Premature subclinical atherosclerosis in pediatric inflammatory bowel disease

Carotid intima media thickness in multiple sclerosis: A CLSA study

BACKGROUND

People with multiple sclerosis (MS) have an increased incidence of atherosclerotic disease, including ischemic heart disease and stroke, compared to people without MS even after accounting for risk factors such as hypertension, dyslipidemia, diabetes and smoking. We compared carotid intima media thickness (CIMT), a surrogate of atherosclerosis, in people with MS and in two groups of people without MS (rheumatoid arthritis [RA]; all other participants).

METHODS

We used data from participants in the Canadian Longitudinal Study on Aging (CLSA) who did not have known vascular disease (ischemic heart disease, stroke, transient ischemic attack, peripheral vascular disease) and who underwent carotid ultrasound for assessment of CIMT. We selected participants with MS, RA and controls who did not have MS or RA. Using age and gender-stratified norms for average CIMT in the CLSA, we identified participants in each cohort with a CIMT ≥75th percentile (subclinical atherosclerosis). We also calculated ten-year level of cardiovascular risk using the Framingham Risk Score (FRS). We tested the association between cohort membership (MS, RA, controls) and atherosclerosis using logistic regression, adjusted for FRS, abdominal obesity, excess alcohol intake, education and elevated symptoms of depression. We adjusted all analyses for the stratified sampling design.

RESULTS

We included 78 participants with MS, 364 participants with RA and 13,891 controls. Overall, the average (SE) CIMT was 0.699 (0.002), and this did not differ between cohorts. Logistic regression analyses revealed that cohort membership was not associated with atherosclerosis based on the average CIMT in unadjusted or adjusted models. However, a 1-point higher FRS was associated with 1.032 (95 %CI: 1.021, 1.043) increased odds of atherosclerosis.

CONCLUSION

Average CIMT does not differ between people with MS, people with RA and people without these diseases. Subclinical atherosclerosis as defined by a CIMT ≥75 % is not observed in people with MS at an increased rate beyond what FRS would predict. Further evaluation is needed to determine what mechanisms underlie the increased rates of cardiovascular disease and stroke in MS.

Impact of Obesity and Metabolic Syndrome on IBD Outcomes

PURPOSE OF REVIEW

The recent surge in inflammatory bowel disease (IBD) cases has paralleled a significant rise in obesity and metabolic comorbidities rates. In this article, we explore the potential influence of obesity and associated metabolic comorbidities on disease progression, complications, treatment response, surgical outcomes, health economics, and the potential impact of obesity treatment on the course of IBD.

FINDINGS

Contrary to visceral adiposity, obesity does not consistently result in an increased risk of IBD-related complications. Patients with IBD have a higher risk of acute arterial events, likely linked to systemic inflammation. Substantial evidence suggests that obesity has a negative impact on the response to IBD treatment, with this effect being most thoroughly studied in biologics and immunomodulators. The rates of overall complications and post-operative infections are higher in patients who are obese. There are limited but promising data regarding the impact of weight loss techniques, including exercise, medications, and bariatric interventions, on the outcomes in IBD. Both obesity and diabetes have adverse effects on the overall quality of life and place an increased financial burden on the IBD population. A growing body of evidence indicates a connection between obesity and associated metabolic comorbidities and negative outcomes in IBD, yet further efforts are required to fully understand this relationship.

Ocular endothelial dysfunction in pediatric inflammatory bowel disease

OBJECTIVES

To assess ocular microvasculature changes using optical coherence tomography angiography (OCTA) in pediatric patients with inflammatory bowel disease (IBD).

METHODS

Patients (aged 6-18 years) with IBD were recruited between September 2021 and May 2023. All eligible participants underwent comprehensive clinical assessment and laboratory investigation. Patients with functional gastrointestinal disorders served as the controls. This study assessed specific IBD phenotypes, disease duration, clinical and endoscopic activity indices, laboratory markers, and medication histories. OCTA was utilized to evaluate ocular microvasculature changes in both groups.

RESULTS

A total of 63 children (mean age 12.9 ± 3.3 years) were enrolled, comprising 38 in the IBD group (16 ulcerative colitis, 22 Crohn's disease, and 25 in the control group). Most patients in the IBD group were in remission or had mild-to-moderate disease activity at enrollment. Analysis of the OCTA results revealed significant differences in the choroidal luminal area and total choroidal area between the IBD and control groups.

CONCLUSIONS

The study identified distinct ocular microvasculature changes in pediatric IBD patients through OCTA, suggestive of potential systemic endothelial dysfunction. These findings underscore the utility of OCTA in evaluating microvascular alterations associated with pediatric IBD, offering insights into potential systemic complications linked to inflammation in IBD patients.

Arterial structure and function in children with inflammatory bowel disease

Background and Aim

People with inflammatory bowel disease (IBD) have an increased risk of cardiovascular disease, including in younger adulthood. This may arise in part from chronic, systemic low-grade inflammation. The process of atherosclerosis may begin in childhood. We sought to determine whether pediatric IBD is associated with adverse changes in arterial structure and function as a marker of early increased cardiovascular risk.

Methods

We performed a case-control study comparing children with IBD for a median disease duration of 2.49 (interquartile range 1.23, 4.38) years with healthy children. In a single visit, we collected baseline clinical and anthropometric data, and measured blood pressure, pulse wave velocity, carotid artery distensibility, and aortic and carotid intima-media thickness. High-sensitivity C-reactive protein and fasting lipids were measured.

Results

We enrolled 81 children with IBD (40 with Crohn's disease, 40 with ulcerative colitis, and 1 with unspecified IBD) and 82 control participants. After adjusting for age, sex, body mass index z-score, blood pressure, and low-density lipoprotein cholesterol, there was no difference in measures of arterial structure and function in children with IBD compared with controls, nor between those with Crohn's disease or ulcerative colitis.

Conclusion

We did not show any differences in arterial structure and function in children with a history of IBD for less than 5 years compared with healthy controls. IBD diagnosed in childhood may provide a window of opportunity to actively reduce standard cardiovascular risk factors and improve future cardiovascular outcomes.

Subclinical atherosclerosis in multiple sclerosis

Background

People with multiple sclerosis (MS) have an increased risk of ischemic heart disease as compared to people without MS after accounting for traditional vascular risk factors.

Objective

We assessed whether subclinical atherosclerosis, an inflammatory disease of arteries, occurs in persons with MS who do not have traditional vascular risk factors, and whether the Framingham Score (FRS) predicted carotid intima media thickness (CIMT) similarly in people with and without MS.

Methods

We recruited participants with and without MS who did not have vascular disease. Participants completed questionnaires, physical assessments, underwent an ultrasound (CIMT), and provided samples for HbA1c and lipid measurements. We defined subclinical atherosclerosis as an average CIMT ≥75th percentile, and tested the association between MS/not-MS, FRS, and atherosclerosis using logistic regression.

Results

We recruited 106 participants with MS 101 without MS. The average (SD) CIMT did not differ between the MS (0.60 [0.11]) and non-MS (0.61 [0.12]) cohorts (p = 0.69), nor did the proportion with atherosclerosis (MS: 11.3% vs. non-MS 13.4%, p = 0.58). On regression analysis a 1-point increase in the FRS was associated with 11% increased odds of having atherosclerosis (95%CI: 1.04, 1.19) but MS was not.

Conclusion

MS was not associated with subclinical atherosclerosis.

Risk of atrial fibrillation development in adolescent patients with inflammatory bowel disease

There is increasing evidence linking chronic inflammation to the initiation and continuation of atrial fibrillation (AF). Inflammatory bowel diseases (IBD), namely (Crohn's disease (CD) and ulcerative colitis (UC), are chronic systemic inflammatory disorders with both intestinal and extra-intestinal manifestations. Atrial electromechanical delay (EMD) has been known as an early marker of AF. The objective of this study was to evaluate the atrial electromechanical properties in children and adolescents with IBD during remission. One hundred IBD patients aged 12-17 years (50 with CD and 50 with UC) in remission state and 100 healthy controls were recruited for the study. Atrial electromechanical properties were measured using transthoracic echocardiography, tissue Doppler imaging, and simultaneous surface ECG recording. Interatrial EMD, left intra-atrial, and right intra-atrial EMD were calculated. IBD patients in remission state have significantly prolonged left and right intra-atrial EMD and interatrial EMD compared to healthy controls (P = 0.03, P = 0.02, and P = 0.01 respectively). No statistical difference was observed between CD and UC in terms of inter- and intra-atrial EMDs.  Conclusion: Atrial EMD is increased in pediatric patients with IBD indicating the increased risk of AF development. Measurement of atrial EMD parameters might be used to predict the risk of the development of AF in pediatric patients with IBD. What is Known: • There is increasing evidence linking chronic inflammation to the initiation and continuation of atrial fibrillation (AF). • Inflammatory bowel diseases are chronic systemic inflammatory disorders with both intestinal and extra-intestinal manifestations. • Atrial electromechanical delay (EMD) has been reported as an early marker of AF. What is New: • Atrial EMD is increased in pediatric patients with IBD indicating the increased risk of AF development. • Measurement of atrial EMD parameters might be used to predict the risk of the development of AF in pediatric patients with IBD.

