Rheumatoid arthritis and risk of acute myocardial infarction--a nationwide retrospective cohort study

Aspirin does not confer protection against major ischemic vascular events in patients diagnosed with rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by inflammatory arthritis and extra-articular involvement. Patients with RA are at increased risk of developing cardiovascular diseases. This retrospective cohort study aimed to determine whether acetylsalicylic acid (aspirin [ASA]) protects against major ischemic vascular events in patients diagnosed with RA.

METHODS

Patients with RA were recruited from a population of 118, 500 participants who were enrolled into the Kailuan Cohort Study between 2014 and 2016. Information regarding demographic characteristics, anthropometric measures, and medical histories were documented. Patients with RA who underwent ASA therapy were propensity score matched at a ratio of 1:4 with patients with RA who did not receive ASA. The risk of ischemic vascular events (myocardial infarction and ischemic stroke) was examined. The relationship between ASA therapy and major ischemic vascular events was analyzed by Cox proportional hazards regression.

RESULTS

A total of 939 patients with RA were included (189 who received ASA and 750 who did not). During the 3.3-year follow-up, six and 35 major ischemic vascular events occurred in the ASA and non-ASA groups, respectively, with no significant between-group difference in the cumulative incidence of such events. Cox proportional hazards regression analysis showed that ASA therapy was not associated with major vascular ischemic events and its subtypes.

CONCLUSIONS

ASA did not confer protection against major ischemic vascular events in patients diagnosed with RA.

Bioinformatics combining machine learning and single-cell sequencing analysis to identify common mechanisms and biomarkers of rheumatoid arthritis and ischemic heart failure

Patients with rheumatoid arthritis (RA) have an increased risk of ischemic heart failure (IHF), but the shared mechanisms are unclear. This study analyzed RNA sequencing data from five RA and IHF datasets to identify common biological mechanisms and significant biomarkers. One hundred and seventy-seven common differentially expressed genes (CDEGs) were identified, with enrichment analysis highlighting pathways related to sarcomere organization, ventricular myocardial tissue morphogenesis, chondrocyte differentiation, prolactin signaling, hematopoietic cell lineage, and protein methyltransferases. Five hub genes (CD2, CD3D, CCL5, IL7R, and SPATA18) were identified through protein-protein interaction (PPI) network analysis and machine learning. Co-expression and immune cell infiltration analyses underscored the importance of the inflammatory immune response, with hub genes showing significant correlations with plasma cells, activated CD4+ T memory cells, monocytes, and T regulatory cells. Single-cell RNA sequencing (scRNA-seq) confirmed hub gene expression primarily in T cells, activated T cells, monocytes, and NK cells. The findings underscore the critical roles of sarcomere organization, prolactin signaling, protein methyltransferase activity, and immune responses in the progression of IHF in RA patients. These insights not only identify valuable biomarkers and therapeutic targets but also offer promising directions for early diagnosis, personalized treatments, and preventive strategies for IHF in the context of RA. Moreover, the results highlight opportunities for repurposing existing drugs and developing new therapeutic interventions, which could reduce the risk of IHF in RA patients and improve their overall prognosis.

Incidence Rate of Cardiovascular Events in Rheumatoid Arthritis: An Observational Cohort Study in Saudi Arabia

Purpose

Rheumatoid arthritis (RA) doubles the morbidity of cardiovascular disease (CVD) and leads to a 50% increase in mortality compared to the general population. This study aims to estimate the CVD incidence among RA patients in Saudi Arabia (SA), vital for assessing CVD burdens within this group.

Patients and Methods

This retrospective study took place at two centers in the Eastern Province of SA, including all adult RA patients who visited the rheumatology clinic from 2016 to 2021 and were prescribed disease-modifying antirheumatic drugs (DMARDs). CVD incidence was determined by the diagnosis of ischemic heart disease (IHD), stroke/transient ischemic attack (TIA), venous thromboembolism (VTE), heart failure (HF), and arrhythmia post-RA diagnosis. Additional data collected included demographics, CVD risk factors, comorbidities, RA-related factors, and medication usage.

Results

The study comprised 651 patients, 80.5% of whom were females with an average age of 51. The overall CVD incidence was 11.2 per 1000 person-years, with males experiencing five times more incidents than females. The prevalence of CVD risk factors included 18.7% with hypertension, 7.8% with hyperlipidemia, 18.9% with diabetes, and 42.9% with obesity. Significant predictors of CVD were male gender and RA duration, with adjusted odds ratios (aOR) of 3.17 (95% CI 1.10 to 9.14, P=0.033) and 64.81 (95% CI 3.68 to 1140.6, P=0.004), respectively.

Conclusion

This unique study from SA examined the CVD incidence in RA patients, identifying long disease duration and male gender as significant predictors. Effective reduction of CVD risk in RA patients requires aggressive management of modifiable risk factors and regular risk assessments.

The Influence of Rheumatoid Arthritis and Osteoarthritis on the Occurrence of Arterial Hypertension: An 8-Year Prospective Clinical Observational Cohort Study

Rheumatoid arthritis (RA) increases the risk of cardiovascular mortality and morbidity, including a 50-60% increased risk of cardiovascular disease (CVD). Arterial hypertension (HT) is considered the major contributing risk factor for CVD development in RA patients. In this investigation, we compared the incidence and prevalence of HT between RA and osteoarthritis (OA) and the influence of HT on CVD development in CVD-naive patients in both groups. This was a prospective clinical cohort investigation with an 8-year follow-up period. A total of 201 participants, 124 with RA (investigation group) and 77 with OA (control group), without diagnosed CVD or symptomatic heart failure were included. After selection according to inclusion and exclusion criteria, both groups underwent initial and final visits, and the investigation group underwent annual visits to assess disease activity. Case report forms were completed for each visit. The obtained data were analyzed by a statistician. No difference in the incidence or prevalence of HT was found between the investigation and control groups. No difference in the prevalence of HT was reported between the study groups and age-standardized data from the general population. The investigation group had a higher incidence of CVD than the control group. RA participants with long-term remission had a marginally lower HT prevalence. Although previous studies reported a higher HT prevalence in RA than in OA and the general population, our findings did not support this. The RA group had a higher incidence of CVD, but it is possible that optimal disease control with long-term remission could reduce HT incidence and prevalence while also having beneficial effects on other cardiovascular risk factors (CV) and, consequently, CVD occurrence.

Acute Outcomes of Cardiac Operations in Patients With Autoimmune Disorders: A National Analysis

BACKGROUND

Accelerated atherosclerosis, inflammation, and valve pathology are known complications of autoimmune connective tissue diseases (AID). However, outcomes of coronary artery bypass graft surgery (CABG) or valve operations among these patients remain underexamined.

METHODS

All adult hospitalizations for elective CABG or valve procedures were identified from the 2010-2019 Nationwide Readmissions Database. Autoimmune connective tissue disease was defined to include systemic lupus erythematosus (SLE), antiphospholipid syndrome (APLS), polymyalgia rheumatica (PMR), and other autoimmune AIDs. Entropy balancing was applied to generate balanced patient cohorts. Multivariable regression models were constructed to assess the independent associations between AID and outcomes of interest.

RESULTS

Of ∼1 652 573 patients, 21 019 (1.3%) had AID (23.7% SLE, 17.2% APLS, 29.5% PMR, and 29.6% other). Autoimmune connective tissue disease patients were more frequently female (60.8 vs 33.1%, P < .001) and insured by Medicare (71.4 vs 62.2%, P < .001) and presented with a higher comorbidity index (5.2 ± 1.8 vs 4.1 ± 1.8, P < .001). Further, AID less frequently underwent isolated CABG (39.0 vs 52.3%) but more commonly isolated valve operations (41.9% vs 31.0%, P < .001), relative to non-AID. Following risk-adjustment, AID was not linked with increased odds of mortality or cardiac complications. However, AID was linked with a greater risk of thrombotic complications, blood transfusion, and non-elective readmission within 30 days, as well as a +$900 decrement in hospitalization costs.

DISCUSSION

Autoimmune connective tissue disease patients demonstrated acceptable outcomes following CABG and valve procedures. However, novel prophylactic care pathways should be developed and instituted to address greater thrombotic and blood transfusion risk. Further investigation is needed to identify factors contributing to greater non-elective readmissions among these patients.

