Atherosclerosis is accelerated in patients with long-term well-controlled systemic lupus erythematosus (SLE)

The potential role of serum amyloid A as biomarker of rheumatic diseases: a systematic review and meta-analysis

The identification of novel, robust biomarkers for the diagnosis of rheumatic diseases (RDs) and the presence of active disease might facilitate early treatment and the achievement of favourable long-term outcomes. We conducted a systematic review and meta-analysis of studies investigating the acute phase reactant, serum amyloid A (SAA), in RD patients and healthy controls to appraise its potential as diagnostic biomarker. We searched PubMed, Scopus, and Web of Science from inception to 10 April 2024 for relevant studies. We evaluated the risk of bias and the certainty of evidence using the JBI Critical Appraisal Checklist and GRADE, respectively (PROSPERO registration number: CRD42024537418). In 32 studies selected for analysis, SAA concentrations were significantly higher in RD patients compared to controls (SMD = 1.61, 95% CI 1.24-1.98, p < 0.001) and in RD patients with active disease compared to those in remission (SMD = 2.17, 95% CI 1.21-3.13, p < 0.001). Summary receiving characteristics curve analysis showed a good diagnostic accuracy of SAA for the presence of RDs (area under the curve = 0.81, 95% CI 0.78-0.84). The effect size of the differences in SAA concentrations between RD patients and controls was significantly associated with sex, body mass index, type of RD, and study country. Pending the conduct of prospective studies in different types of RDs, the results of this systematic review and meta-analysis suggest that SAA is a promising biomarker for the diagnosis of RDs and active disease.

Changes in Arterial Stiffness Monitored Using the Cardio-Ankle Vascular Index in Patients with Rheumatic Disease Receiving Initial Glucocorticoid Therapy: A Clinical Pilot Study

Systemic inflammatory rheumatic diseases predispose to premature birth, accelerated atherosclerosis, and increased cardiovascular disease (CVD). While glucocorticoids (GCs) are used in various rheumatic diseases, and the associations between GC excess and increased prevalence of CVD complications are well established, the mechanisms underlying GCs' role in atheroma development are unclear. We conducted an observational study to address GC therapy's effect on arterial stiffness using the cardio-ankle vascular index (CAVI) in patients with rheumatic diseases. Twenty-eight patients with rheumatic disease received initial GC therapy with prednisolone at doses ranging from 20 to 60 mg/d. CAVI was examined at baseline and 3 and 6 months after GC therapy. Changes in CAVI and inflammatory parameters were evaluated. GC therapy increased the mean CAVI after 3 months but decreased it to pretreatment levels after 6 months. The mean CAVI substantially decreased with GC treatment in patients <65 years but increased in patients ≥65 years. Alterations in CAVI during the 6-month GC treatment negatively correlated with the lymphocyte-to-monocyte ratio (LMR) at baseline. Conversely, no correlation was observed between alterations in CAVI values and conventional inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Multivariate analysis of factors related to changes in CAVI highlighted young age, high prednisolone dosage, and LMR at baseline. GC temporarily exacerbates but eventually improves arterial stiffness in rheumatic diseases. Particularly in young patients, GC may improve arterial stiffness by reducing inflammation. Therefore, the LMR before GC therapy in rheumatic diseases may be a potential predictor of arterial stiffness.

Peroxisome proliferator activated receptor-γ agonist pioglitazone improves vascular and metabolic dysfunction in systemic lupus erythematosus

OBJECTIVES

Premature cardiovascular events in systemic lupus erythematosus (SLE) contribute to morbidity and mortality, with no effective preventive strategies described to date. Immune dysregulation and metabolic disturbances appear to play prominent roles in the induction of vascular disease in SLE. The peroxisome proliferator activated receptor-gamma agonist pioglitazone (PGZ suppresses vascular damage and immune dysregulation in murine lupus and improves endothelial dysfunction in other inflammatory diseases. We hypothesised that PGZ could improve vascular dysfunction and cardiometabolic parameters in SLE.

METHODS

Eighty SLE subjects with mild to severe disease activity were randomised to a sequence of PGZ followed by placebo for 3 months, or vice versa, in a double-blind, cross-over design with a 2-month wash-out period. Primary endpoints were parameters of endothelial function and arterial inflammation, measured by multimodal assessments. Additional outcome measures of disease activity, neutrophil dysregulation, metabolic disturbances and gene expression studies were performed.

RESULTS

Seventy-two subjects completed the study. PGZ was associated with a significant reduction in Cardio-Ankle Vascular Index (a measure of arterial stiffness) compared with placebo. Various metabolic parameters improved with PGZ, including insulin resistance and lipoprotein profiles. Circulating neutrophil extracellular trap levels also significantly decreased with PGZ compared with placebo. Most adverse events experienced while on PGZ were mild and resolved with reduction in PGZ dose.