A Mendelian randomization study on causal effects of inflammatory bowel disease on the risk of erectile dysfunction

This study aimed to evaluate the causal effects of inflammatory bowel disease (IBD) and erectile dysfunction (ED) using Mendelian randomization (MR). All datasets were obtained from the public genome-wide association study database. In the exposure group, 12,882 IBD patients and 21,770 controls were included. A total of 1154 ED patients and 94,024 controls were included in the outcome group. Two-sample MR was conducted to estimate the causal effect of IBD on ED. Furthermore, Crohn's disease (CD) and ulcerative colitis (UC) were exposure factors in subgroup analyses. Weighted median, MR-egger, Inverse-variant weighted (IVW), weighted mode, and simple mode methods were used in MR analysis. Horizontal pleiotropy test, heterogeneity test, and leave-one-out method were utilized to evaluate the sensitivity and stability of results. After analysis, 62, 52, and 36 single nucleotide polymorphisms (SNPs) that IBD-ED, CD-ED, and UC-ED were included, respectively. The incidence of ED was increased by IBD (IVW: OR = 1.110, 95% CI = 1.017-1.211, P = 0.019; P-heterogeneity > 0.05) and, in addition, ED was affected by CD (IVW: OR = 1.085, 95% CI = 1.015-1.160, P = 0.016; P-heterogeneity > 0.05). However, there was no causal effect of UC on ED (IVW: OR = 1.018, 95% CI = 0.917-1.129, P = 0.743; P-heterogeneity < 0.05). All SNPs showed no significant horizontal pleiotropy (P > 0.05). These results indicate that IBD and CD can cause ED; However, UC did not cause ED. Additional research was required to determine causality and potential mechanisms further.

The Immune Landscape and Molecular Subtypes of Pediatric Crohn's Disease: Results from In Silico Analysis

Pediatric Crohn's disease (CD) presents a distinct phenotype from adult-onset disease. A dysregulated immune response is critical in CD pathogenesis; thus, it is clinically important to describe immune cell alterations and to identify a new molecular classification for pediatric CD. To this end, in this study, a RNA-seq derived dataset GSE101794-which contains the expression profiles of 254 treatment-naïve pediatric CD samples, including CIBERSORTx and weighted gene-co-expression network analysis (WGCNA)-were performed to estimate the ratio of immune cells and to identify modules and genes related to specific immune cell infiltration, respectively. Hub genes derived from WGCNA were further employed to create a molecular classification using unsupervised K-means clustering. In the pediatric CD samples, it was found that M2 macrophages, CD4⁺ memory resting T cells, CD8⁺ T cells, and resting mast cells were the most prominent immune cells in intestinal tissues. Then, 985 up-regulated genes and 860 down-regulated genes were identified in samples with high immune cell infiltration. Of these differential genes, 10 hub genes (APOA1, CYB5A, XPNPEP2, SLC1A7, SLC4A6, LIPE, G6PC, AGXT2, SLC13A1, and SOAT2) were associated with CD8⁺T cell infiltration. Clinically, the higher expression of these 10 hub genes was strongly associated with an earlier age of CD onset and colonic-type CD. Furthermore, based on these key genes, pediatric CD could be classified into three molecular subtypes, displaying a different immune landscape. Altogether, this in silico analysis provides a novel insight into the immune signature of pediatric CD, and a new classification of pediatric CD is presented, which may help us develop more personalized disease management and treatments for pediatric CD.

Contribution of Blood Vessel Activation, Remodeling and Barrier Function to Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) consist of a group of chronic inflammatory disorders with a complex etiology, which represent a clinical challenge due to their often therapy-refractory nature. In IBD, inflammation of the intestinal mucosa is characterized by strong and sustained leukocyte infiltration, resulting in the loss of epithelial barrier function and subsequent tissue destruction. This is accompanied by the activation and the massive remodeling of mucosal micro-vessels. The role of the gut vasculature in the induction and perpetuation of mucosal inflammation is receiving increasing recognition. While the vascular barrier is considered to offer protection against bacterial translocation and sepsis after the breakdown of the epithelial barrier, endothelium activation and angiogenesis are thought to promote inflammation. The present review examines the respective pathological contributions of the different phenotypical changes observed in the microvascular endothelium during IBD, and provides an overview of potential vessel-specific targeted therapy options for the treatment of IBD.

Children with inflammatory bowel disease already have an altered arterial pulse wave

Adults with inflammatory bowel disease (IBD) have an increased risk for vascular events. This study aims to evaluate arterial parameters in paediatric IBD. Carotid intima-media thickness (CIMT) was measured by ultrasound, and Arteriograph was used to assess aortic pulse wave velocity (PWVao), brachial and aortic augmentation indexes (AixBrach, AixAo), central systolic blood pressure (SBPao), and heart rate (HR). A total of 161 children were included; 55 (34%) children with newly diagnosed IBD (median age 14.35 (11.88-16.31) years, 53% males), 53(33%) in remission (median age 15.62 (13.46-16.70) years, 66% males), and 53 (33%) controls (median age 14.09 (11.18-14.09) years, 55% males) were recruited into a case-control study. Compared to controls, patients with active disease and those in clinical remission had significantly lower AixBrach and AixAo (P < 0.001, P = 0.009; P < 0.001, P = 0.003). PWVao and CIMT were still normal. HR was higher in both IBD groups than in controls (P < 0.001; P = 0.006). HR positively correlated with disease duration (P = 0.001). In the ordinary least squares regression models, anti-tumour necrosis factor (TNF) α treatment predicted lower peripheral and central systolic blood pressures, in contrast to aminosalicylates and methotrexate. Aminosalicylate treatment predicted increased HR.  Conclusion: Children with IBD have an increased heart rate, a lower augmentation index and, therefore, an altered pulse waveform. In paediatric IBD, arterial stiffness and CIMT are still normal, indicating the potential for adequate IBD treatment to preserve arterial health. What is Known: • Adult patients with inflammatory bowel disease (IBD) have increased carotid intima-media thickness and arterial stiffness, which positively correlates with cardiovascular risk and predicts mortality. Adequate treatment, especially anti-tumour necrosis factor (TNF) α medications, lower these risks. • Children with IBD have impaired endothelial function and reduced heart rate (HR) variability. What is New: • Children with IBD have impaired endothelial function and reduced heart rate (HR) variability. • Anti-TNFα treatment in children and adolescents with IBD lowers systolic pressure, whereas methotrexate and aminosalicylates have the opposite effect. Amiynosalyiciylate treatment also increases HR.

Current applications for measuring pediatric intima-media thickness

Intima-media thickness is a known subclinical radiologic marker of the early manifestations of atherosclerotic disease. It is the thickness of the vessel wall, most often the carotid artery. Intima-media thickness is measured on conventional US manually or automatically. Other measurement techniques include radiofrequency US. Because there is variation in its measurement, especially in children, several recommendations have been set to increase the measurement's validity and comparability among studies. Despite these recommendations, several pitfalls should be avoided, and quality control should be performed to avoid erroneous interpretation. This article summarizes current literature in relation to the clinical applications for intima-media thickness measurement in children with known risk factors such as obesity, liver steatosis, hypercholesterolemia, diabetes, hypertension, systemic inflammatory diseases, cancer survival, kidney and liver transplant, and sickle cell disease or beta thalassemia major. Most potential indications for intima-media thickness measurement remain in the research domain and should be interpreted combined with other markers. The objective of diagnosing an increased intima-media thickness is to start a multidisciplinary treatment approach to prevent disease progression and its sequelae in adulthood.