Comparison of Cardiovascular Outcomes in Patients With and Without Rheumatoid Arthritis: A Meta-Analysis of Observational Studies

The aim of this meta-analysis was to determine the risk of incident cardiovascular disease (CVD) in patients with rheumatoid arthritis compared to patients without rheumatoid arthritis. We conducted a thorough search of online databases, including PubMed, EMBASE, and Web of Science, to identify English-language publications examining cardiovascular outcomes in patients with rheumatoid arthritis from January 1, 2005, to May 15, 2023. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was performed using relevant keywords such as "rheumatoid arthritis," "cardiovascular diseases," and "risk," along with their synonyms. Medical subject heading (MeSH) terms and Boolean operators (AND, OR) were employed to optimize the search. Outcomes assessed in this study included composite cardiovascular events (as defined by individual studies), myocardial infarction, and stroke (including ischemic and hemorrhagic stroke). Overall, 14 studies met the inclusion criteria and were included in the present meta-analysis. We found that the risk of composite CVD was higher in patients with rheumatoid arthritis compared to patients without rheumatoid arthritis. We also found a higher risk of myocardial infarction and stroke in rheumatoid arthritis patients compared to their counterparts. This study demonstrates the elevated risk of CVD in patients with rheumatoid arthritis and highlights the importance of incorporating cardiovascular management and assessment into the care of these patients.

Associations between Cardiovascular Outcomes and Rheumatoid Arthritis: A Nationwide Population-Based Cohort Study

Despite a growing burden posed by cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, large-scale studies on the association between the characteristics of RA patients and CVD risks and studies adjusted for various confounding factors are lacking. In this large-scale nationwide cohort study, we aimed to investigate the association between CVD risk and RA and factors that may increase CVD risk using a dataset provided by the Korean National Health Insurance Service (NHIS). We enrolled 136,469 patients with RA who participated in national health examinations within two years of RA diagnosis between 2010 and 2017 and non-RA controls matched by age and sex (n = 682,345). The outcome was the occurrence of myocardial infarction (MI) or stroke. MI was defined as one hospitalization or two outpatient visits with ICD-10-CM codes I21 or I22. Stroke was defined as one hospitalization with ICD-10-CM codes I63 or I64 and a claim for brain imaging (CT or MRI). The Cox proportional hazard model and Kaplan-Meier curve were used for analysis. The mean follow-up duration was 4.7 years, and the incidence rate of CVD was higher in the RA group than the control group (MI: 3.20 vs. 2.08; stroke: 2.84 vs. 2.33 per 1000 person-years). The risk of MI and stroke was about 50% and 20% higher, respectively, in RA patients. The association between RA and CVD was prominent in females after adjusting for confounding variables. The association between RA and risk of MI was significant in individuals without DM. Therefore, appropriate screening for CVD is important in all RA patients including females and younger patients.

Associations Between Sarcopenia, Heart Failure and Myocardial Infarction in Patients With Systemic Lupus Erythematosus and Rheumatoid Arthritis

Objectives

To evaluate associations between sarcopenia, type of autoimmune disease and risk of heart failure (HF) and myocardial infarction (MI) in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).

Methods

In this population-based, cross-sectional study, discharge data from the 2005–2014 US Nationwide Inpatient Sample (NIS) of hospitalized patients with SLE or RA were extracted and analyzed. Univariate and multivariable regression analyses were conducted to determine associations between sarcopenia, type of autoimmune disease and risk of HF/MI.

Results

After exclusions, 781,199 hospitalized patients diagnosed with SLE or RA were included. Among the study cohort, 127,812 (16.4%) were hospitalized with HF, and 12,781 (1.6%) were hospitalized with MI. Sarcopenia was found in only 0.1% of HF/MI patients. Logistic regression analyses revealed that sarcopenia was not significantly associated with presence of either HF or MI. Patients with RA had significantly lower odds of HF than SLE patients (aOR = 0.77, 95%CI: 0.76, 0.79) or MI (aOR = 0.86, 95%CI: 0.82, 0.91).

Conclusion

In the US, among hospitalized adults diagnosed with SLE or RA, patients with RA are significantly less likely to have HF or MI than those with SLE. Whether sarcopenia leads to increased HF or MI remains inconclusive. Further studies are warranted to investigate the pathophysiology underlying discrepancies between RA and SLE regarding risk for MI or HF.

The prevalence of comorbidity in rheumatoid arthritis: a systematic review and meta-analysis

This systematic review and meta-analysis estimates the prevalence of common comorbid health disorders in adults with rheumatoid arthritis (RA). A multi-database search strategy was undertaken. Screening, data extraction and quality assessment were carried out by two independent reviewers. A meta-analysis and meta-regression were used to generate a pooled prevalence estimate and identify relevant moderators. After study selection, 33 studies (74633 participants) were included in the meta-analysis. Some 31 studies were judged to be of low risk of bias, and two studies were judged to be at moderate risk of bias. The three most common comorbidities in RA were anxiety disorders (62.1%, 95% Cl: 43.6%; 80.6%), hypertension (37.7%, 95% Cl: 29.2%; 46.2%) and depression (32.1%, 95% Cl: 21.6%; 42.7%). There was substantial statistically significant heterogeneity for all comorbidities (I2 ≥77%). Meta-regression identified that the covariate of mean age (unit increase) had a statistically significant effect on the prevalence of hypertension (+2.3%, 95% Cl: 0.4%; 4.2%), depression (-0.5%, 95% Cl: -0.6%; -0.4%) and cancer (0.5%, 95% Cl: 0.2%; 0.8%) in adults with RA. A country's income was identified to have a statistically significant effect on the prevalence of depression, with low-to moderate-income countries having 40% (95% Cl: 14.0%; 66.6%) higher prevalence than high-income countries. No studies consider health inequalities. It is concluded that comorbidities are prevalent among people with RA, particularly those associated with mental health and circulatory conditions. Provision of health services should reflect the importance of such multimorbidity and the consequences for quality and length of life.

TNFα induces endothelial dysfunction in rheumatoid arthritis via LOX-1 and arginase 2: reversal by monoclonal TNFα antibodies

AIMS

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting joints and blood vessels. Despite low levels of low-density lipoprotein cholesterol (LDL-C), RA patients exhibit endothelial dysfunction and are at increased risk of death from cardiovascular complications, but the molecular mechanism of action is unknown. We aimed in the present study to identify the molecular mechanism of endothelial dysfunction in a mouse model of RA and in patients with RA.

METHODS AND RESULTS

Endothelium-dependent relaxations to acetylcholine were reduced in aortae of two tumour necrosis factor alpha (TNFα) transgenic mouse lines with either mild (Tg3647) or severe (Tg197) forms of RA in a time- and severity-dependent fashion as assessed by organ chamber myograph. In Tg197, TNFα plasma levels were associated with severe endothelial dysfunction. LOX-1 receptor was markedly up-regulated leading to increased vascular oxLDL uptake and NFκB-mediated enhanced Arg2 expression via direct binding to its promoter resulting in reduced NO bioavailability and vascular cGMP levels as shown by ELISA and chromatin immunoprecipitation. Anti-TNFα treatment with infliximab normalized endothelial function together with LOX-1 and Arg2 serum levels in mice. In RA patients, soluble LOX-1 serum levels were also markedly increased and closely related to serum levels of C-reactive protein. Similarly, ARG2 serum levels were increased. Similarly, anti-TNFα treatment restored LOX-1 and ARG2 serum levels in RA patients.

CONCLUSIONS

Increased TNFα levels not only contribute to RA, but also to endothelial dysfunction by increasing vascular oxLDL content and activation of the LOX-1/NFκB/Arg2 pathway leading to reduced NO bioavailability and decreased cGMP levels. Anti-TNFα treatment improved both articular symptoms and endothelial function by reducing LOX-1, vascular oxLDL, and Arg2 levels.