CONCLUSION

PGZ was well tolerated and induced significant improvement in vascular stiffness and cardiometabolic parameters in SLE. The results suggest that PGZ should be further explored as a modulator of cardiovascular disease risk in SLE.

TRIAL REGISTRATION NUMBER

NCT02338999.

High-density lipoprotein functionality in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a heterogeneous disease which is characterized with excessive inflammation and autoantibodies, macrophage and complement activation, and subsequently immunologically mediated tissue damage. In spite of improved treatments of SLE, these patients experience premature atherosclerosis and the rate of mortality among them remains high. Autoantibodies and circulating immune complexes might contribute to the pathogenesis of atherosclerosis by injuring the endothelium, as well as inducing pro-inflammatory and pro-adhesive endothelial cell phenotypes, as well as altering the metabolism of lipoproteins involved in atherogenesis. Hence, high levels of atherogenic lipoproteins (like low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL)) and low levels of high-density lipoprotein (HDL-C) are important risk factors for atherosclerotic cardiovascular complications in SLE patients but these traditional risk factors fail to fully explain the increased risk of cardiovascular disease (CVD) in these patients. The exact mechanism by which inflammation decreases HDL levels is not defined, but decreases in apoA-I production and lecithin cholesterol acyltransferase (LCAT) activity, as well as increased serum amyloid A (SAA), endothelial lipase and secretory phospholipase A2 activity (PLA2) could all contribute. In addition, during inflammation multiple changes in HDL structure occur, leading to alterations in HDL function which may be implicated in the CVD complications of SLE. Therefore, this review will aim to identify the mechanisms implicated in HDL dysfunction which occurs in SLE patients.

Foot and ankle characteristics in systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVE

To determine characteristics of the foot and ankle in people with systemic lupus erythematosus (SLE).

METHODS

Medline, CINAHL, Sports-Discus, Scopus and Cochrane Library databases were searched up to January 2018. Studies reporting foot- and ankle-related outcomes in the following domains were included: vascular, neurological, musculoskeletal, cutaneous (skin and nail) or pain/function. The Quality Index tool was used to assess methodological quality. Where appropriate, odds ratio (OR) and mean difference meta-analyses were conducted for case-control studies; and pooled mean prevalence meta-analyses for studies assessing characteristics in SLE.

RESULTS

Forty-nine studies were included with mean (range) quality scores of 75% (38-100%). Twenty-three studies assessed vascular characteristics, followed by musculoskeletal (n = 16), neurological (n = 11), cutaneous (n = 5) and pain/function (n = 4). Foot and ankle characteristics in people with SLE included impaired vascular supply, abnormal nerve function, musculoskeletal pathology, skin and nail pathology, and pain and functional disability. Twenty-four studies were included in meta-analyses. Pooled OR for abnormal ankle brachial index was 3.08 for SLE compared with controls. Pooled mean difference in brachial-ankle pulse-wave velocity between SLE and controls was significant (161.39 cm/s, P = 0.004). Pooled prevalence was 0.54 for intermittent claudication, 0.50 for Raynaud's phenomenon, 0.28 for chilblains, 0.00 for gangrene, 0.30 for hallux valgus, 0.15 for onychomycosis, 0.76 for history of foot pain, and 0.36 for current foot pain.

CONCLUSION

People with SLE experience a wide range of foot and ankle manifestations. Published research highlights the impact of peripheral arterial disease, peripheral neuropathy, musculoskeletal deformity, skin and nail pathology and patient-reported foot pain and disability.

Long-term prognosis and factors associated with damage accrual in Japanese patients with systemic lupus erythematosus

OBJECTIVE

Using a single-center cohort of Japanese patients with SLE, we attempted to clarify the long-term outcome and factors associated with damage accrual using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI).

METHODS

We examined a cohort of 557 patients who had been referred to Niigata University Hospital and diagnosed as having SLE between 1961 and 2013. The patients' data at the latest visit were collected from their clinical records, and causes of death were defined on the basis of those data. Survival from the time of diagnosis was calculated by the Kaplan-Meier method. The SDI was calculated and analyzed using Spearman's correlation coefficient and stepwise multiple regression analysis to reveal the factors associated with any organ damage.

RESULTS

Data from 458 of the patients were successfully obtained. The overall 5-year survival rate was 92.2%, and patients diagnosed after 2000 had a significantly high 5-year survival rate of 96.4%. Stepwise multiple regression analysis selected serum creatinine levels (B = 0.6051, p < 0.0001), age (standardized beta = 0.2762, p < 0.001), hypertension (standardized beta = 0.2267, p < 0.001), and antiphospholipid antibody syndrome (standardized beta = 0.1533, p = 0.005) as positive independent variables, whereas administration of bisphosphonate (standardized beta = - 0.1295, p = 0.016) was selected as a negative independent variable.

CONCLUSION

These results suggest that Japanese patients with SLE have a favorable long-term prognosis, and also indicate that disease control as well as management of chronic complications such as hypertension and osteoporosis has possible effects for prevention of organ damage.