Endothelial Dysfunction and Arterial Stiffness in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Population-based studies have suggested that patients with inflammatory bowel disease (IBD) might be at an increased risk for cardiovascular diseases. A meta-analysis was performed on clinical studies to evaluate endothelial function, arterial stiffness, and carotid intima-media thickness (cIMT) in patients with IBD, after searching PubMed, Embase, Cochrane library, and Web of Science databases. A random-effects model was used to allow for the pooling of studies and for determination of the overall effect. After exclusion, a total of 41 eligible studies with 2330 patients with IBD and 2032 matched controls were identified and included for the analysis. It was found that cIMT was significantly increased in patients with IBD as compared with that in matched controls (Cohen’s d: 0.63; 95% CI: 0.34, 0.93; I² = 91.84%). The carotid–femoral pulse wave velocity was significantly higher in patients with IBD compared to that in matched controls (Cohen’s d: 0.76; 95% CI: 0.54, 0.98; I² = 70.03%). The augmentation index was also significantly increased in patients with IBD compared to matched control subjects (Cohen’s d: 0.35; 95% CI: 0.08, 0.63; I² = 61.37%). Brachial artery flow-mediated dilatation was significantly decreased in patients with IBD than that in matched controls (Cohen’s d: −0.73; 95% CI: −1.10, −0.36; I² = 81.02%). Based on the meta-analysis, it was found that patients with IBD exhibit significant endothelial dysfunction, increased arterial stiffness, and cIMT. Thus, patients with IBD may benefit from aggressive risk stratification for cardiovascular diseases.

Evaluation of Risk for Thromboembolic Events in Pediatric Inflammatory Bowel Disease

OBJECTIVES

The occurrence of thrombotic events in adult patients with inflammatory bowel disease (IBD) is linked to multiple interactions between hereditary and acquired risk factors. There are few published data concerning children with iBD. The aim of this study was to investigate the presence of thromboembolic risk factors also in children with iBD.

METHODS

We enrolled three groups of children: one with Crohn disease (cD), one with ulcerative colitis (Uc), and a control group of healthy subjects. For all the participants the potential thromboembolic risk was evaluated clinically and with laboratory tests.

RESULTS

We studied: 30 children (25.6%) with CD, 28 (23.9%) with UC, and 59 (50.4%) healthy control subjects. Regarding Pediatric Crohn Disease Activity Index, no significant differences between thromboembolic risk factors and disease activity were detected. Instead, in the patients with UC, stratified with the Pediatric Ulcerative Colitis Activity Index, there was a statistically significant difference in serum fibrinogen levels between patients with mild and moderate/severe disease [3.8 (3.2-4.5) g/L vs 5.7 (4.8-6.2) g/L, P  < 0.0032]. serum homocysteine levels were lower in healthy controls than in CD (P = 0.176) and UC (P = 0.026). An increased level ofhomocysteine in UC with a homozygous mutation in the methylene tetrahydrofolate reductase C677T gene was also observed.

CONCLUSIONS

Our study showed that children with IBD have clinical features, acquired and congenital factors that can increase thrombotic risk, similarly to adults.

Liver Pathology in Children with Diagnosed Inflammatory Bowel Disease-A Single Center Experience

BACKGROUND

Inflammatory bowel disease (IBD) in children is frequently associated with liver pathology manifested as transient elevation of liver enzymes or specified liver diseases. The aim of the study was to evaluate the prevalence and the type of liver pathology in children with IBD within 2 years' follow-up after the IBD diagnosis.

METHODS

We retrospectively reviewed records of children with IBD. Liver pathology was defined as elevated activity of liver enzymes (alanine transaminase (ALT) and/or gamma-glutamyl transpeptidase (GGT)) and bilirubin concentration in serum and/or as pathological changes of the organ on imaging tests (abdominal ultrasound and/or magnetic resonance cholangiopancreatography) or on liver histology performed when indicated.

RESULTS

Liver pathology was detected in 21 from 119 children (18%), including 7 (17%) with Crohn's disease (CD) and 14 (18%) with ulcerative colitis (UC). Specified diagnosis for liver abnormality was found in 14 of 21 children (67%), including primary sclerosing cholangitis (PSC, 19%), non-alcoholic fatty liver disease (NAFLD, 19%), autoimmune sclerosing cholangitis (ASC, 5%), autoimmune hepatitis (AIH, 5%), cholelithiasis (5%), drug-induced liver disease (9%) and viral infection (herpes simplex virus, 5%). Most patients manifested mild IBD or were in clinical remission at the time of liver pathology diagnosis. 14% of patients with liver disease (including only cases with PSC) were diagnosed before IBD, 33% at the same time, and 52% in the later period. Patients with the specified diagnosis of liver pathology were younger, had higher ALT activity and more often demonstrated liver abnormalities on imaging tests. UC patients with idiopathic elevation of liver enzymes had higher pediatric ulcerative colitis activity index scores compared to children with specified liver disease.

CONCLUSIONS

Liver pathology was observed in a significant percentage of children with IBD in our study. The majority of cases of hepatobiliary abnormalities were detected after diagnosis of IBD; therefore, children with IBD should undergo routine monitoring of liver enzymes.

Understanding the role of Inflammasome in Angina Pectoris

Angina pectoris, associated with coronary artery disease, a cardiovascular disease where, pain is caused by adverse oxygen supply in myocardium, resulting in contractility and discomfort in chest. Inflammasomes, triggered by stimuli due to infection and cellular stress have identified to play a vital role in the progression of cardiovascular disorders and thus, causing various symptoms like angina pectoris. Nlrp3 inflammasome, a key contributor in the pathogenesis of angina pectoris, requires activation and primary signaling for the commencement of inflammation. Nlrp3 inflammasome elicit out an inflammatory response by emission of pro inflammatory cytokines by ROS (reactive oxygen species) production, mobilization of K+ efflux and Ca2+ and by activation of lysosome destabilization that eventually causes pyroptosis, a programmed cell death process. Thus, inflammasome are considered to be one of the factors involved in the progression of coronary artery diseases and have an intricate role in development of angina pectoris.

Relations between disease status and body composition in pediatric inflammatory bowel disease

To evaluate the effect of remission status on physical activity and body composition in pediatric patients with inflammatory bowel disease (PIBD) and healthy peers. Single-center cohort study, including 54 PIBD patients and 33 healthy peers. During the initial study visit, a brief demographic questionnaire, physical activity questionnaire completed by participants, and instructions on recording dietary intake were given. Physicians completed the Physician Global Assessment (PGA) for disease severity. Medical chart abstraction was done to obtain disease variables of interest. DEXA scan completed 1 week later to obtain information on body composition. Variables of interest were compared between the three groups (IBD-Remission, IBD-Active, and healthy controls) using an ANOVA or Chi-square test as appropriate. IBD patients were older than controls, reported lower quality of life (73.9 vs. 80.9), and engaged in less MVPA (195.4 versus 361.1). The IBD-Active group had a significantly lower lean body mass, bone mineral density, and time spent in MVPA compared to the IBD-Remission group and healthy controls. IBD-Remission group had a significantly lower percentage of biologic use (55% vs. 87%) and comorbidities (26% vs. 44%) compared to IBD-active group. IBD-remission group also had a lower fat mass percentage. In this study, we report significantly favorable LBM, BMD, and time spent in MVPA in patients with IBD in remission compared to those not in remission with the former demonstrating a body composition resembling that of healthy peers.Conclusion: While an improvement in BMD was observed with remission, the scores were still lower than controls. What is Known: • Body composition deficits in pediatric inflammatory bowel disease are common and some persist despite achievement of remission leading to long term outcomes including osteopenia and osteoporosis. • Weight restoration in patients with pediatric IBD is primarily explained by gains in fat mass without similar gains in lean mass. What is New: • While an improvement in bone mineral density was observed, the achievement of remission significantly improves affects physical activity and body composition in pediatric inflammatory bowel disease. • However, some parameters of body composition do not reach levels comparable to healthy peers.

Lipid Profiles in Patients With Ulcerative Colitis Receiving Tofacitinib-Implications for Cardiovascular Risk and Patient Management

BACKGROUND

Patients with ulcerative colitis (UC) are at elevated risk of cardiovascular disease vs the general population, despite a lower prevalence of traditional risk factors, including hyperlipidemia. Mechanistic studies in patients with rheumatoid arthritis and psoriasis suggest that tofacitinib restores serum lipids to preinflammation levels by reversing inflammation-induced cholesterol metabolism changes. We reviewed data on lipid levels and cardiovascular events, alongside recommendations for managing lipid levels during tofacitinib treatment in patients with UC, based on up-to-date expert guidelines.

METHODS

Data were identified from a phase 3/open-label, long-term extension (OLE) tofacitinib UC clinical program (cutoff May 27, 2019). Literature was identified from PubMed (search terms "lipid," "cholesterol," "lipoprotein," "cardiovascular," "inflammation," "atherosclerosis," "tofacitinib," "rheumatoid arthritis," "psoriasis," "inflammatory bowel disease," "ulcerative colitis," "hyperlipidemia," and "guidelines") and author knowledge. Data were available from 4 phase 3 clinical trials of 1124 patients with moderately to severely active UC who received ≥1 dose of tofacitinib 5 or 10 mg twice daily in induction (two identical trials), maintenance, and OLE studies (treatment duration ≤6.8 years; 2576.4 patient-years of drug exposure).