Prognostic factors and population-based analysis of melanoma with sentinel lymph node biopsy

Cutaneous malignant melanoma is a rare but fatal disease in East Asia. Despite its increasing incidence, a general lack of awareness about the disease was noted. This study aims to provide population-based prognostic analysis of melanoma with sentinel lymph node biopsy (SLNB) in Taiwan. We conducted this retrospective cohort study using the data from Taiwan National Health Insurance Research Database during 1997–2013. The study cohort contains 3284 patients. The 5-year survival rates of patients undergoing SLNB and not undergoing SLNB were 45.5% and 33.6%. In multivariate analysis, age ≥ 80 years [adjusted hazard ratio (aHR) = 2.15] and male (aHR = 1.19) were associated with a poorer prognosis, while high social economic status (SES) (aHR = 0.69) and undergoing SLNB (aHR = 0.84) were good prognostic factors. Old age and low SES were associated with lower percentages of patients undergoing SLNB (P < 0.001). E-value analysis suggested robustness to unmeasured confounding. In conclusion, undergoing SLNB was associated with a better prognosis. The poor prognosis of old age and low SES may be due to decreased percentages of patients undergoing SLNB. Therefore, we recommend that SLNB should be performed on patients, especially in old age or low SES, who are candidates for SLNB according to current guidelines to achieve maximal survival.

Patients With Rheumatoid Arthritis With an Inadequate Response to Disease-Modifying Antirheumatic Drugs at a Higher Risk of Acute Coronary Syndrome

Background

Cardiovascular disease is the most common cause of death in patients with rheumatoid arthritis. It is believed that using disease‐modifying antirheumatic drugs (DMARDs) to control inflammation can reduce the risk of cardiovascular disease. In this study, we investigated whether patients who responded differently to DMARDs might sustain different cardiovascular events.

Methods and Results

We designed a cohort study using the Chang Gung Research Database. We identified 7114 patients diagnosed with rheumatoid arthritis. After strict exclusion criteria, we collected 663 individuals as an inadequate response to DMARDs group. Then, 2034 individuals were included as the control group. The end point was composite vascular outcomes, including acute coronary syndrome or ischemic stroke. We used the inverse probability of treatment weighting to keep the covariates between these 2 groups well balanced. We compared the risk of these outcomes using the Cox proportional hazards model. The mean follow‐up time was 4.7 years. During follow‐up, there were 7.5% and 6.4% of patients with composite vascular outcomes in the DMARD‐inadequate response and control groups, respectively. There was no significant difference in the risk of composite vascular outcomes (95% CI, 0.94–1.41) and ischemic stroke (95% CI, 0.84–1.36). The risk of acute coronary syndrome was significantly higher in the DMARD‐inadequate response group (hazard ratio, 1.45; 95% CI, 1.02–2.05).

Conclusions

Patients with DMARD‐inadequate response rheumatoid arthritis have a higher risk of developing acute coronary syndrome than those whose disease can be controlled by DMARDs.

Deep Neck Infection Risk in Patients with Sleep Apnea: Real-World Evidence

(1) Background: Sleep apnea may be a risk factor for deep neck infection (DNI). The objective of this study was to investigate the effects of sleep apnea on DNI. (2) Methods: In this first nationwide retrospective cohort study on the sleep apnea–DNI correlation, we obtained data from the Longitudinal Health Insurance Database 2005, a subset of the Taiwan National Health Insurance Research Database. Patients who were newly diagnosed with sleep apnea between 1997 and 2012 were identified, and patients without sleep apnea were matched at a 1:4 ratio in age, sex, socioeconomic status, and urbanization level. The primary outcome of this study was DNI occurrence. The treatment modalities for sleep apnea and the comorbidities that occurred during the study period were also analyzed. (3) Results: Our sleep apnea and comparison (non-sleep apnea) cohorts comprised 6114 and 24,456 patients, respectively. We compared the cumulative incidence of DNI between these cohorts and found a greater incidence of DNI in the sleep apnea cohort (p < 0.001). A strong sleep apnea–DNI association was found following analysis via the adjusted Cox proportional-hazards model (full model hazard ratio, 1.71; 95% confidence interval, 1.28–2.28; p < 0.001). In the subgroup analysis, sleep apnea increased DNI risk in men, in those aged < 50 years, and in those without diabetes mellitus, end-stage renal disease, liver cirrhosis, autoimmune disease, obesity, tonsillectomy, or adenotonsillectomy. (4) Conclusions: Our results confirmed sleep apnea to be an independent risk factor for DNI. Physicians should be aware of the potential occurrence of DNI in patients with sleep apnea.

Impact of Interferon-Based Therapy on Hepatitis C-Associated Rheumatic Diseases: A Nationwide Population-Based Cohort Study

Whether hepatitis C virus (HCV) infection-associated risk of rheumatic diseases is reversed by anti-HCV therapy remain elusive. A nationwide population-based cohort study of the Taiwan National Health Insurance Research Database was conducted. Of 19,298,735 subjects, 3 cohorts (1:4:4, propensity score-matched), including HCV-treated (6919 HCV-infected subjects with interferon and ribavirin therapy ≥ 6 months), HCV-untreated (n = 27,676) and HCV-uninfected (n = 27,676) cohorts, were enrolled and followed (2003–2015). The HCV-uninfected cohort had the lowest cumulative incidence of rheumatic diseases (95% confidence interval (CI): 8.416–10.734%), while HCV-treated (12.417–17.704%) and HCV-untreated (13.585–16.479%) cohorts showed no difference in the cumulative incidences. Multivariate analyses showed that HCV infection (95% CI hazard ratio (HR): 1.54–1.765), female sex (1.57–1.789), age ≥ 49 years (1.091–1.257), Charlson comorbidity index ≥ 1 (1.075–1.245), liver cirrhosis (0.655–0.916), chronic obstruction pulmonary disease (1.130–1.360), end-stage renal disease (0.553–0.98), diabetes mellitus (0.834–0.991) and dyslipidemia (1.102–1.304) were associated with incident rheumatic diseases. Among the 3 cohorts, the untreated cohort had the highest cumulative incidence of overall mortality, while the treated and un-infected cohorts had indifferent mortalities. Conclusions: HCV infection, baseline demographics and comorbidities were associated with rheumatic diseases. Although HCV-associated risk of rheumatic diseases might not be reversed by interferon-based therapy, which reduced the overall mortality in HCV-infected patients.

Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (P_{for interaction} < 0.001) and/or acute coronary syndromes (P_{for interaction} = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.

Acute Myocardial Infarction in Autoimmune Rheumatologic Disease: A Nationwide Analysis of Clinical Outcomes and Predictors of Management Strategy

OBJECTIVES

To examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014.

METHODS

All AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD.

RESULTS

Of 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography-0.87; 0.84 to 0.91; PCI-0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication.

CONCLUSION

In a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.

Risk of New-Onset Acute Coronary Syndrome and Atrial Fibrillation in Patients With Rheumatoid Arthritis Compared With a Risk-Set and Propensity Score-Matched Cohort - A Nationwide Cohort Study

BACKGROUND

Rheumatoid arthritis (RA) has extra-articular manifestations of cardiovascular diseases and is associated with a high mortality rate in Western populations. This study aimed to investigate the risk of acute coronary syndrome (ACS) and atrial fibrillation (AF) associated with RA in a Korean population.

METHODS AND RESULTS

Patients were selected from a senior cohort from the Korean National Health Insurance Service in 2002, and followed until 31 December 2015. Patients with newly developed ACS and AF were identified and compared with controls for a 10-year period using time-dependent propensity and risk-set matching. A total of 4,217 incident RA patients and their 8,432 controls comprised the incident RA and matched cohorts, respectively. ACS was identified during 24,642 person-years [incidence rate (IR) 402 per 10,000 person-years, 95% confidence interval (CI) 330-489] among the RA cohort. In the matched cohort, 141 ACS patients were identified during 50,011 person-years (IR 282 per 100,000 person-years, 95% CI 239-333). RA patients were 1.43-fold more likely to develop ACS than the matched controls [hazard ratio (HR) 1.43, 95% CI 1.10-1.84], but showed similar occurrence risk of AF (HR 1.06, 95% CI 0.83-1.35).

CONCLUSIONS

A higher risk for ACS and a similar risk for AF were found by risk-set matched analysis in a senior RA cohort compared with the control, using Korean nationwide long-term data.