Protocol for Evaluating the Cardio-Ankle Vascular Index to Predict Cardiovascular Events in Japan: A Prospective Multicenter Cohort Study

INTRODUCTION

The cardio-ankle vascular index (CAVI) was developed in Japan and is a blood pressure-independent index of arterial stiffness from the origin of the aorta to the ankle. In recent years, it has been studied by many researchers worldwide, and it is strongly anticipated that it will play a role as a predictive factor for arteriosclerotic diseases. The objective of this study was to examine the benefits of using CAVI as a predictor of cardiovascular events in high-risk patients.

METHODS AND DESIGN

This prospective multicenter study to evaluate the usefulness of the CAVI to predict cardiovascular events in Japan (CAVI-J) is a cohort study with central registration. Participants (n = 3,000) will be scheduled to enroll and data will be collected for up to 5 years from entry of participants into the study. To be eligible to participate in the CAVI-J study, individuals have to be aged between 40 and 74 years and have at least one of the following risk factors for arteriosclerosis: (1) type 2 diabetes mellitus; (2) high-risk hypertension; (3) metabolic syndrome; (4) chronic kidney disease (stage 3), or (5) history of coronary artery disease or noncardiogenic cerebral infarction. The primary endpoints of this study are cardiovascular death, nonfatal myocardial infarction, and stroke. The secondary endpoints are composite cardiovascular events including all cause death, angina pectoris with revascularization, new incidence of peripheral artery disease, abdominal aortic aneurysm, aortic dissection, heart failure requiring hospitalization, and deterioration in renal function. The cutoff for CAVI against the incidence of cardiovascular events will be determined.

Assessment of Arterial Stiffness Using the Cardio-Ankle Vascular Index

BACKGROUND

Arterial stiffness is an independent predictor of outcomes for patients with cardiovascular disease. Although measurement of pulse wave velocity is a widely accepted, noninvasive approach for the assessment of arterial stiffness, its accuracy is affected by changes in blood pressure.

SUMMARY

The cardio-ankle vascular index (CAVI) is an index of the overall stiffness of the artery from the origin of the aorta to the ankle and is theoretically independent of blood pressure at the time of measurement. CAVI increases linearly with age and is elevated even in mild arteriosclerotic disease. It can identify differences in the degree of arteriosclerosis among patients with severe arteriosclerotic disease and better reflects the severity of disease of the coronary artery than does brachial-ankle pulse wave velocity. Patients with higher CAVI values show a poor prognosis compared with those with lower CAVI values. Furthermore, CAVI can be lowered by controlling diabetes mellitus and hypertension.

KEY MESSAGES

The primary aims of assessing arterial stiffness using CAVI are to assist in the early detection of arteriosclerosis, allowing timely treatment and lifestyle modification, and to quantitatively evaluate the progression of disease and the effectiveness of treatment. Whether CAVI-guided therapy can improve prognosis in high-risk patients needs to be further examined to confirm the clinical usefulness of this measure.

Subclinical atherosclerosis in patients with systemic lupus erythematosus: A systemic review and meta-analysis

OBJECTIVE

Systemic lupus erythematosus (SLE) is associated with increased risk of cardiovascular disease. Carotid intima media thickness (CIMT) and carotid plaques are both frequently used to identify populations at higher cardiovascular risk. A systematic literature search and meta-analysis were performed to evaluate CIMT and carotid plaques difference between SLE patients and normal controls.

METHODS

The literatures comparing markers of cardiovascular risk (CIMT and prevalence of carotid plaques) in SLE and controls were systematically searched in PubMed, EMBASE and Cochrane databases. The overall mean CIMT difference and pooled odds ratio (OR) for the prevalence of carotid plaques between SLE patients and control groups were calculated by fixed-effects or random-effect model analysis. Meta-regression was performed to explore the potential influencing factors. Publication bias was examined by a funnel plot and Egger's test.

RESULTS

A total of 80 studies (6085 SLE patients and 4794 controls) were included in the final analysis, 71 studies with data on CIMT (4814 cases and 3773 controls) and 44 studies reporting on the prevalence of carotid plaques (4417 cases and 3528 controls). As compared to controls, SLE patients showed a higher CIMT (WMD: 0.07 mm; 95%CI: 0.06, 0.09; P<0.001), and an increased prevalence of carotid plaques (OR: 2.45; 95%CI: 2.02, 2.97; P<0.001). Meta-regression models showed that traditional cardiovascular risk factors (age, HDL and triglyceride of SLE patients) and lupus related risk factors (as expressed by duration, ESR, SLEDAI and steroids) had a significant influence on CIMT, steroids and triglyceride had significant influence on the prevalence of carotid plaques.

CONCLUSIONS

Our findings support the current evidence base for an increased cardiovascular burden in SLE patients and support the use of CIMT and carotid plaques in observational studies in SLE patients. The findings are of importance to design more specific prevention and treatment strategies.