RESULTS

In the OLE study, tofacitinib treatment was not associated with major changes from baseline in total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol/high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol, with lipid levels and ratios generally remaining stable over time. The major adverse cardiovascular events incidence rate was 0.26/100 patient-years (95% confidence interval, 0.11-0.54).

CONCLUSIONS

Lipid levels and ratios remained generally unchanged from baseline in the OLE study after tofacitinib treatment, and major adverse cardiovascular events were infrequent. Long-term studies are ongoing.

CLINICALTRIALS.GOV IDENTIFIERS

NCT01465763, NCT01458951, NCT01458574, NCT01470612.

The risk of cardiovascular complications in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic, relapsing disease of unknown etiology involving gastrointestinal tract. IBD comprises two main entities: ulcerative colitis and Crohn's disease. Several studies showed increased risk of cardiovascular complications in chronic inflammatory disorders, especially during IBD relapses. Endothelium plays a role in physiologic regulation of vascular tone, cell adhesion, migration and resistance to thrombosis. Also, its dysfunction is associated with increased risk of atherosclerosis development. There are several potential links between chronic IBD-related inflammatory processes and the risk of cardiovascular disease, but insight into pathogenetic pathways remains unclear. We present the current concepts and review of adult and pediatric studies on the risk of CVD in IBD.

Experimental and Clinical Evidence of Endothelial Dysfunction in Inflammatory Bowel Disease

The endothelium has a crucial role in proper hemodynamics. Inflammatory bowel disease (IBD) is mainly a chronic inflammatory condition of the gastrointestinal tract. However, considerable evidence points to high cardiovascular risk in patients with IBD. This review positions the basic mechanisms of endothelial dysfunction in the IBD setting (both clinical and experimental). Furthermore, we review the main effects of drugs used to treat IBD in endothelial (dys)function. Moreover, we leave challenging points for enlarging the therapeutic arsenal for IBD with new or repurposed drugs that target endothelial dysfunction besides inflammation.

Connecting the Dots Between Inflammatory Bowel Disease and Metabolic Syndrome: A Focus on Gut-Derived Metabolites

The role of the microbiome in health and disease has gained considerable attention and shed light on the etiology of complex diseases like inflammatory bowel disease (IBD) and metabolic syndrome (MetS). Since the microorganisms inhabiting the gut can confer either protective or harmful signals, understanding the functional network between the gut microbes and the host provides a comprehensive picture of health and disease status. In IBD, disruption of the gut barrier enhances microbe infiltration into the submucosae, which enhances the probability that gut-derived metabolites are translocated from the gut to the liver and pancreas. Considering inflammation and the gut microbiome can trigger intestinal barrier dysfunction, risk factors of metabolic diseases such as insulin resistance may have common roots with IBD. In this review, we focus on the overlap between IBD and MetS, and we explore the role of common metabolites in each disease in an attempt to connect a common origin, the gut microbiome and derived metabolites that affect the gut, liver and pancreas.

NLRP3 Inflammasome and Its Central Role in the Cardiovascular Diseases

Materials

The NLRP3 inflammasome controls the activation of the proteolytic enzyme caspase-1. Caspase-1 in turn regulates the maturation of the proinflammasome cytokines IL-1β and IL-18, which leads to an inflammatory response. We made a mini-review on the association of regulatory mechanisms of NLRP3 inflammasome with the development of cardiovascular diseases systematically based on the recent research studies. Discussion. The inflammasome plays an indispensable role in the development of atherosclerosis, coronary heart diseases (CHD), and heart ischemia-reperfusion (I/R) injury, and NLRP3 inflammasome may become a new target for the prevention and treatment of cardiovascular diseases. Effective regulation of NLRP3 may help prevent or even treat cardiovascular diseases.

Conclusion

This mini-review focuses on the association of regulatory mechanisms of NLRP3 inflammasome with the development of cardiovascular diseases, which may supply some important clues for future therapies and novel drug targets for cardiovascular diseases.

The Effect of Vitamin D on Serum Asymmetric Dimethylarginine in Patients with Mild to Moderate Ulcerative Colitis

Abstract. Purpose: In inflammatory bowel disease increased asymmetric dimethylarginine (ADMA) levels could inhibit nitric oxide (NO) synthase. Vitamin D may increase activity and expression of endothelial NO synthase, which could be done through its possible mechanism of decreasing ADMA levels. The aim of this study is to investigate the possible effect of Vitamin D3 on serum ADMA levels in ulcerative colitis (UC) patients. Methods: Ninety mild to moderate UC patients were randomized. Each patient received one single muscular injection of 300,000 IU (7500 μg) Vitamin D3 (Vitamin D group) or 1 ml normal saline (Placebo group). At baseline and 90 days after the intervention measurements were done. Data were analyzed using independent t-test and analysis of covariance. Baseline correlations were assessed by Pearson and Spearman correlation coefficients. Results: Following data analysis of 86 participants (40 in placebo and 46 in vitamin D group), there was no correlation between baseline ADMA with baseline vitamin D, ESR and hs-CRP at baseline (p = 0.77) and at the end of study (p = 0.82). Serum ADMA levels were not statistically different between two groups. Adjustment for baseline ADMA levels and baseline body mass index (BMI) did not change the results. With subgroup analyses based on gender and vitamin D level no statistical differences in ADMA levels between two groups were found. Conclusions: In this study, we found no significant changes in serum ADMA levels 3 months following a high dose vitamin D administration in mild to moderate UC patients. Further studies in vitamin D deficient patients are needed.

The Role of Inflammation in the Endothelial Dysfunction in a Cohort of Pediatric Patients With Inflammatory Bowel Disease

OBJECTIVES

Chronic inflammation plays a central role in the etiology of endothelial damage. Endothelial dysfunction (ED) is the inability of the artery to dilate in response to an endothelial stimulus. We assessed the ED by measuring the reactive hyperaemia index (RHI) and the flow-mediated dilation (FMD) in a cohort of pediatric patients affected by inflammatory bowel disease (IBD) and comparing these parameters to a group of healthy controls (HC).

METHODS

Forty-one patients were consecutive enrolled. ED was evaluated by both the plethysmographic RHI method and the measurement of the FMD of brachial artery after occlusion of the blood flow. Differences between patients and controls were assessed by the Mann-Whitney test. In each patient with IBD, the main inflammation markers were detected and correlated to RHI and FMD by a linear regression test.

RESULTS

We enrolled 26 (59%) patients with IBD and 18 (41%) HC. When comparing FMD value at diagnosis it was significantly lower in IBD patients than in HC (P = 0.04). This result was confirmed at follow-up, when this difference became even more significant (P = 0.004). A significant indirect correlation was found between FMD and fecal calprotectin (r: 0.17; P = 0.04). No differences were found when comparing RHI.

CONCLUSIONS

Our results suggest that inflammation could lead to ED assessed by ultrasound FMD. These data were not confirmed by RHI; however, this could be due to the lack of a standardized pediatric cut-off. More studies are necessary to confirm our data.

Measurement of Microvascular Function in Pediatric Inflammatory Bowel Disease

BACKGROUND AND AIMS

Altered vascular flow is known to both play a role in the pathogenesis and influence the severity of inflammatory bowel disease (IBD). This phenomenon has been described in other systemic conditions and contributes to disease progression by facilitating inflammation and thrombosis. Microvascular dysfunction may represent an early sign of generalized vascular disease (VD). It manifests by failure to achieve a normal response of vasodilation and increased blood flow following a period of vaso-occlusion. Although thromboembolic complications are well described in IBD, their pathogenesis is not fully understood. This study sought to assess microvascular responsiveness in pediatric subjects with IBD, by recording postocclusion peripheral arterial pulsatile volume changes.

PATIENTS AND METHODS

A total of 32 pediatric subjects were studied, including 16 with IBD and 16 age-matched controls. All patients with IBD were in clinical remission, and none had known VD. Vascular reactivity was evaluated using the Itamar Medical EndoPAT2000, a noninvasive device utilizing plethysmography to measure microvascular flow. Results were reported as the reactive hyperemia index (RHI), indicating post- to preocclusion pulsatile volume changes.

RESULTS

Baseline characteristics, including body mass index, plasma lipid levels, hemoglobin, and serum albumin, were similar in both study groups. All patients with IBD were in clinical remission, assessed by standard disease activity scoring methods. Measurements of microvascular function indicated patients with IBD exhibited a mean RHI both within the range associated with VD risk in adults (≤1.67) and significantly lower than that in controls (IBD vs control = 1.66 vs 2.02, P = 0.036).