The global prevalence of rheumatoid arthritis: a meta-analysis based on a systematic review

The objective is to determine the global population prevalence of rheumatoid arthritis (RA) based on population-based studies and assess factors that influence RA prevalence estimates. Four electronic databases were searched (ProQuest Central, MEDLINE, Web of Science, and EMBASE) for peer-reviewed English publications that report prevalence estimates of RA from 1980 and 2019. We included case-control studies, cross-sectional studies, and prospective or retrospective cohort studies in our search strategy. A random-effect meta-analysis model was used to produce the pooled prevalence estimates. The potential between-study heterogeneity was identified using sensitivity analysis, sub-group and meta-regression analyses. A total of 67 studies were included in the meta-analysis, containing 742,246 RA patients and 211,592,925 healthy controls in the study period. The global RA prevalence estimate was 0.46% (95% confidence interval [CI] 0.39-0.54; I² = 99.9%) with a 95% prediction interval (0.06-1.27). The RA point-prevalence was 0.45% (95% CI 0.38-0.53%) between 1986 and 2014, while the pooled period-prevalence was 0.46% (95% CI 0.36% and 0.57%) from 1955 to 2015. The highest RA pooled prevalence (0.69%; 95% CI 0.47-0.95) was derived from linked data source studies. Based on meta-regression, the factors that explain the studies' heterogeneity of RA prevalence, including geographical location, the risk bias assessment of studies and sample size. The global prevalence of RA between 1980 and 2019 was 460 per 100,000 population, with variations due to geographical location and study methodology. Linked data are the preferred method to estimate RA population prevalence as they provide the best case ascertainment.

Postimplantation Syndrome Is Not Associated with Myocardial Injury after Noncardiac Surgery after Endovascular Aneurysm Repair

BACKGROUND

Postimplantation syndrome (PIS) is the clinical and biochemical expression of an inflammatory response following endovascular aneurysm repair (EVAR), with a reported incidence ranging from 2% to 100%. Although generally benign, some studies report an association between PIS and postoperative major adverse cardiovascular events (MACEs). Nonetheless, the role of PIS in postoperative myocardial injury after noncardiac surgery (MINS) is unknown. This work aims to evaluate the relationship between PIS and MINS in a subset of EVAR patients, as well as assess the impact of PIS in all-cause mortality.

METHODS

All patients undergoing elective standard EVAR between January 2008 and June 2017, and with at least one measurement of contemporary (cTnI) or high sensitivity troponin I (hSTnI) in the first 48h after surgery, were retrospectively analyzed. PIS was defined as the presence of fever and leukocytosis in the postoperative period in the absence of infectious complications. MINS was defined as the value exceeding the 99th percentile of a normal reference population with a coefficient of variation <10%, which was >0.032 ng/mL for cTnI and 0.0114 (female) and 0.027 ng/mL (male) for hSTnI. Patients' demographics, comorbidities, medication, access, and anesthesia were also evaluated.

RESULTS

One hundred thirty-three consecutive patients were included (95.5% male; mean age 75.66 ± 7.13 years). Mean follow-up was 46.35 months. Survival rate was 86.5%, 80.5%, and 57.6% at 1, 3, and 5 years of follow-up, with 2 fatalities at 30 days of follow-up. The prevalence of PIS was 11.4%. MACE occurred in 2.3% of the patients, while MINS was reported in 16.5% of the patients. No association was found between PIS and patients' gender, comorbidities, type of anesthesia, or transfusional support. The type of graft used significantly affected the prevalence of PIS, with all cases reported when polyester grafts were used (P = 0.031). MACE occurred in 2.3% of the patients, while MINS was reported in 16.5% of the patients. PIS was found to be significantly associated with postoperative MACE (P = 0.001), but not MINS. Survival analysis revealed no differences between patients with or without PIS regarding 30-day mortality as well as long-term all-cause mortality. American Society of Anesthesiologists score (hazard ratio [HR] 2.157, 95% confidence interval [CI] 1.07-4.33, P = 0.031) and heart failure (HR 2.284, 95% CI 1.25-4.18, P = 0.008) were found to be independently associated with increased long-term all-cause mortality in this cohort of patients.

CONCLUSIONS

PIS is a common complication after EVAR, occurring in 11.4% of the patients from this cohort. Graft type seems to significantly affect the risk of PIS, since all reported cases occurred when polyester grafts were used. PIS did not influence 30-day or long-term survival and was found to be significantly associated with postoperative MACE but not MINS, suggesting the involvement of different pathophysiological mechanisms.

Deep Neck Infection in Systemic Lupus Erythematosus Patients: Real-World Evidence

Systemic lupus erythematosus (SLE) might increase deep neck infection (DNI) risk, but evidence supporting this hypothesis is limited. In this retrospective follow-up study, the SLE-DNI association was investigated using data from the Registry for Catastrophic Illness Patients, which is a subset of the Taiwan National Health Insurance Research Database. All patients newly diagnosed as having SLE in 1997-2011 were identified, and every SLE patient was individually matched to four patients without SLE according to sex, age, and socioeconomic status. The study outcome was DNI occurrence. DNI treatment modalities and prognoses in SLE and non-SLE patients, along with the association of steroid dose with DNI risk, were also studied. In total, 17,426 SLE and 69,704 non-SLE patients were enrolled. Cumulative DNI incidence was significantly higher in the SLE cohort than in the non-SLE cohort (p < 0.001). The Cox regression model demonstrated that SLE significantly increased DNI risk (hazard ratio: 4.70; 95% confidence interval: 3.50-6.32, p < 0.001). Moreover, in the sensitivity and subgroup analyses, the effect of SLE on DNI was stable. Relatively few SLE-DNI patients received surgical interventions (15.6% vs. 28.6%, p = 0.033). The between-group differences in tracheostomy use and hospitalisation duration were nonsignificant. In SLE patients, high steroid doses significantly increased DNI incidence (≥3 vs. <3 mg/day = 2.21% vs. 0.52%, p < 0.001). This is the first study demonstrating that SLE increases DNI risk by approximately five times and that high steroid dose increases DNI incidence in SLE patients.

Real-world evidence for increased deep neck infection risk in patients with rheumatoid arthritis

OBJECTIVE

To investigate the association between rheumatoid arthritis (RA) and deep neck infection (DNI).

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients newly diagnosed with RA between 2000 and 2011 were identified from the National Health Insurance Research Database in Taiwan. Moreover, patients without RA were randomly selected and matched at a 1:4 ratio by age, sex, urbanization level, income, and diabetes mellitus. The patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of DNI.

RESULTS

In total, 30,207 patients with RA and 120,828 matched patients without RA were enrolled. Patients with RA had a significantly higher cumulative incidence of DNI than those without RA (P < 0.001). The adjusted Cox proportional hazard model demonstrated that RA was significantly associated with a higher incidence of DNI (hazard ratio: 2.80, 95% confidence interval: 2.26-3.46, P < 0.001). Therapeutic methods (surgical or nonsurgical) did not differ significantly between the patients with RA-DNI and with non-RA-DNI. Patients with RA-DNI had higher rates of tracheostomy, mediastinitis, mediastinitis-related mortality, and mortality than patients with non-RA-DNI, although these differences were without statistical significance. RA patients receiving no therapy experienced higher rates of DNI compared with those receiving methotrexate alone, disease-modifying antirheumatic drugs, or biologic therapies.

CONCLUSION

This study is the first to investigate the association between RA and DNI. We conclude RA is an independent predisposing factor for DNI.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1402-1407, 2020.

Spark That Lights the Fire: Infection Triggers Cardiovascular Events

See Article by https://doi.org/10.1161/JAHA.118.009683

The Microbial Metabolite Trimethylamine N-Oxide Links Vascular Dysfunctions and the Autoimmune Disease Rheumatoid Arthritis

Diet and microbiota each have a direct impact on many chronic, inflammatory, and metabolic diseases. As the field develops, a new perspective is emerging. The effects of diet may depend on the microbiota composition of the intestine. A diet that is rich in choline, red meat, dairy, or egg may promote the growth, or change the composition, of microbial species. The microbiota, in turn, may produce metabolites that increase the risk of cardiovascular disease. This article reviews our current understanding of the effects of the molecule trimethylamine-N-oxide (TMAO) obtained from food or produced by the microbiota. We review the mechanisms of actions of TMAO, and studies that associate it with cardiovascular and chronic kidney diseases. We introduce a novel concept: TMAO is one among a group of selective uremic toxins that may rise to high levels in the circulation or accumulate in various organs. Based on this information, we evaluate how TMAO may harm, by exacerbating inflammation, or may protect, by attenuating amyloid formation, in autoimmune diseases such as rheumatoid arthritis.