The Role of Monitoring Arterial Stiffness with Cardio-Ankle Vascular Index in the Control of Lifestyle-Related Diseases

Arteriosclerosis is a major contributor to cardiovascular diseases. One of the difficulties in controlling those diseases is the lack of a suitable indicator of arteriosclerosis or arterial injury in routine clinical practice. Arterial stiffness was supposed to be one of the monitoring indexes of arteriosclerosis. Cardio-ankle vascular index (CAVI) is reflecting the stiffness of the arterial tree from the origin of the aorta to the ankle, and one of the features of CAVI is independency from blood pressure at a measuring time. When doxazosin, an α1-adrenergic blocker, was administered, CAVI decreased, indicating that arterial stiffness is composed of both organic stiffness and functional stiffness, which reflects the contraction of arterial smooth muscle. CAVI shows a high value with aging and in many arteriosclerotic diseases, and is also high in persons possessing main coronary risk factors such as diabetes mellitus, metabolic syndrome, hypertension and smoking. Furthermore, when the most of those risk factors were controlled by proper methods, CAVI improved. Furthermore, the co-relationship between CAVI and heart function was demonstrated during treatment of heart failure. This paper reviews the principle and rationale of CAVI, and discusses the meaning of monitoring CAVI in following up so-called lifestyle-related diseases and cardiac dysfunction in routine clinical practice.

Elevated arterial stiffness and diastolic dysfunction in subclinical hypothyroidism

BACKGROUND

Thyroid hormone is associated with arterial stiffness and left ventricular diastolic function in hypothyroid disease. The relationship of thyroid hormone level to cardio-ankle vascular index (CAVI) and left ventricular diastolic function, however, remains unclear in subjects with subclinical hypothyroidism.

METHODS AND RESULTS

We conducted a cross-sectional study of 83 patients with untreated subclinical hypothyroidism and compared them with 83 randomly selected controls from health check-ups. Log N-terminal prohormone of brain natriuretic peptide (NT-proBNP), C-reactive protein (CRP), and arterial stiffness were measured. In addition, we measured early diastolic mitral annular velocity (E') in 43 participants with subclinical hypothyroidism and in 40 controls. When compared with the control group, patients with subclinical hypothyroidism had higher logNT-proBNP (1.9±0.5 vs. 1.7±0.3pg/ml, P<0.05), CRP (0.22±0.04 vs. 0.09±0.06mg/dl, P<0.05), and CAVI (8.8±1.7 vs. 7.8±1.4, P<0.001) and lower E' (5.8±1.7 vs. 7.5±2.1cm/s, P<0.001). CAVI was significantly associated with logNT-proBNP, CRP and E' in the subclinical hypothyroidism group.

CONCLUSIONS

High logNT-proBNP was associated with a raised CAVI in patients with subclinical hypothyroidism. Subclinical hypothyroidism may be a risk factor for cardiovascular events related to arterial stiffening and left ventricular diastolic dysfunction.

Th17/Treg imbalance induced by increased incidence of atherosclerosis in patients with systemic lupus erythematosus (SLE)

The objective of the study was to investigate whether the immunological factors in patients with Systemic Lupus Erythematosus (SLE) and a high incidence of atherosclerosis correlate with a Th17/Treg imbalance. All cases were recruited from the Affiliated Hospital of Guilin Medical University: a random sample of 42 cases with SLE and atherosclerosis, 39 positive control cases with SLE alone with no anomalies detected via coronary artery angiography or carotid color Doppler ultrasound examination, as well as 45 normal controls based on physical examination were included. The serum expression levels of IL-10, IL-17, IL-6, TNF-α, Th17, Th17 cell transcription factor RORγt, and Treg cell transcription factor Foxp3 were measured in each group of patients. Correlations among Th17/Treg, their secreted cell factors, transcription factors, SLE, and SLE with concurrent atherosclerosis (SLE + AS) were analyzed. The results are as follows: (1) total cholesterol and triacylglycerol levels in the SLE and SLE + AS groups were higher than those in the control group (P < 0.05 and P < 0.01); (2) serum IL-10 in the SLE + AS group was lower than the SLE and control groups; however, serum IL-17 and IL-6 levels in the SLE + AS group were elevated compared to the SLE and control groups (average P < 0.01); (3) the percentage of Treg cells in the SLE + AS patients was lower than those found in the SLE and control groups; in contrast, percentages of serum Th17 cells in SLE + AS patients were higher than the SLE and control groups (average P < 0.01); (4) FoxP3 expression in the SLE + AS group was lower than levels observed in the SLE and control groups (average P < 0.05); in contrast, RORγt expression in the SLE + AS group was higher than levels found in the SLE and control groups (average P < 0.05). The abnormal balance between Th17 cells and Treg cells in SLE + AS patients has obvious implications for Th17 migration. The results suggest that Th17 cell proportion and function can be enhanced, relatively or absolutely, whereas the proportion and function of Treg cells can abate, relatively or absolutely. This imbalance may be an important reason for the high incidence of SLE with atherosclerosis.