CONCLUSIONS

Microvascular plethysmography is a safe and noninvasive method for assessing microvascular function in children with IBD. Patients with IBD in clinical remission demonstrate an attenuated, postocclusion microvascular hyperemic response, compared with the normal response in controls. These findings suggest pediatric IBD subjects with a mean RHI within the VD "at risk" range should be monitored for thromboembolic phenomena. Further studies in a larger patient population and over longer periods should be conducted to validate our findings and to determine the importance of these measurements in guiding IBD management.

Conceptual Model of Lean Body Mass in Pediatric Inflammatory Bowel Disease

Youth with inflammatory bowel disease (IBD) demonstrate deficits in lean mass (LM) placing them at increased risk for future health problems, including reduction of bone mass and impaired bone architecture. Research suggests that deficits in LM are multifactorial, including influences from the disease and its treatment, and health behaviors such as diet and physical activity. Based on a systematic literature review examining factors related to LM deficits in IBD, this article presents a conceptual model to explain the development of LM in youth with IBD. The model considers predictors of LM across 4 domains: demographic; medical; diet; and physical activity. Much existing research is cross-sectional, but suggests multiple factors work together to promote or inhibit LM accrual in youth with IBD. The conceptual model, developed based on empirical findings to date, can be used to understand and further elucidate the process through which LM is developed and maintained, to inform the development of empirically supported clinical interventions, and to guide future research objectives and priorities.

Influence of environmental tobacco smoke on morphology and functions of cardiovascular system assessed using diagnostic imaging

Exposure to tobacco smoke is a significant problem of environmental medicine. Tobacco smoke contains over one thousand identified chemicals including numerous toxicants. Cardiovascular system diseases are the major cause of general mortality. The recent development of diagnostic imaging provided methods which enable faster and more precise diagnosis of numerous diseases, also those of cardiovascular system. This paper reviews the most significant scientific research concerning relationship between environmental exposure to tobacco smoke and the morphology and function of cardiovascular system carried out using diagnostic imaging methods, i.e. ultrasonography, angiography, computed tomography and magnetic resonance imaging. In the forthcoming future, the studies using current diagnostic imaging methods should contribute to the reliable documentation, followed by the wide-spreading knowledge of the harmful impact of the environmental tobacco smoke exposure on the cardiovascular system.

Arterial Structure and Function Following Viral Myocarditis

Acute viral myocarditis is an uncommon inflammatory disease of the myocardium. Little is known about the long-term cardiovascular risk for individuals who have recovered from the acute illness. We compared intermediate vascular phenotypes relating to arterial structure (aortic and carotid intima-media thickness) and function (pulse wave velocity, carotid arterial distensibility and compliance) in 15 participants, a median of 9.1 years after an episode of acute viral myocarditis, and 45 control participants. Following adjustment for age, sex and triglycerides, there were no differences in mean and maximum carotid and aortic intima-media thickness, pulse wave velocity, carotid artery distensibility and compliance between viral myocarditis participants and controls. In conclusion, we found no evidence of changes in intermediate vascular phenotypes indicative of increased cardiovascular risk in individuals who had fully recovered from viral myocarditis.

The Role of Sleeve Gastrectomy in Reducing Cardiovascular Risk

BACKGROUND

Obesity is an independent cardiovascular risk factor and a catalyst of other cardiovascular risk factors, such as hypertension, dyslipidemia, type 2 diabetes mellitus (DM2) and metabolic syndrome.

METHODS

We analyzed cardiovascular risk in obese patients before and after sleeve gastrectomy (SG). To this end, we studied changes in body mass index (BMI), blood chemistry parameters that characterize the risk of atherosclerosis and instrumental parameters (objective markers of this risk), namely intima-media thickness (IMT) and flow-mediated dilation (FMD), the latter reflecting endothelial function. We also considered purely cardiac parameters-mitral annular plane systolic excursion (MAPSE) and tricuspid annular plane systolic excursion (TAPSE)-which describe cardiac risk more specifically than the ejection fraction. Alteration of one or more of these parameters determines an increase in cardiovascular morbidity and mortality.

RESULTS

The results showed that weight loss, in patients undergoing SG, is accompanied by a reduced BMI and a marked improvement in blood chemistry, confirming what has already been shown in many other studies, but the most interesting finding was the effect of SG on the instrumental markers of atherosclerosis. In particular, carotid IMT was significantly reduced (p < 0.001) and FMD significantly improved. MAPSE and TAPSE also improved significantly at both follow-up assessments (p < 0.001).

CONCLUSIONS

This study suggests that SG should be considered from a broader perspective, i.e. as a weight loss treatment that also improves obesity-related morbidity and mortality, benefitting both the patient and, in an economic sense, the society as a whole.

Pulse wave velocity measurement as a marker of arterial stiffness in pediatric inflammatory bowel disease: a pilot study

In adults with inflammatory bowel disease (IBD), the incidence of cardiovascular events is increased, leading to long-term morbidity. Arterial stiffness (AS) measured by pulse wave velocity (PWV) is a validated early precursor of cardiovascular disease (CVD), and measurement of PWV was shown to be a feasible test in children. The aim of this study was to assess AS in children with IBD. In this prospective study, we determined PWV between the carotid and femoral artery (PWV_cf) in 25 children and adolescents with IBD (11 females, median age 14.1 years, median disease duration 2.8 years). The majority (68%) of the subjects were in clinical remission, and 48% received anti-tumor necrosis factor alpha (TNFα) treatment. AS was not increased in this cohort of children and adolescents with IBD, who did not have signs of cardiovascular disease, such as arterial hypertension.

CONCLUSION

PWV seems to be normal in children with IBD in remission or with mild disease activity. Larger studies should assess its potential role as a valid and non-invasive follow-up marker in children with IBD, to avoid cardiovascular complications. What is Known : • Inflammatory bowel disease (IBD) is a risk factor of cardiovascular disease (CVD). • Pulse wave velocity (PWV) measurement is the current gold standard to assess arterial stiffness (AS), which is an early predictor of CVD. What is New: • This is the first study using PWV measurements to determine AS in children with IBD. • In children with IBD in remission or only mild disease activity AS is not increased.

Speckle Tracking Stress Echocardiography Uncovers Early Subclinical Cardiac Involvement in Pediatric Patients with Inflammatory Bowel Diseases

Inflammatory bowel disease (IBD) is an established risk factor for cardiovascular disease (CVD). However, whether cardiac consequences present early in IBD is unknown. This is the first study in children aiming to unmask altered myocardial mechanics in IBD. We enrolled 50 consecutive normotensive children with Crohn’s disease (CD) (n = 28) or ulcerative colitis (UC) (n = 22). The study groups consisted of 18 patients with active inflammatory disease (mean age 14.6 ± 2.5 years) and 32 children with IBD in remission (14.3 ± 2.3 years). 60 age- and gender-matched children served as healthy controls. Speckle tracking stress echocardiography (STE) was used to assess left ventricular (LV) myocardial strain and strain rate. Circumferential strain rate was significantly decreased in children with active IBD (−1.55 ± 0.26 s⁻¹) and IBD in remission (−1.49 ± 0.26 s⁻¹) versus healthy controls (1.8 ± 0.4 s⁻¹) both at rest (p < 0.001) and during exercise (p = 0.021). Moreover, longitudinal strain rate, circumferential strain and E/E′ ratio were significantly impaired in IBD. Pediatric patients with IBD feature subclinical signs of LV systolic and diastolic myocardial impairment early in the course of CD and UC. This may not be reversible even when IBD is clinically controlled. Patients with IBD should be regularly screened for signs of CVD.

Increased expression of markers of early atherosclerosis in patients with inflammatory bowel disease

BACKGROUND & AIMS

Recent studies documented an increased cardiovascular risk in patients with inflammatory bowel disease (IBD). Our study aimed at investigating the prevalence of intima-media thickness (IMT) of the carotid arteries and the arterial stiffness indices as markers of early atherosclerosis in young IBD patients.

METHODS

We recruited 68 consecutive IBD patients, and 38 matched healthy controls less than 45years old (median age 31.6±8.1years). Clinical and demographic features, cardiovascular risk factors, history of cardiovascular events, concomitant therapies were registered on a dedicate database. Carotid IMT was evaluated by using high resolution B-mode ultrasonography. Arterial stiffness was assessed by measurement of carotid-femoral Pulse Wave Velocity (PWV) and Augmentation Index (AIx).