Association of Autoimmune Connective Tissue Disease and Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation

Patients with autoimmune connective tissue disease (CTD) are at higher risk for developing aortic valve pathology, but the safety and value of transcatheter aortic valve implantation (TAVI) in this population has not been investigated. This study evaluated mortality, complication, and readmission rates along with length of stay and total costs after TAVI in patients with CTD. We retrospectively reviewed 47,216 patients who underwent TAVI from the National Readmissions Database between January 2011 and September 2015. Patients with systemic lupus erythematosus, scleroderma, rheumatoid arthritis, and other autoimmune CTD comprised the cohort. The primary outcome was mortality at index hospitalization. The 2,557 CTD patients (5.4%) had a higher Elixhauser co-morbidity index (7.1 vs 6.1, p <0.001) than non-CTD patients. CTD and non-CTD patients had similar mortality (2.8 vs 4.1%, p = 0.052), 30-day readmission (19.3 vs 17.0%, p = 0.077), length of stay (8.2 vs 8.3 days, p = 0.615), and total adjusted costs ($57,202 vs $58,309, p = 0.196), respectively. However, CTD patients were more frequently readmitted for postoperative infection (9.4 vs 5.6%, p = 0.042) and septicemia (8.2 vs 4.5%, p = 0.019). After multivariable adjustment, CTD patients faced lower mortality at index hospitalization (odds ratio [OR] 0.56 [0.38 to 0.82], p = 0.003) but were more frequently readmitted for septicemia (OR = 1.95 [1.10 to 3.45], p = 0.023) and postoperative infection (OR = 3.10 [1.01 to 9.52], p = 0.048) relative to non-CTD patients. In conclusion, CTD is not a risk factor for in-hospital mortality but is an independent risk factor for infectious complications post-TAVI.

Increased risk of asthma in patients with rheumatoid arthritis: A longitudinal follow-up study using a national sample cohort

The aim of this study was to evaluate the risk of asthma in rheumatoid arthritis patients using matched control group for socioeconomic factors and past medical history. Adults >20 years old were collected from the Korean Health Insurance Review and Assessment Service - National Sample Cohort (HIRA-NSC) from 2002 through 2013. A total of 6,695 individuals with rheumatoid arthritis were matched for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia with 26,780 individuals included in a control group. In both the rheumatoid arthritis and control groups, subjects' history of asthma was evaluated. Asthma (J45 and J46) and rheumatoid arthritis (M05 and M06) were included based on the International Classification of Disease-10 (ICD-10) codes and medication history. The crude and adjusted (depression and Charlson Comorbidity Index) hazard ratios (HRs) and 95% confidence intervals (CI) of asthma for rheumatoid arthritis patients were analyzed using a stratified Cox proportional hazard model. Subgroup analyses were conducted according to age and sex, number of treatment histories, and medication histories. Approximately 16.4% (1,095/6,695) of rheumatoid arthritis group and 13.0% (3,469/26,780) of the control group had asthma (P < 0.001). The rheumatoid arthritis group demonstrated a higher adjusted HR for asthma than the control group (adjusted HR = 1.23, 95% CI = 1.15-1.32, P < 0.001). This result was consistent in all subgroups. Rheumatoid arthritis was related to an increase risk of asthma.

Soluble CD83 Triggers Resolution of Arthritis and Sustained Inflammation Control in IDO Dependent Manner

Interference with autoimmune-mediated cytokine production is a key yet poorly developed approach to treat autoimmune and inflammatory diseases such as rheumatoid arthritis. Herein, we show that soluble CD83 (sCD83) enhances the resolution of autoimmune antigen-induced arthritis (AIA) by strongly reducing the expression levels of cytokines such as IL-17A, IFNγ, IL-6, and TNFα within the joints. Noteworthy, also the expression of RANKL, osteoclast differentiation, and joint destruction was significantly inhibited by sCD83. In addition, osteoclasts which were cultured in the presence of synovial T cells, derived from sCD83 treated AIA mice, showed a strongly reduced number of multinuclear large osteoclasts compared to mock controls. Enhanced resolution of arthritis by sCD83 was mechanistically based on IDO, since inhibition of IDO by 1-methyltryptophan completely abrogated sCD83 effects on AIA. Blocking experiments, using anti-TGF-β antibodies further revealed that also TGF-β is mechanistically involved in the sCD83 induced reduction of bone destruction and cartilage damage as well as enhanced resolution of inflammation. Resolution of arthritis was associated with increased numbers of regulatory T cells, which are induced in a sCD83-IDO-TGF-β dependent manner. Taken together, sCD83 represents an interesting approach for downregulating cytokine production, inducing regulatory T cells and inducing resolution of autoimmune arthritis.

Cardiovascular outcomes of patients with rheumatoid arthritis prescribed disease modifying anti-rheumatic drugs: a review

INTRODUCTION

Rheumatoid arthritis (RA) is associated with a heightened risk of cardiovascular disease (CVD), with both traditional CV risk factors and inflammation contributing to this risk.

AREAS COVERED

This review highlights the burden of CVD in RA and associated traditional CV risk factors, including the complexity of dyslipidemia in RA and the so-called 'lipid paradox.' Furthermore, the recognized RA-disease-specific factors associated with higher risk of CVD and the role of systemic inflammation in the pathogenesis of CVD in RA will be addressed. With the advent of biologic and targeted synthetic therapies in the treatment of RA, the effect of conventional and newer generation disease modifying anti-rheumatic therapies (DMARDs) on CV risk and associated risk factors will also be discussed.

EXPERT OPINION

Identifying the RA phenotype at greatest risk of CVD, understanding the interplay of increased traditional risk factors, common inflammatory processes and RA-specific factors, and personalized use of DMARDs according to disease phenotype and comorbidity to reduce this risk are key areas for future research.

Increased risk of acute coronary syndrome in patients with bronchiectasis: A population-based cohort study

BACKGROUND AND OBJECTIVE

There are few studies on the relationship between bronchiectasis and acute coronary syndrome (ACS). We conducted a population-based cohort study to assess whether bronchiectasis was associated with an increased risk of ACS.

METHODS

We identified 3521 patients diagnosed with bronchiectasis between 2000 and 2010 (bronchiectasis cohort) and frequency matched them with 14 084 randomly selected people without bronchiectasis from the general population (comparison cohort) according to sex, age and index year using the Longitudinal Health Insurance Database. Both cohorts were followed until the end of 2010 to determine the ACS incidence. Hazard ratios of ACS were measured.

RESULTS

Based on 17 340 person-years for bronchiectasis patients and 73 639 person-years for individuals without bronchiectasis, the overall ACS risk was 40% higher in the bronchiectasis cohort (adjusted hazard ratio (HR) = 1.40; 95% CI: 1.20-1.62). Compared with those in the comparison cohort with one respiratory infection-related emergency room (ER) visit per year, the ACS risk was 5.46-fold greater in bronchiectasis patients with three or more ER visits per year (adjusted HR = 5.46, 95% CI: 4.29-6.96). Patients with bronchiectasis and three or more respiratory infection-related hospitalizations per year had an 8.15-fold higher ACS risk (adjusted HR = 8.15, 95% CI: 6.27-10.61).

CONCLUSION

Bronchiectasis patients, particularly those experiencing frequent exacerbations with three or more ER visits and consequent hospitalization per year, are at an increased ACS risk.

Sleep disorders associated with risk of rheumatoid arthritis

BACKGROUND

Immune disorders impair sleep quality and sleep disorders (SDs) may derange immune function.

PURPOSE

The study evaluated the incidence and risk of rheumatoid arthritis (RA) in patients with SDs using a nationwide cohort.