Mycophenolate mofetil (MMF) does not slow the progression of subclinical atherosclerosis in SLE over 2 years

Accelerated atherosclerosis is a major cause of mortality in SLE. Mycophenolate mofetil (MMF) has been shown to suppress growth factor-induced proliferation of vascular smooth muscle and endothelial cells in animal models. We hypothesized that MMF might modify the inflammatory component of atherosclerosis in SLE. We examined the effect of MMF on atherosclerosis as measured by changes in carotid intima-media thickness (IMT) or coronary artery calcium (CAC) over 2 years. CAC and carotid IMT were measured at baseline and 2 years later in a cohort of 187 patients with SLE. The cohort was 91% women, 59% Caucasian, and 35% African-American, with a mean age of 45 ± 11 years. Of these, 12.5% (n = 25) received MMF during follow-up. The daily dose ranged from 500 to 3,000 mg/day, and duration ranged from 84 days to the entire 2 years. We divided MMF users into three groups: low exposure (<1,500 mg average daily dose), high exposure (≥1,500 average daily dose), and any exposure of MMF (<1,500 or ≥1,500 average daily dose) for 2 years. The mean CAC increased in all four groups: no MMF: 1.17-1.28, low MMF: 1.02-1.13, high MMF: 1.44-1.61, and any MMF: 1.21-1.34 log-Agatston units. Compared to no MMF, there was no statistically different change between the three groups (p = 0.99, 0.87, and 0.91). Similarly, mean carotid IMT increased in all four groups: no MMF: 0.58-0.66, low MMF: 0.55-0.60, high MMF: 0.56-0.71, and any MMF: 0.56-0.66. We then adjusted for statin use, lupus nephritis, body mass index, systolic blood pressure, cholesterol, and age during the 2-year follow-up. The association between MMF exposure and change in CAC or carotid IMT was not statistically significant (p = 0.63 for CAC, and p = 0.085 for carotid IMT). There was no evidence that MMF slowed or decreased the progression of atherosclerosis as measured by carotid IMT or CAC. Because the number of patients taking MMF was only twenty-five, larger studies for longer time periods are needed to explore any effect of MMF on subclinical atherosclerosis in SLE.

Ethnic differences in cardiovascular risk in rheumatic disease: focus on Asians

Rheumatic diseases are associated with high cardiovascular morbidity and mortality. Considerable differences exist in the frequency of cardiovascular disease (CVD) risk factors and events among people of different ethnic origins, but little is known of the ethnic variations in the relative distribution of CVD risk factors and the degree of atherosclerosis in patients with rheumatic diseases. Understanding this variation will provide insight into the underlying pathogenesis of CVD in patients with rheumatic diseases, and aid in future studies of the detection and management of this complication. In general, although Asian patients seem to have fewer background CVD risk factors and are less affected by metabolic syndrome (MetS) than their non-Asian counterparts, those with rheumatic disease are equally as susceptible to CVD. Furthermore, it seems that systemic inflammation and mechanisms that do not involve conventional CVD risk factors and MetS have an important role in the development of atherosclerosis in patients with rheumatic diseases. Here we examine the frequency of conventional CVD risk factors and the prevalence of MetS in both Asian and non-Asian patients with selected rheumatic diseases. We also discuss the burden of CVD, as evaluated using various surrogate markers in these patients, and their overall CVD mortality rate.

Predictors of progression in atherosclerosis over 2 years in systemic lupus erythematosus

OBJECTIVES

Cardiovascular disease remains the major cause of death in SLE. We assessed the degree to which cardiovascular risk factors (CVRFs) and disease activity were associated with 2-year changes in measures of subclinical atherosclerosis.

METHODS

One hundred and eighty-seven SLE patients participating in a placebo-controlled trial of atorvastatin underwent multi-detector CT [for coronary artery calcium (CAC)] and carotid duplex [for carotid intima-media thickness (IMT) and carotid plaque] twice, 2 years apart. During the 2 years, patients were assessed every 3 months for CVRF. Both groups were combined for analysis, as atorvastatin did not differ from placebo in preventing progression of coronary calcium. We examined the correlation between these clinical measures and progression of CAC, IMT and plaque during the follow-up period.

RESULTS

In an analysis adjusting for age, gender and ethnicity, CAC progression was positively associated with total serum cholesterol measured over the 2-year period (P = 0.04) and smoking (P = 0.003). Carotid IMT progression was associated with systolic BP (P = 0.003), high-sensitivity CRP (hsCRP) (P = 0.013) and white blood cell (WBC) count (P = 0.029). Carotid plaque progression, defined as patients without carotid plaque at baseline with subsequent development of plaque at follow-up, was associated with systolic BP (P = 0.003), WBC count (P = 0.02), physician's global assessment (P = 0.05), blood lymphocyte count (P = 0.048), urine protein (P = 0.017) and duration of SLE (P = 0.019).