RESULTS

Total cholesterol (P<0.013) and LDL-cholesterol (P<0.019) levels were significantly lower in IBD patients compared to controls. Carotid IMT was higher in IBD than in controls (P<0.047), but there was no statistically significant difference among Crohn's Disease (CD) and Ulcerative Colitis (UC) patients. Moreover, PWV and AIx were significantly higher in patients as compared to controls (P<0.006 and P<0.004 respectively). No medication seemed to affect vascular measurements, though stiffness parameters were significantly higher in patients treated with 5-ASA (11.9 (9.7) vs 18.2 (10.2), P<0.021), suggesting a lack of efficacy of 5-ASA in protecting IBD patients from early atherogenesis.

CONCLUSIONS

Young IBD patients show an increase in subclinical markers of atherosclerosis. Future studies need to address whether these markers result in an increased risk of cardiovascular events in these patient.

Cardiovascular risk in chronic autoimmune thyroiditis and subclinical hypothyroidism patients. A cluster analysis

BACKGROUND

Subclinical hypothyroidism (SCH) and chronic autoimmune thyroiditis (CAT) are linked to an increased risk of atherosclerosis and coronary heart disease (CHD). The aim of this study was to look for positive markers of CHD and correlations with thyroid blood tests in patients with SCH or CAT, but no symptoms of CHD, so as to identify CHD risk conditions that otherwise would likely be missed.

METHODS

We measured a series of thyroid, clinical-metabolic and cardiovascular parameters in 30 consecutive endocrinology patients enrolled in our ambulatory endocrinological referral center of "Sapienza" University of Rome. (19 with CAT, 11 with SCH) from January 2015 to March 2015. 13 asymptomatic subjects were enrolled as controls. In each patient, we measured a series of 34 thyroid, clinical-metabolic and cardiovascular parameters.

RESULTS

in the statistical analysis of collected data, the oblique principal components clustering procedure (OPC) revealed the presence of an interesting mixed cluster, composed of a thyroid parameter (TPO-Ab), a metabolic parameter (homocysteine level) and a cardiovascular parameter (MAPSE), in which we assessed the relationships between the single components. Our preliminary results indicate that in both groups of patients elevated TPO-Ab, when accompanied by reduced MAPSE and increased IMT and homocysteine values, may be taken to indicate the presence of clinically unrecognized CHD.

CONCLUSIONS

Confirmation of these results in larger series of patients could justify hormone therapy for prevention of CHD in these thyroid patients versus placebo treatment.

Evaluation of Early Atherosclerosis Markers in Patients with Inflammatory Bowel Disease

BACKGROUND The aim of this study was to investigate relationships between early atherosclerosis and inflammatory bowel disease (IBD) using laboratory, functional, and morphological markers of atherosclerosis. MATERIAL AND METHODS In the present prospective single-center study, 96 patients with IBD (58 patients with ulcerative colitis and 36 patients with Crohn's disease) and 65 healthy control subjects were included. The demographic data of each patient and control subject were recorded. The patients with IBD and healthy controls were compared in terms of the carotid intima-media thickness (CIMT), the values of flow-mediated dilatation (FMD) and nitroglycerine-mediated dilatation (NMD), and the levels of von Willebrand factor antigen (VWF-Ag), D-dimer, and lipoprotein (a). RESULTS There were no significant differences between the IBD patients and controls in terms of age, sex, BMI, systolic and diastolic BPs, serum levels of total cholesterol, low-density lipoprotein, or triglycerides. IBD patients had significantly higher levels of VWF-Ag (156.6±58.9 vs. 104.2±43.3, P<0.001) and D-dimer (337.2±710.8 vs. 175.9±110.9, P<0.001) as compared to the controls. No significant differences were determined between the 2 groups in terms of FMD and NMD values. Although statistically not significant, the CIMT values were higher in the IBD patients than in the controls (0.517±0.141 mm vs. 0.467±0.099 mm, P=0.073). In the correlation analysis, the CIMT was found to be correlated negatively with FMD and positively with high sensitive C-reactive protein, VWF-Ag, and D-dimer. CONCLUSIONS These findings suggest that VWF-Ag and D-dimer can be beneficial early atherosclerosis markers in IBD patients.

Epicardial Adipose Tissue Is Increased in Patients With Inflammatory Bowel Disease

OBJECTIVES

Patients with inflammatory bowel disease (IBD) have high cardiovascular morbidity, and, in general, epicardial adipose tissue thickness is related to atherosclerotic vascular disease. This study aimed to investigate the association between epicardial adipose tissue thickness and carotid intima-media thickness as markers of early atherosclerosis in patients with IBD.

METHODS

The study comprised 47 patients with IBD (25 with Crohn disease and 22 with ulcerative colitis) and 35 control participants. In all individuals, epicardial adipose tissue and carotid intima-media thickness values were measured by sonography.

RESULTS

The mean age ± SD of the 47 patients with IBD was 42.3 ± 11.2 years, versus 41.4 ± 10.1 years for the control group. The epicardial adipose tissue thickness was higher in both the Crohn disease and ulcerative colitis groups compared to the control group (P < .001), but not the carotid intima-media thickness (P = .695 and .917, respectively). There was a strong positive correlation between the carotid intima-media and epicardial adipose tissue thickness values in the Crohn disease and ulcerative colitis groups (r = 0.757; 95% confidence interval, 0.711-0.901; r = 0.786; 95% confidence interval, 0.364-0.615; both P < .001). However, there was no significant difference between the patients who were in the active and inactive disease periods in both groups in terms of carotid intima-media and epicardial adipose tissue thickness values.

CONCLUSIONS

Our findings suggest that epicardial adipose tissue thickness might be a marker for detection of early atherosclerosis in patients with IBD. There was a strong positive correlation between carotid intima-media thickness and epicardial adipose tissue thickness values in the patients with IBD. However, there was no correlation between IBD activity and carotid intima-media or epicardial adipose tissue thickness.

Assessment of Endothelial Dysfunction With Adhesion Molecules in Patients With Celiac Disease

OBJECTIVES

Celiac disease (CD) is a systemic immune disorder. We assessed serum levels of adhesion molecules as a marker of endothelial dysfunction in patients with CD at first diagnosis and in those on a gluten-free diet.

METHODS

Sixty-five patients with CD (mean age 6.74 ± 4.6 years) and 51 age- and sex-matched control patients participated in the present case-controlled, prospective clinical study. Serum levels of vascular adhesion molecule-1, intercellular adhesion molecule-1, endothelial selectin, vascular endothelial cadherin, high-sensitivity C-reactive protein, and homocysteine levels were measured.

RESULTS

Average soluble vascular adhesion molecule-1 (CD vs control group: 1320 ± 308 vs 1120 ± 406 ng/mL, P = 0.006), soluble intercellular adhesion molecule-1 (336 ± 99 vs 263 ± 67 ng/mL, P = 0.025), and soluble endothelial selectin (113.9 ± 70 vs 76.9 ± 32 ng/mL, P = 0.007) levels were significantly higher in cases of newly diagnosed CD than in the control group. Soluble vascular adhesion molecule-1 (1050 ± 190 ng/mL) and soluble endothelial selectin (68.7 ± 45 ng/mL) levels in patients with CD, who were fully compliant with a gluten-free diet, were significantly lower than that in those newly diagnosed as having CD (P = 0.003 and P = 0.0012, respectively).

CONCLUSIONS

These results show that serum adhesion molecule levels are higher in patients with CD. Some of the risks associated with endothelial dysfunction may be related to CD and these risks can be reduced with an appropriate and fully controlled diet.

Subclinical Atherosclerosis in Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis

We evaluated the differences in major markers of cardiovascular (CV) risk between inflammatory bowel diseases (IBDs) and controls by a systematic review and a meta-analysis. We searched PubMed, EMBASE, and Cochrane databases for literature comparing CV risk markers in IBDs and controls. The overall mean carotid intima-media thickness (CIMT), flow-mediated dilation (FMD%), and carotid-femoral pulse wave velocity (cfPWV) difference between patients with IBDs and control groups were calculated. Twenty-eight studies were included in the meta-analysis, including 16 studies with data on CIMT, 7 studies reporting FMD%, and 9 studies on cfPWV. Compared to controls, patients with IBDs showed significantly higher CIMT (standardized mean difference [ SMD]: 0.534 mm; 95% confidence interval [CI], 0.230 to 0.838; P = .001), significantly lower FMD% ( SMD, -0.721%; 95% CI, -1.020 to -0.421; P < .0001), and significantly increased cfPWV ( SMD, 0.849; 95% CI, 0.589 to 1.110; P < .0001). When analyzing subgroups with ulcerative colitis and Crohn disease (CD), all results were still significant except CIMT in CD. Our findings support the current evidence for an elevated CV burden in patients with IBD and support the clinical utility of markers of subclinical atherosclerosis in the management of these patients.