METHODS

We recognized the patients with SDs from 1998 to 2002 by using the Taiwan National Health Insurance Research Database. One control patient for each SD patient was randomly selected and matched based on the proportion of age, sex, and index year. We calculated the person years of follow-up for each participant from the index date to RA diagnosis, censoring, or until December 31, 2011. The risk of RA was estimated by using Cox models incorporating demographics and comorbidities.

RESULTS

We enrolled 65,754 patients with SDs and 65,753 controls and followed for 637,906 and 662,514 person-years, respectively. The patients with SDs exhibited a 1.49-fold greater risk of RA development compared with the comparison cohort when we adjusted for covariates. The patients with sleep apnea (SA) showed the greatest incidence density rate of RA, followed by those with non-apnea SDs and the non-SD cohort (4.11, 3.29, and 2.15 per 10,000 person-years, respectively). The SA cohort had a 2.56-fold adjusted hazard ratio (aHR) of RA (95% confidence interval [CI] = 1.11-5.91) and the non-apnea SD cohort had a 1.47-fold aHR of RA (95% CI = 1.18-1.84) compared with the non-SD cohort. Women with SDs presented a considerable risk of developing RA.

CONCLUSIONS

This nationwide cohort study indicates that SDs are associated with the risk of RA development.

Acetaminophen Poisoning May Increase Coronary Artery Disease Risk: A Nationwide Cohort Study

The purpose of this nationwide cohort study was to investigate the incidence and risk of coronary artery disease (CAD) in patients with acetaminophen (APAP) poisoning. We identified the patients with APAP poisoning and randomly selected comparison patients according to a 1:4 ratio, matching them by age, sex, and the index year using data from the National Health Insurance Research Database from 2000 to 2010. We traced both cohorts until a diagnosis of CAD, loss to follow-up, or the end of 2011. In total, 2723 patients with APAP poisoning and 10,892 comparison patients have followed. The incidence rate of CAD was higher in the APAP poisoning cohort than in the non-APAP poisoning cohort (1.53 vs 0.87 per 1000 patient-years). The APAP poisoning cohort exhibited a 1.85-fold higher risk of CAD than did the non-APAP poisoning cohort (adjusted hazard ratio [aHR] 1.85; 95% confidence interval [CI] 1.16-2.94). Male sex, advanced age, and hypertension were independently associated with CAD risk. The risk of CAD was considerably higher within 3 years following APAP poisoning (aHR 2.73; 95% CI 1.31-5.69). This study indicated that APAP poisoning may increase risk of CAD development.

Protective Effects of Methotrexate against Proatherosclerotic Cytokines: A Review of the Evidence

There is good epidemiological evidence that patients with autoimmune rheumatic disease states, particularly rheumatoid arthritis, have an increased risk of cardiovascular morbidity and mortality when compared to the general population. The presence of a chronic systemic proinflammatory state in this patient group disrupts the structural and functional integrity of the endothelium and the arterial wall, favouring the onset and progression of atherosclerosis. A significant role in the detrimental effects of inflammation on endothelial function and vascular homeostasis is played by specific proatherosclerotic cytokines such as tumour necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6). Recent systematic reviews and meta-analyses have shown that treatment with methotrexate, a first-line disease-modifying antirheumatic drug (DMARD), is associated with a significant reduction in atherosclerosis-mediated cardiovascular events, such as myocardial infarction and stroke, and mortality, when compared to other DMARDs. This suggests that methotrexate might exert specific protective effects against vascular inflammation and atherosclerosis in the context of autoimmune rheumatic disease. This review discusses the available evidence regarding the potential antiatherosclerotic effects of methotrexate through the inhibition of TNF-α, IL-1, and IL-6 and provides suggestions for future experimental and human studies addressing this issue.

Comparative Risk of Cardiovascular Outcomes Between Topical and Oral Nonselective NSAIDs in Taiwanese Patients With Rheumatoid Arthritis

BACKGROUND

Topical NSAIDs have less systemic absorption than oral NSAIDs. We examined the risk of cardiovascular events associated with nonselective topical NSAIDs versus oral NSAIDs among patients with rheumatoid arthritis in Taiwan.

METHODS AND RESULTS

We conducted a retrospective cohort study that included patients with incident rheumatoid arthritis who were newly starting therapy with nonselective topical NSAIDs or oral NSAIDs. We used the Taiwan National Health Insurance Research Database (NHIRD). The first date patients received either type of NSAID was defined as the index date. NSAID exposures continued until there was a treatment gap of >30 days. The main outcome was composite cardiovascular events, including myocardial infarction, unstable angina, heart failure, stroke, or revascularization. Follow-up was censored at treatment discontinuation, switch or addition of other NSAID category, cardiovascular outcome, death, or the end of the study. Propensity score weighted Cox regression models were used to compare the risk of cardiovascular events between topical NSAIDs and oral NSAIDs. There were 10 758 and 78 056 treatment episodes for topical and oral NSAIDs identified. After weighting by propensity score, the cohorts were well balanced over all covariates. The crude cardiovascular event rate was 1.87 per 100 person-years for topical NSAIDs and 2.14 per 100 person-years for oral NSAIDs. Results of propensity score weighted Cox regression found the topical NSAID group had 36% lower risk for cardiovascular events compared with the oral NSAID group (hazard ratio, 0.64; 95% confidence interval, 0.43-0.95).

CONCLUSIONS

We found topical NSAID users experienced a reduced risk of cardiovascular events compared with oral NSAID users. If future studies with a larger sample size and longer follow-up confirm these results, NSAID prescribing might change accordingly.

Impact of anti-rheumatic treatment on cardiovascular risk in Asian patients with rheumatoid arthritis

OBJECTIVES

To estimate the incidence of cardiovascular disease (CVD) in Asian patients with rheumatoid arthritis (RA) and to evaluate the impact of anti-rheumatic treatment on the development of CVD.

METHODS

A retrospective cohort of Asian patients with RA was established to identify the incidence rate (IR) of CVD in RA patients. The cohort was generated using the Korean National Healthcare claims database, which contained claims from Jan 2009 to Dec 2013. A total of 137,512 RA patients were identified; individuals with a history of CVD for 6 months or more before the index date were excluded. Nested case-control samples were drawn from the full study population with a case:control ratio of 1:4 (n = 7102 cases; n = 27,018 controls without CVD). A conditional multivariate regression model was used to evaluate the impact of anti-rheumatic treatment on the development of CVD in RA patients after matching for age, sex, RA index date, comorbidities, and drug use (e.g., antiplatelet agents and cholesterol-lowering agents).

RESULTS

The IR for development of overall CVD in RA patients was 182.1 (95% CI: 178.4-185.9) per 10,000 person-years. In models adjusted for other CVD risk factors, disease-modifying anti-rheumatic drugs (DMARDs) (OR = 0.79) were protective against CVD, and biologic DMARDs were not significantly associated with CVD risk (OR = 0.85). Corticosteroids (OR = 1.26) and NSAIDs (nonselective NSAIDs: OR = 1.32, Cox-2 inhibitors: OR = 1.31) were risk factors for CVD in RA patients.

CONCLUSIONS

The use of DMARDs is protective against CVD, while corticosteroids and NSAIDs increased the risk of CVD in RA patients.

Incident myocardial infarction associated with major types of arthritis in the general population: a systematic review and meta-analysis

OBJECTIVE

To synthesise, quantify and compare risks for incident myocardial infarction (MI) across five major types of arthritis in population-based studies.

METHODS

A systematic search was performed in MEDLINE, EMBASE and CINAHL databases with additional manual/hand searches for population-based cohort or case-control studies published in English of French between January 1980 and January 2015 with a measure of effect and variance for associations between incident MI and five major types of arthritis: rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), gout or osteoarthritis (OA), adjusted for at least age and sex. All search screening, data abstraction quality appraisals were performed independently by two reviewers. Where appropriate, random-effects meta-analysis was used to pool results from studies with a minimum of 10 events.