CONCLUSION

Our data did not provide evidence of an association between measures of SLE disease activity (SLEDAI, anti-dsDNA, anti-phospholipid and treatment) and progression of subclinical atherosclerosis. Age and hypertension were associated with the progression of carotid IMT and plaque. Age, smoking and cholesterol were associated with progression of CAC.

Cardiovascular co-morbidity in Asians with lupus: theoretical concern or clinical reality?

Immuno-inflammatory diseases like lupus are associated with premature atherosclerosis. With improved survival, atherosclerotic cardiovascular disease has emerged as an important late complication of systemic lupus erythematosus. The burden of this co-morbidity in Asian patients is not fully known but is likely to be high. We review the literature available and draw attention to this oft overlooked problem.

Statin therapy reduces inflammatory markers in hypercholesterolemic patients with high baseline levels

AIM

Hypercholesterolemic patients with inflammation are at high risk for cardiovascular events. Statins exert anti-inflammatory action independent of their cholesterol-lowering action. This study sought to clarify whether statin therapy reduces inflammatory markers in hypercholesterolemic patients and to determine factors that predict the reduction in these markers.

METHODS

Fasting concentrations of lipoproteins and inflammatory markers were measured in 54 hypercholesterolemic patients, and age- and gender-matched healthy volunteers. Carotid atherosclerosis was determined by ultrasonography. Blood samples were also analyzed in hypercholesterolemic patients after 4 weeks of statin therapy.

RESULTS

The high-sensitivity C-reactive protein (hs-CRP) and serum amyloid A (SAA) protein concentrations did not differ between the two groups. Statin therapy reduced the median hs-CRP and SAA concentrations in hypercholesterolemic patients from 0.75 to 0.60 mg/L (p=0.05), and from 3.95 to 3.20 microg/mL (p=0.20), respectively. These reductions were significant for both markers, but only in subgroups with high baseline concentrations. Statins exhibited different results for hs-CRP and SAA in the presence of carotid atherosclerosis.

CONCLUSIONS

Statin therapy reduces inflammatory markers in hypercholesterolemic patients, and this anti-inflammatory action is limited to patients whose inflammatory markers are elevated at baseline.

Rheumatic Disease and Carotid Intima-Media Thickness

Objective— To perform a systematic review and meta-analysis to examine whether rheumatic disease is associated with an increased carotid intima-media thickness (CIMT; increasingly used as a surrogate marker for atherosclerosis) when compared with healthy control subjects.

Methods and Results— A prespecified search strategy was used to identify relevant studies in the MEDLINE and EMBASE databases (January 1, 1986 to December 31, 2008). Methodological quality was assessed using the Newcastle-Ottawa score for observational studies. A total of 68 controlled comparisons from 60 different studies were reviewed: 25 (37%) on rheumatoid arthritis, 24 (35%) on systemic lupus erythematosus, 6 (9%) on systemic sclerosis, and 13 (19%) on other rheumatic diseases. Random-effects meta-regression analysis was performed. The estimated summary effect size between control and study subject CIMT measurement comparisons, with preexisting cardiovascular disease excluded, was 0.64 (95% CI, 0.46 to 0.82). This represented an overall absolute mean difference of 0.06 mm (95% CI, 0.05 to 0.06 mm). Preexisting cardiovascular disease, rheumatic disease type, and disease duration contributed to heterogeneity.

Conclusion— Accelerated atherosclerosis is a common complication of autoimmune rheumatic diseases, with early changes seen even in pediatric patients. CIMT was significantly increased in rheumatic disease populations. Future studies need to use a standardized protocol to ensure clinically meaningful results when measuring CIMT as a surrogate for premature atherosclerosis.

Lymphopenia is a risk factor in the progression of carotid intima-media thickness in juvenile-onset systemic lupus erythematosus

OBJECTIVE

To characterize the atherosclerotic risk factors in the progression of subclinical atherosclerosis in patients with juvenile-onset systemic lupus erythematosus (SLE).

METHODS

This was a longitudinal study of 76 patients with juvenile-onset SLE. Carotid arteries were evaluated using ultrasonography at baseline and at followup visits at 6-month intervals over the 6-year study period. Clinical and laboratory parameters, disease activity, treatment, and traditional risk factors for atherosclerosis were evaluated. Data were analyzed using generalized estimating equations.