Inflammatory and Lipid-Associated Markers of Cardiovascular Diseases in Children with First Exacerbation of Inflammatory Bowel Disease

Background

Adult patients with inflammatory bowel disease (IBD) are at increased risk of early atherosclerosis and atherosclerosis-driven cardiovascular diseases. However, data on the development of early, subclinical atherosclerosis in children with IBD are scarce. The aim of this study was to assess selected biomarkers of atherosclerosis in children with IBD.

Material/Methods

The study group comprised 30 children with first exacerbation of IBD. Twenty healthy children were enrolled into the control group. Total cholesterol, triglycerides, low-density lipoproteins (LDL), high-density lipoproteins (HDL), lipoprotein (a) (Lp(a)), interleukin 6 (Il-6), high sensitivity C-reactive protein (hs-CRP), and oxidized LDL (ox LDL) were determined.

Results

There were no significant differences in lipids profiles in IBD children and controls. Mean IL-6 level (8.996 pg/ml) was significantly higher in the IBD group compared to controls (3.502 pg/ml). Mean hs-CRP concentration was significantly higher in IBD children than in controls (7.648 and 1.290 μg/ml, respectively). In the IBD group, mean ox-LDL concentration (144.837 ng/ml) was lower than in controls (162.352 ng/ml), but the difference was non-significant (P=0.4). Mean Lp(a) serum level was higher in patients with IBD (19.418 mg/dl) than in controls (10.970 mg/dl), but it was also non-significant.

Conclusions

No significant differences were found in biomarkers of atherosclerosis in children with IBD compared to controls. Elevated IL-6 and hs-CRP level are well-established inflammatory markers. Further studies are needed to fully determine cardiovascular risk factors in IBD children.

Endothelial dysfunction in inflammatory bowel diseases: Pathogenesis, assessment and implications

Endothelial dysfunction is considered one of the etiological factors of inflammatory bowel disease (IBD). An inflammatory process leads to functional and structural changes in the vascular endothelium. An increase of leukocyte adhesiveness and leukocyte diapedesis, as well as an increased vascular smooth muscle tone and procoagulant activity is observed. Structural changes of the vascular endothelium comprise as well capillary and venule remodeling and proliferation of endothelial cells. Hypoxia in the inflammatory area stimulates angiogenesis by up-regulation of vascular endothelial growth factor, fibroblast growth factor and tumor necrosis factor-α. Inflammatory mediators also alter the lymphatic vessel function and impair lymph flow, exacerbating tissue edema and accumulation of dead cells and bacteria. The endothelial dysfunction might be diagnosed by the use of two main methods: physical and biochemical. Physical methods are based on the assessment of large arteries vasodilatation in response to an increased flow and receptors stimulation. Flow-mediated vasodilatation (FMD) is the method that is the most widely used; however, it is less sensitive in detecting early changes of the endothelium function. Most of the studies demonstrated a decrease of FMD in IBD patients but no changes in the carotic intima-media thickness. Biochemical methods of detecting the endothelial dysfunction are based on the assessment of the synthesis of compounds produced both by the normal and damaged endothelium. The endothelial dysfunction is considered an initial step in the pathogenesis of atherosclerosis in the general population. In IBD patients, the risk of cardiovascular diseases is controversial. Large, prospective studies are needed to establish the role of particular medications or dietary elements in the endothelial dysfunction as well to determine the real risk of cardiovascular diseases.

Effect of Inflammatory Bowel Disease-Related Characteristics and Treatment Interventions on Cardiovascular Disease Incidence

BACKGROUND

An association between inflammatory bowel disease (IBD) and cardiovascular diseases has been shown in multiple studies. However, little is known about the effect of IBD-related characteristics on cardiovascular events.

METHODS

The authors conducted a retrospective, nested case-control study of IBD patients who presented to the institution from 2000 to 2004, allowing for a 10-year follow-up period. One hundred eleven patients who developed cardiovascular events (cases) and 222 patients who did not develop cardiovascular events (cases) were included in the study after matching for Framingham cardiovascular risk score (2008). Relationships between predictor variables and cardiovascular outcome were assessed by conditional logistic regression.

RESULTS

The cases and controls were similar in age, gender, smoking and cholesterol level. There was no difference in disease subtype (ulcerative colitis or Crohn's disease). On conditional logistic regression, thiopurine treatment (odds ratio [OR]: 0.42, 95% confidence interval [CI]: 0.19-0.87; P = 0.02) was associated with decreased cardiovascular events and tumor necrosis factor alpha antagonist use (OR: 2.63, 95% CI: 1.49-4.63; P = 0.001) was associated with increased cardiovascular events. Although not statistically significant, disease-related surgery (OR: 0.57, 95% CI: 0.32-1.02; P = 0.06) was associated with decreased cardiovascular events and disease-related hospitalization (OR: 1.58, 95% CI: 0.96-2.57; P = 0.07) was associated with increased incidence of cardiovascular disorders.

CONCLUSIONS

The authors observed decreased incidence of cardiovascular diseases in patients with IBD who were treated with thiopurines and increased incidence of cardiovascular outcomes among patients treated with tumor necrosis factor alpha antagonist.

Is Carotid Stenosis in Women a Gender-Related Condition?

BACKGROUND

We set out to study, through ultrasound examinations, the carotid bifurcation in men and women with/without carotid stenosis to look for anatomical and electrophysiologic differences. We evaluated other variables to look for differences that might explain the dissimilar behavior of this disease in the two sexes and the presence and impact of risk factors.

METHODS

We examined 974 subjects aged 25 to 88 years (478 men and 496 women) in whom we considered heart rate, smoking status, and the presence of hypertension, diabetes, hypercholesterolemia, and hypertriglyceridemia. Ultrasound examination of the neck vessels included measurement of intimal medial thickness (IMT), vessel diameter, and outflow area/inflow area ratio. We established plaque location, echogenicity and echostructure, and the percentage of stenosis owing to plaque and measured systolic velocity, flow direction, and the depth of detection of these parameters. We used the apnea and hyperpnea test to assess cerebrovascular reactivity.

RESULTS

Hypertension and hypercholesterolemia were the most frequent risk factors. Women had a higher heart rate, whereas men had significantly greater IMT. The presence of atheromatous plaque was significantly correlated with age in both sexes, with men having a higher prevalence of carotid plaques. The sexes differed significantly with regard to plaque location, echogenicity, echostructure, and intracranial circulation. Women had a slightly higher blood flow velocity in the intracranial arteries. Risk factors affected plaque formation and extent more in men than in women.

CONCLUSIONS

These findings suggest that carotid stenosis is a gender-related trait.

Arterial structure and function in inflammatory bowel disease

Inflammatory bowel disease (IBD) is the result of a combination of environmental, genetic and immunologic factors that trigger an uncontrolled immune response within the intestine, which results in inflammation among genetically predisposed individuals. Several studies have reported that the prevalence of classic cardiovascular risk factors is lower among subjects with IBD than in the general population, including obesity, dyslipidaemia, diabetes and hypertension. Therefore, given the risk profile of IBD subjects, the expected cardiovascular morbidity and mortality should be lower in these patients than in the general population. However, this is not the case because the standardized mortality ratio is not reduced and the risk of coronary heart disease is increased in patients with IBD. It is reasonable to hypothesize that other factors not considered in the classical stratification of cardiovascular risk may be involved in these subjects. Therefore, IBD may be a useful model with which to evaluate the effects of chronic low-grade inflammation in the development of cardiovascular diseases. Arterial stiffness is both a marker of subclinical target organ damage and a cardiovascular risk factor. In diseases characterized by chronic systemic inflammation, there is evidence that the inflammation affects arterial properties and induces both endothelial dysfunction and arterial stiffening. It has been reported that decreasing inflammation via anti tumor necrosis factor alpha therapy decreases arterial stiffness and restores endothelial function in patients with chronic inflammatory disorders. Consistent with these results, several recent studies have been conducted to determine whether arterial properties are altered among patients with IBD. In this review, we discuss the evidence pertaining to arterial structure and function and present the available data regarding arterial stiffness and endothelial function in patients with IBD.

Infectious diseases are associated with carotid intima media thickness in adolescence

OBJECTIVE

Inflammatory risk factors in childhood, e.g. obesity, impact on carotid artery intima media thickness (CIMT), an early indicator of atherosclerosis. Little is known on potential infectious origins in childhood. We investigated the association between number of reported different childhood infectious diseases and CIMT in adolescence.