RESULTS

We identified a total of 4, 285 articles; 27 met review criteria and 25 criteria for meta-analyses. In studies adjusting for age and sex, MI risk was significantly increased in RA (pooled relative risk (RR): 1.69, 95% CI 1.50 to 1.90), gout (pooled RR: 1.47, 95% CI 1.24 to 1.73), PsA (pooled RR: 1.41, 95% CI 1.17 to 1.69), OA (pooled RR: 1.31, 95% CI 1.01 to 1.71) and tended towards increased risk in AS (pooled RR: 1.24, 95% CI 0.93 to 1.65). Traditional risk factors were more prevalent in all types of arthritis. MI risk was attenuated for each type of arthritis in studies adjusting for traditional risk factors and remained significantly increased in RA, PsA and gout.

CONCLUSIONS

MI risk was consistently increased in multiple types of arthritis in population-based studies, and was partially explained by a higher prevalence of traditional risk factors in all types of arthritis. Findings support more integrated cardiovascular (CV) prevention strategies for arthritis populations that target both reducing inflammation and enhancing management of traditional CV risk factors.

Incidence and risk of acute coronary syndrome in patients with acute pancreatitis: A nationwide cohort study

BACKGROUND

Studies on the relationship between acute pancreatitis (AP) and acute coronary syndrome (ACS) are scant. We conducted a nationwide cohort study to investigate the incidence and risk of ACS in patients with AP.

METHODS

We enrolled patients newly diagnosed with AP between 2000 and 2010 from the Taiwan National Health Insurance Research Database and randomly selected a control cohort without a history of AP after frequency-matching for age, sex, and index year at a ratio of 4:1 for each patient with AP. The follow-up period was from the index date of new AP diagnosis to the diagnosis of ACS, censoring, or the end of 2011.

RESULTS

We assessed 87 068 patients in the AP cohort and 348 272 participants in the control cohort for 508 991 and 2 301 317 person-years, respectively. The AP cohort exhibited a higher overall incidence of ACS than the control cohort (5.44 vs 3.03 per 1000 person-y). After adjustment for sex, age, and comorbidities, the AP cohort exhibited a 1.24-fold higher adjusted hazard ratio (aHR) of ACS (95% confidence interval = 1.19-1.30) than did the control cohort. When stratified by age, the patients with AP aged ≤39 years presented a 2.37-fold higher aHR of ACS than did their corresponding controls (95% CI = 1.88-2.99). Approximate one third of ACS developed within 1 month of AP occurrence.

CONCLUSIONS

This nationwide cohort study indicated that patients with AP are at an increased risk of ACS compared with those without AP.

Risk of cardiovascular disease in Chinese patients with rheumatoid arthritis: A cross-sectional study based on hospital medical records in 10 years

OBJECTIVE

Though the risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) has been established in Western population, little is known about the risk in Chinese people with RA. Our objective was to estimate the risk of CVD in Chinese people with RA using hospital medical records data.

METHODS

The inpatients medical record database 2005-2015 of Sichuan provincial people's hospital was examined. All individuals with a primary diagnosis of RA were included as cases, and those of osteoarthritis (OA) were included as controls, which consisted of the unmatched dataset. Then, RA cases and OA controls were matched by sex and age at 1:1 ratio, forming the matched dataset. The morbidity of CVD (including ischemia heart disease (IHD), congestive heart failure (CHF), et al), stroke and arthrosclerosis were extracted from the database, so as the demographic data and comorbidities related to CVD. Multiple logistic regression analysis was used to estimate the risk of CVD in RA adjusted for demographics and comorbidities using the unmatched dataset. Sensitivity analysis was conducted 1) considering interaction terms between RA and comorbidities, and 2) using multivariable conditional logistic regression for the matched dataset.

RESULTS

The unmatched dataset comprised of 1824RA cases and 1995 OA controls and the matched dataset comprised of 1022 pairs of sex and age matched RA and OA patients. RA exhibited increased odds of prevalent CVD compared with OA, and the adjusted ORs (95%CIs) for CVD, stroke, IHD, CHF, and atherosclerosis were1.86(1.42-2.43), 1.11(0.71-1.74), 1.47(0.97-2.24), 2.09(1.03-4.22), and 2.49 (1.97-3.13), respectively, and was 2.26 (1.29-3.96)for IHD further adjusted for interaction term. The matched dataset analysis found similar results.

CONCLUSIONS

Chinese people with RA were approximated 2 times more likely to have CVD, IHD, CHF and atherosclerosis compared with those with OA. The findings justified the need of further longitudinal study to establish the causal-relationship between RA and CVD and to estimate the precise risk in this population.

Increased risks of venous thromboembolism in patients with psoriasis. A Nationwide Cohort Study

Systemic inflammation and hypercoagulability in psoriasis are related to cardiovascular morbidity. The aim of the study was to investigate the incidence and risk of venous thromboembolism (VTE) in patients with psoriasis in Taiwan. We identified inpatients aged ≥ 18 years with a diagnosis of psoriasis and controls at a 1: 1 ratio of frequency matched by sex, age, frequency of medical visits, length of stay, and comorbidities between 2000 and 2010 in the Taiwan National Health Insurance Research Database. Each patient was traced to the date of VTE occurrence, loss to follow-up, death, or the December 31, 2011, whichever occurred first. We analysed 8945 patients with psoriasis and 8945 controls. The patients with psoriasis exhibited a greater incidence rate of VTE (19.2 vs 9.88 per 10 000 person-years) than did the controls. After adjustment for covariates, the patients with psoriasis presented a 2.02-fold risk of VTE (adjusted hazard ratio [aHR] = 2.02, 95 % confidence interval [CI] = 1.42-2.88) compared with that in the control cohort. The aHR of VTE was significantly higher in the first year of follow-up (aHR = 3.30, 95 % CI = 1.45-7.55) than after one year (aHR = 1.68, 95 % CI = 1.13-2.49).

Diabetes mellitus and arthritis: is it a risk factor or comorbidity?: A systematic review and meta-analysis

BACKGROUND

Investigators have explored the association between diabetes mellitus and arthritis for a long time; however, there are uncertainties and inconsistencies among various studies. In this study, we tried to explore the relationship between diabetes mellitus and the overall risk of arthritis, as well as the potential modifiers for this relationship.

METHODS

We conducted a comprehensive literature search through PubMed and identified 36 eligible studies. The overall analyses, subgroup analyses, as well as sensitivity analyses, were conducted to illustrate the association between diabetes mellitus and arthritis. Study quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale. All statistical analyses were conducted using STATA SE version 13.0.

RESULTS

In our study, 36 eligible studies were identified and involved in the meta-analysis. The overall association between diabetes mellitus and arthritis is 1.61 (95% confidence interval [CI]: 1.14-2.28, P = .007). The association exists only in nongouty arthritis, where we observed the estimated odds ratio (OR) 1.33 (95% CI: 1.05-1.67, P < .001). The opposite point estimates from different types of diabetes may indicate possible different associations for type I (OR: 0.98, 95% CI: 0.18-5.39, P = .985) or type II diabetes (OR: 1.28, 95% CI: 0.88-1.84, P = .194).

CONCLUSION

Diabetes mellitus performs more likely as a comorbidity of arthritis rather than a risk factor; however, more studies will be helpful to increase the confidence of identifying the association between diabetes and arthritis.

Prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis in Southern Brazil

OBJECTIVE

To estimate the prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis.

METHODS

A cross-sectional study using the American College of Rheumatology diagnostic criteria in order to select patients seen at primary or secondary health care units in Blumenau, Santa Catarina, Southern Brazil, in 2014. The presence of ischemic heart disease was defined as an acute myocardial infarction with percutaneous coronary intervention or coronary artery bypass graft surgery that has occurred after diagnosis. Fischer's exact test, Wald's linear trend test, and multivariate logistic regression analysis were used to test the associations.

RESULTS

Among 296 patients (83.1% female) with a mean age of 56.6 years and a mean rheumatoid arthritis duration of 11.3 years, 13 reported having acute myocardial infarction requiring a percutaneous or surgical reperfusion procedure, a prevalence of 4.4% (95% CI 2.0-6.7). Diabetes Mellitus (odds ratio [OR] 4.9 [95% CI 1.6-13.8]) and disease duration >10 years (OR 8.2 [95% CI 1.8-39.7]) were the only factors associated with an ischemic disease that remained in the final model, after the multivariate analysis.