RESULTS

The mean+/-SD age of the patients at baseline was 15.01+/-3.48 years and the mean+/-SD disease duration was 2.65+/-2.5 years. The mean+/-SD duration of followup was 3.74+/-1.24 years. The mean+/-SD intima-media thickness (IMT) of the common carotid arteries differed significantly between the patient and control (n=38) groups (0.63+/-0.08 mm versus 0.54+/-0.06 mm; P<0.001). The presence of lymphopenia at diagnosis and at baseline and higher levels of serum creatinine and C-reactive protein at baseline were positively associated with progression of carotid IMT (P=0.006, P=0.043, P=0.037, and P=0.049, respectively). In multivariate analysis, only lymphopenia at baseline and at diagnosis were consistently associated with progression of IMT (P=0.012 and P=0.045, respectively).

CONCLUSION

In patients with juvenile-onset SLE, some nontraditional risk factors for the progression of subclinical atherosclerosis were identified. Lymphopenia was the only independent risk factor for the progression of IMT. The pathogenic mechanisms warrant further investigation.

Risk Factors for Development of Coronary Artery Disease in Women with Systemic Lupus Erythematosus

Objective.

To ascertain coronary artery disease (CAD) outcomes and predictive factors in a prospective study of patients with systemic lupus erythematosus (SLE) and matched healthy controls.

Methods.

SLE patients and non-SLE age-matched controls without a history of CAD were recruited into a prospective study between 1997 and 1999. CAD events were assessed at clinic visit for SLE patients and through telephone interview and chart review for controls. All events were verified with patient medical records.

Results.

Followup information was available on 237 controls and 241 SLE patients. The mean followup time was 7.2 years. Univariate analyses identified age and postmenopausal status as predictors of CAD in both the groups. Sedentary lifestyle, hypertension, the presence of metabolic syndrome, and the number of Framingham risk factors were predictive in the control group only. The 10-year risk of CAD score was predictive in both groups but was not as marked in the SLE group as in the controls. None of the lipid subfractions were predictive for CAD in the SLE group, whereas in the controls, a high triglyceride level ≥ 2.8 was predictive. Time-to-event multivariate analysis for CAD in all subjects revealed SLE itself, older age, and triglycerides ≥ 2.8 to be highly predictive for CAD.

Conclusion.

In a prospective study of patients with SLE and matched controls followed over a median of 8 years, patients with SLE developed significantly more CAD events than controls. Accounting for demographic variability, CAD risk factors, and lipid factors, SLE is an independent risk factor for the development of CAD.

High-sensitivity CRP reflects insulin resistance in smokers

AIM

The elevation of high-sensitivity C-reactive protein (hs-CRP) is a strong risk factor for cardio-vascular disease (CVD) and is associated with insulin resistance. The hs-CRP concentration also increases in smokers known to be at a high risk for CVD. We examined whether hs-CRP concentra-tion reflects insulin resistance in smokers.

METHODS

The hs-CRP levels were measured in 121 male subjects (54 nonsmokers and 67 smokers) with a normal glucose tolerance. The hs-CRP concentration was compared to the homeostasis model assessment of insulin resistance (HOMA-IR) and other clinical variables related to insulin resistance.

RESULTS

Smokers had a 64.5% higher hs-CRP concentration than nonsmokers (p<0.0001). In both nonsmokers and smokers, hs-CRP positively correlated with HOMA-IR (r=0.301, p<0.05 and r=0.312, p<0.01) and fasting insulin (r=0.281, p<0.05 and r=0.356, p<0.01). The correlation between hs-CRP and HOMA-IR or fasting insulin was stronger in smokers than in nonsmokers. In smokers, hs-CRP significantly correlated with BMI and HDL-cholesterol (r=0.386, p<0.01 and r=-0.307, p<0.05). Stepwise regression analysis revealed that BMI and HOMA-IR were significant predictors of hs-CRP in smokers (r=0.423, p<0.01).

CONCLUSIONS

The hs-CRP concentration reflects insulin resistance in smokers. It would be preferable to consider insulin resistance in evaluating hs-CRP concentrations, even in smokers.

Subclinical atherosclerosis and endothelial dysfunction in young South-Asian patients with systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE), especially Asian Indians, are at increased risk of developing premature atherosclerosis. To find out the prevalence and predictors of carotid intima-medial thickness (IMT) and brachial artery flow-mediated dilatation (FMD). Endothelial dysfunction was assessed by FMD in brachial artery and IMT was measured in common carotid artery in SLE patients and healthy controls. Sixty SLE patients (mean age 31 +/- 9 years) and 38 healthy controls (mean age 34 +/- 6 years) were included. The IMT was higher in SLE patients as compared to controls (0.49 +/- 0.08 mm vs. 0.39 +/- 0.05 mm, p < 0.0001). SLE and damage were independent predictors of abnormal IMT. FMD was impaired in SLE patients compared to controls (9.97% vs. 18.97%, p < 0.00001). None of the classical cardiovascular risk factors were predictors of FMD or abnormal IMT. Indian patients with SLE have higher prevalence of subclinical atherosclerosis and endothelial dysfunction. Presence of damage was associated with abnormal IMT in SLE patients.

