1.75%-1.80%). A significant increase in stroke [OR = 1.50 (95% CI: 1.39-1.62)] in AS patients was found.

CONCLUSION

AS patients appear to have a higher risk of MI and stroke. Management of cardiovascular risk factors and control of systemic inflammation should be taken into account in AS to decrease this high cardiovascular risk.

The risk of ischemic stroke in major rheumatic disorders

Rheumatic disorders (RD) are a range of conditions associated with inflammation of joints and connective tissue. They can manifest beyond the musculoskeletal system. Recent focus has been placed on the association of ischemic stroke with these conditions. Traditional vascular risk factors seem to be more prevalent in patients with certain types of RD than in the general population, but these factors do not fully explain the enhanced vascular risk in this population. Four major RD will be discussed in terms of their relationship with ischemic stroke: rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and psoriatic arthritis.

Etoricoxib and the treatment of ankylosing spondylitis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapies in the management of patients with ankylosing spondylitis. This chronic inflammatory skeletal disorder, a subtype of spondyloarthritis, is characterized by inflammatory back pain and affects young adults causing important suffering and disability. Long-term use of conventional NSAIDs is associated with a risk of gastrointestinal complications. Etoricoxib is a specific cyclooxygenase 2 inhibitor with strong anti-inflammatory effects and a favorable pharmacokinetic profile for the management of inflammatory disorders. The drug has been associated with reduced severe gastrointestinal adverse events. However, the cardiovascular safety of cyclooxygenase 2 inhibitors has been debated.

AREAS COVERED

This review discusses etoricoxib in the treatment of ankylosing spondylitis. Literature searches were performed in PubMed, Web of Science, and the Cochrane library based on the terms "etoricoxib" and "ankylosing spondylitis" or "spondyloarthritis" as well as "safety" and "side-effects."

EXPERT OPINION

Etoricoxib is useful in the first-line management of ankylosing spondylitis patients. Its anti-inflammatory effects and relative protection against severe gastrointestinal side effects should be balanced with negative effects on the cardiovascular system and an overall subjective tolerance not better than that of conventional NSAIDs. Whether etoricoxib will also become a mainstay in the prevention of structural damage in ankylosing spondylitis is not yet clear.