CONCLUSION

The prevalence of acute myocardial infarction was similar to that observed in other studies. Among the traditional risk factors, Diabetes Mellitus, and among the factors related to rheumatoid arthritis, disease duration, were the variables associated with comorbidity.

[Treatment of cardiovascular risk factors]

Cardiovascular (CV) events are among the most important comorbidities and are the major cause of death in inflammatory rheumatic diseases, such as rheumatoid arthritis (RA). Disease activity and traditional CV risk factors contribute to the total CV risk. Among the antirheumatic drugs used for long-term treatment of RA, non-steroidal anti-inflammatory drugs (NSAID) and glucocorticoids lead to an increased risk but disease-modifying antirheumatic drugs (DMARD), such as hydroxychloroquine, methotrexate and especially biologics significantly reduce the risk. Besides achieving the best possible disease control, rheumatologists should identify additional CV risk factors and also initiate adequate treatment in order to reduce or even eliminate the CV risk. When treating rheumatic diseases possible drug-induced elevation of CV risk must be considered. Finally, the CV risk should be regularly monitored.

Cardiovascular safety of hydroxypropyl-β-cyclodextrin-diclofenac in the management of acute postsurgical pain: a pooled analysis of 2 randomized, double-blind, placebo- and active comparator-controlled phase III clinical trials

STUDY OBJECTIVE

Long-term use of nonsteroidal anti-inflammatory drugs, including selective and nonselective cyclooxygenase inhibitors, has been suggested to be associated with cardiovascular (CV) safety risks. Data are limited regarding CV risks associated with short-term nonsteroidal anti-inflammatory drug use, including injectable formulations, although it has been suggested that even a single dose may increase CV adverse event (AE) risk. The objective of this study was to examine the CV safety of an injectable diclofenac formulation solubilized with hydroxypropyl-β-cyclodextrin (HPβCD) when given for ≤5days postoperatively.

DESIGN

A pooled analysis of CV AEs from 2 pivotal phase III clinical trials examining the efficacy and safety of intravenous (IV) HPβCD-diclofenac vs placebo and the active comparator ketorolac was conducted.

SETTING

Postoperative, with treatment initiated in the postanesthesia care unit ≤6hours postsurgery.

PATIENTS

Overall, 608 abdominal/pelvic and orthopedic surgery patients met inclusion criteria and received ≥1 study medication dose.

INTERVENTIONS

Patients received either HPβCD-diclofenac, ketorolac, or placebo via IV bolus injection every 6hours, for ≤5days postsurgery.

MEASUREMENTS

CV AEs, reported by study investigators, were evaluated through the treatment period and follow-up (≤37days after last study medication dose), and relative CV AE risks were estimated.

MAIN RESULTS

IV HPβCD-diclofenac was not associated with increased treatment-emergent CV AE incidence vs placebo (11.6% vs 12.2%; relative risk, 0.96 [95% confidence interval, 0.56-1.62]). Serious CV AEs as well as treatment-related AEs were uncommon, and there were no reports of myocardial infarction or cerebrovascular accident. CV AEs were uncommon during the follow-up period, occurring in 1.3%, 0%, and 1.4% of patients in the HPβCD-diclofenac, ketorolac, and placebo groups, respectively.

CONCLUSIONS

Although a longer duration follow-up study in a larger patient population would expand our understanding of potential CV risks, the present analysis suggests that postoperative use of HPβCD-diclofenac does not present an added CV safety risk over placebo.

Increased risk of lung cancer among patients with bronchiectasis: a nationwide cohort study

BACKGROUND

We conducted a longitudinal nationwide cohort study in Taiwan to determine whether patients with bronchiectasis are at an increased risk of developing lung cancer.

METHODS

This study investigated the incidence and risk for lung cancer in 57 576 patients newly hospitalized with bronchiectasis between 1998 and 2010 from the Taiwan National Health Insurance Research Database. The comparison cohort comprised 230 304 individuals from the general population without bronchiectasis. The follow-up period was from the time of the initial hospitalization for bronchiectasis to the date of a lung cancer diagnosis, censoring, or 31 December 2011. We used Cox proportional hazard regression models to analyse the risk of lung cancer by including the variables of sex, age and comorbidities.

RESULTS

The incidence of lung cancer was higher in patients with bronchiectasis than in the comparison cohort (4.58 vs. 2.02 per 1000 person-years). The bronchiectasis patients exhibited a 2.36-fold increased risk of lung cancer compared with the comparison cohort after adjustment for age, sex and comorbidities (adjusted hazard ratio [aHR] = 2.36, 95% confidence interval [CI] = 2.19-2.55). The sex-specific bronchiectasis cohort to comparison cohort revealed that the aHR was 2.41 (95% CI = 2.11-2.76) for the women and 2.33 (95% CI = 2.12-2.56) for the men. The incidence rate of lung cancer increased as age increased in both cohorts.

CONCLUSION

This nationwide study determined that the patients with bronchiectasis exhibited an increased risk of lung cancer compared with the general population.

Mycoplasma pneumonia increases the risk of acute coronary syndrome: a nationwide population-based cohort study

BACKGROUND

Studies investigating the epidemiological relationship between Mycoplasma pneumonia (MP) and the subsequent development of acute coronary syndrome (ACS) are scant. We conducted a nationwide longitudinal cohort study in Taiwan to explore whether MP patients are at an increased risk of developing ACS.

METHODS

This study investigated the incidence and risk factors for ACS in 12 152 newly diagnosed MP patients from the Taiwan National Health Insurance Research Database between 2004 and 2011. The control group consisted of 48 600 individuals without MP. The follow-up period ran from the time of initial MP diagnosis to the date of an ACS event, censoring, or 31 December 2011. We analyzed the risk of ACS by using Cox proportional hazard regression models, including variables for sex, age and comorbidities.

RESULTS

The incidence of ACS was higher in MP patients than in comparison cohort (3.08 vs. 2.42 per 1000 person-years). The hazard ratio of developing ACS increased 37% in MP patients compared with that in the comparison cohort after adjustment for covariates. The effect of MP on subsequent ACS development appeared to 12 months after infection.

CONCLUSION

This nationwide study determined that compared with the general population, MP patients exhibited a 37% increase in the risk of subsequently developing ACS. Clinicians should be aware of this risk in MP patients and provide appropriate cardiovascular management in addition to MP treatment.

Subcutaneous nodules are associated with cardiovascular events in patients with rheumatoid arthritis: results from a large US registry

Subcutaneous nodules are the most common conspicuous extra-articular manifestation of rheumatoid arthritis (RA). Cardiovascular disease (CVD) is the leading cause of death in patients with RA. The objective of this study is to examine the possibility of a relationship between subcutaneous nodules and "first ever" cardiovascular disease event, i.e., myocardial infarction (MI), stroke, or cardiovascular death in a large registry-cohort of patients with RA. Patient information was collected from the CORRONA registry from October 2001 to September 2011. A total of 26,042 patients with RA were studied for the presence or absence of subcutaneous nodules. Cox proportional hazards regression models were constructed to estimate the hazard ratios (HR) for CVD events in relation to subcutaneous nodules at baseline. Three statistical models were used to examine the association between subcutaneous nodules and CVD: Model A adjusted for age and sex associated risk, model B adjusted for traditional CV risk factors, and model C adjusted for factors in models A and B plus underlying RA-specific measures. The definition of primary exposure was "subcutaneous nodules at baseline." A total of 3908 patients had subcutaneous nodules at baseline. Of the 566 total composite CVD events, 138 occurred in the group that had SCN at baseline. Incidence rate-ratio values (patients with subcutaneous nodules at baseline vs. no subcutaneous nodules at baseline) for composite CVD events, MI, stroke, and cardiovascular death were 1.55, 1.65, 1.37, and 1.68, respectively. Adjusted HR values (95 % CI) for composite CVD events based on "subcutaneous nodules-status at baseline" (primary exposure) were as follows: 1.35 (1.11-1.63) for model A, 1.25 (1.03-1.52) for model B, and 1.03 (0.831-1.277) for model C. Subcutaneous nodules were associated with increased CVD events in RA. This association persisted after adjusting for age, sex, and traditional CV risk factors.