The altered expression of inflammation-related molecules and secretion of IL-6 and IL-8 by HUVEC from newborns with maternal inactive systemic lupus erythematosus is modified by estrogens

Systemic lupus erythematosus (SLE) predominantly affects women, especially those in reproductive age. Genetic contributions to disease susceptibility as well as immune dysregulation, particularly persistent inflammatory responses, are considered essential features. Our aim was to determine whether human umbilical vein endothelial cells (HUVEC) isolated from healthy newborns to women with inactive SLE show inflammation-related abnormalities that might lead to an early development of SLE in the offsprings. HUVEC isolated from six women with inactive SLE were stimulated with 2.5 ng/mL of TNF-alpha and/or physiological and pharmacological doses of 17-I(2) estradiol (E2). Then the expression of VCAM-1, ICAM-1, E-selectin, toll-like receptor-9 (TLR-9), heat shock protein 70 (HSP70) and HSP90 were measured. The concentrations of IL-6, IL-8, and IL-10 were also determined in maternal serum and in TNF-alpha stimulated and non-stimulated HUVEC culture supernatant. HUVEC from children with no family history of autoimmune disease served as controls. Our results showed that in HUVEC from SLE+ mothers, a constitutively low expression of adhesion molecules was enhanced by TNF-alpha treatment. The E2 (1 ng/mL) increased the expression of adhesion molecules but had no effect upon TNF-alpha-treated cells. IL-6 was constitutively higher in SLE+ HUVEC, whereas IL-8 was lower; E2 treatment diminished the latter. The E2 had no effect upon IL-6 and IL-8 secretions in TNF-alpha-treated cells. SLE+ HUVEC showed a disordered cytoskeleton and overexpressed HSP70, HSP90, and TLR-9. Our results indicate that endothelial cells of newborns to SLE+ mothers are in a proinflammatory condition which can be upregulated by estrogens.

Stiffness parameters, intima-media thickness and early atherosclerosis in systemic lupus erythematosus patients

Detection of early carotid vascular disease in patients with systemic lupus erythematosus (SLE) is considered mandatory for evaluation of subclinical atherosclerosis (ATS), and various ultrasonographic (US) parameters have been proposed. In the present investigation, 33 SLE and 33 healthy age-matched females have been studied by colour-coded sonography of the common carotid artery, assessing intima-media thickness (IMT), vascular strain (VS), vascular distensibility (VD), vascular stiffness (VSf) and pressure-strain elastic modulus (PSEM) as possible markers of early ATS. Patients with SLE, despite equivalent exposure to “traditional” cardiovascular risk factors, presented a higher mean IMT of the common carotid artery than healthy subjects (0.7 ± 0.2 mm vs 0.5 ± 0.1 mm – P < 0.0001). Of the stiffness parameters, patients with lupus showed a mean VSf of 0.72 ± 0.38 vs 0.54 ± 0.14 in controls ( P < 0.0001) and a mean PSEM of 6.0 ± 2.8 Pa vs 3.0 ± 1.4 Pa in controls ( P < 0.0001). Mean VS and VD were significantly lower in patients with SLE than in healthy subjects ( P < 0.0001). Among individuals with IMT < 0.6 mm, patients with SLE presented more compromised stiffness parameters. IMT was shown to be a useful parameter in the evaluation of vascular damage, even in a “sub-clinical” phase, while stiffness parameters provide additional details regarding endothelial and vessel functional state. Combined evaluation may allow ATS to be detected in the early stages in patients with SLE.

Relationship of cardio-ankle vascular index (CAVI) to carotid and coronary arteriosclerosis

BACKGROUND

The cardio-ankle vascular index (CAVI) has been recently reported as a new index of aortic stiffness, which is less influenced by blood pressure than pulse wave velocity (PWV). The present study investigated the relationship between the levels of CAVI and carotid and coronary arteriosclerosis.

METHODS AND RESULTS

The 443 consecutive patients who underwent CAVI, carotid sonography, and coronary angiography in hospital were examined. Intima-media thickness (IMT) and carotid plaque were evaluated by ultrasonography. The severity of coronary artery disease (CAD) was evaluated by coronary angiography and the subjects were divided into 4 groups (0, no significant organic stenosis: 1, 1-vessel disease: 2, 2-vessel disease: 3, 3-vessel disease). Univariate analyses showed that both CAVI and brachial-ankle PWV (baPWV) were associated with IMT and the presence of carotid plaque. Multiple stepwise regression analyses revealed that CAVI (p=0.0427), but not baPWV, was associated with the IMT. Both CAVI (p<0.0001) and baPWV (p=0.0140) were significantly associated with the severity of CAD. Multiple logistic analyses revealed that CAVI (p=0.0342), but not baPWV (p=0.8027), was associated with the presence of multivessel disease.

CONCLUSION

High CAVI implies progression of carotid and coronary arteriosclerosis. CAVI may be more closely linked with arteriosclerosis than baPWV.