STUDY DESIGN

288 SAPALDIA offspring (8-21years) underwent a clinical examination in 2010-2011: anthropometry, blood pressure, CIMT, blood draw (cardiovascular biomarkers, cotinine). Offspring and parents gave information on individuals' and family health, child's vaccination status, infectious diseases and other early life factors. Life-time prevalence of bronchitis, pneumonia, tonsillitis, otitis, mononucleosis, meningitis, appendicitis, and scarlet fever were investigated, separately, and as cumulative infectious disease score. Multilevel adjusted linear regression analysis on the association between subjects' CIMT average and infectious diseases score was performed, stratifying by sex.

RESULTS

Youth (mean age 14.8 yrs; 53% female) reported on average 1.3 of the listed infectious diseases; 22% boys and 15% girls reported ≥3 infectious diseases (p = 0.136). Two-thirds were vaccinated according to recommendations (boys 56%, girls 61.5%, p = 0.567). Sex-stratified analyses yielded significantly increased CIMT in boys with ≥3 infectious diseases vs. none (0.046 mm, 95%CI 0.024; 0.068). In girls, the effect was of same direction but statistically non-significant (0.011 mm, 95%CI -0.015; 0.036).

CONCLUSION

The SAPALDIA Youth study complements current evidence on infectious origins of atherosclerosis in adults. The larger effects observed in boys may relate to a higher vulnerability of the vasculature and/or to infectious pathogens. Our data are suggestive of an early impact of childhood infectious diseases on vascular health.

Impact of Health Status and Lifestyle Modifications on Vascular Structure and Function in Children and Adolescents

Until recently cardiovascular disease is often thought of as a disease that manifests itself during middle age. Researchers and clinicians have begun to realize that the initial signs of cardiovascular disease begin early on in childhood with changes present in both vascular structure and function. This increased recognition has resulted in considerable effort to develop accurate and reliable methods to measure as well as track changes in vascular structure and function applicable to study this process in children and adolescents. Certain genetic abnormalities and chronic diseases, which present or emerge in childhood often result in meaningful changes to vascular structure and function, which aid in our understanding of the vascular disease process. In this review, we will discuss different methods of assessing vascular structure and function, the diseases in childhood associated with decrements and maladaptive changes in the vascular system, and whether modification of lifestyle (ie, weight loss, dietary and/or exercise changes) can affect vascular structure and function in children.

Combination of Azathioprine and Aminosalicylate Treatment Prevent Risk of Cardiovascular Disease in Women with Ulcerative Colitis by Reducing Inflammation

Background

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with involvement of the immune system. Chronic inflammatory diseases have been associated with increased risk of cardiovascular disease (CVD) but few studies have assessed this risk in patients with UC and the influence of drug treatment. Thus, we evaluated the risk of development of CVD in women with UC in clinical remission, considering the drug treatment.

Material/Methods

Twenty-one women with UC participated in this study: 12 used aminosalicylates (ASA group) and 9 used azathioprine added to aminosalicylates (AZA+ASA group). The healthy control group was matched for age. We evaluated blood pressure, body composition, and biochemical and immunological parameters.

Results

Compared to the respective control group, the UC groups showed expansion of body fat and less lean body mass. Blood pressure, pro-inflammatory cytokines, nitric oxide, C reactive protein, erythrocyte sedimentation rate (ESR), and anti-oxidized LDL antibodies were higher in UC groups. Only AZA+ASA group showed increased anti-inflammatory cytokines (IL-10 and TGF-β). Framingham scores showed higher risk of CVD in UC groups. UC groups were compared and women treated with azathioprine showed reduction of total protein, globulin, ESR, and lymphocytes, with increased IL-6, TNF, IL-10, and TGF-β.

Conclusions

Our data suggest that women with UC in clinical remission have a higher risk for development of atherosclerosis and CVD when compared to the control group, while women treated with azathioprine seem more protected than those treated only with aminosalicylates, due to better regulation of the inflammatory process.

Aortic Intima-Media Thickness as an Early Marker of Atherosclerosis in Children With Inflammatory Bowel Disease

OBJECTIVES

The aims of this study were to determine the presence of endothelial dysfunction by measuring aortic intima-media thickness (aIMT) and carotid intima-media thickness (cIMT) and to evaluate the role of traditional risk factors for premature atherosclerosis in children with inflammatory bowel disease (IBD).

METHODS

Thirty-four children with IBD (25 Crohn disease [CD] and 9 ulcerative colitis [UC]; mean age 11.1 years) and 27 healthy subjects matched for sex and age were enrolled. In all of the patients, demographic characteristics and risk factors for atherosclerosis (age, sex, body mass index, blood pressure, dyslipidemia, active and passive smoking, and family history for cardiovascular diseases), CD and UC clinical activity scores, and inflammatory markers were evaluated. aIMT and cIMT were measured by high-resolution B-mode ultrasound.

RESULTS

aIMT was significantly higher in patients than in controls (P < 0.0005). No significant differences were found for cIMT, although the carotid thickness was higher in patients with IBD than in healthy subjects. At a univariate analysis, inflammatory markers levels and tobacco smoking exposure were significantly related to higher aIMT values, whereas in a multivariate regression model, the inflammatory status was the only independent variable correlated with high aIMT.

CONCLUSIONS

aIMT is an earlier marker of preclinical atherosclerosis than cIMT in young children with active IBD. The inflammatory status and the smoking exposure are significantly correlated with the premature endothelial dysfunction. These data emphasize the importance of controlling the chronic intestinal inflammation and endorsing smoke-free environments for children and adolescents with IBD.

Epidemiology, risk factors and management of cardiovascular diseases in IBD

IBD is an established risk factor for venous thromboembolism. In the past few years, studies have suggested that patients with IBD might also be at an increased risk of coronary heart disease and stroke. The increased risk is thought to be similar to the level of risk seen in patients with other chronic systemic inflammatory diseases such as rheumatoid arthritis. The risk of developing these conditions is particularly increased in young adults with IBD, and more so in women than in men. Conventional cardiovascular risk factors are not over-represented in patients with IBD, so the increased risk could be attributable to inflammation-mediated atherosclerosis. Patients with IBD often have premature atherosclerosis and have biochemical and genetic markers similar to those seen in patients with atherosclerotic cardiovascular disease. The role of chronic inflammation in IBD-associated cardiovascular disease merits further evaluation. Particular attention should be given to the increased risk observed during periods of increased disease activity and potential modification of the risk by immunosuppressive and biologic therapies for IBD that can modify the disease activity. In addition, preclinical studies suggest that cardiovascular medications such as statins and angiotensin-converting enzyme inhibitors might also favourably modify IBD disease activity, which warrants further evaluation.

Lipoprotein-associated phospholipase A2 and arterial stiffness evaluation in patients with inflammatory bowel diseases

BACKGROUND AND AIMS

The association between inflammatory bowel diseases (IBD) and cardiovascular disease (CVD) remains equivocal. Arterial stiffness, as assessed by pulse wave velocity (PWV), and lipoprotein-associated phospholipase A2 (Lp-PLA2) are surrogates of CVD risk.

AIM

The aim of this study was to assess carotid-femoral PWV and Lp-PLA2 in patients with IBD without history of CVD.

METHODS

Established CVD risk factors, IBD characteristics, PWV and Lp-PLA2 activity were assessed in 44 patients with IBD, 29 with Crohn's disease (CD) and 15 with ulcerative colitis (UC), and 44 matched controls.

RESULTS

IBD patients had lower total and low density lipoprotein cholesterol (LDL-C) levels. There was no difference in PWV between patients and controls (6.8 vs. 6.4m/s), but patients with CD had higher PWV compared to those with UC (7 vs. 6.3m/s; p=0.044), and to controls. Smoking rates were significantly higher among CD patients. Factors associated with PWV were age, mean arterial pressure and smoking. Lp-PLA2 activity was significantly lower in patients with IBD (46.8 vs. 53.9 nmol/mL/min; p=0.011). There was no difference in Lp-PLA2 between CD and UC patients. LDL-C was the only significant predictor of Lp-PLA2.

CONCLUSIONS

Our study showed lower Lp-PLA2 activity in patients with IBD compared with controls, reflecting lower LDL-C in the former. There was no difference in PWV between the two groups. Arterial stiffness was higher in patients with CD, which is likely related to higher smoking rates. These findings challenge a possible association between IBD and CVD, but further studies are required.

Impaired coronary microvascular and left ventricular diastolic function in patients with inflammatory bowel disease

BACKGROUND AND AIM

Increased incidence of coronary vascular events in patients with inflammatory bowel disease (IBD) is known. However, the association between coronary microvascular function and IBD has not been fully defined. We aimed to investigate whether coronary flow reserve (CFR) and left ventricular diastolic function were impaired in IBD patients.

METHODS

Seventy-two patients with IBD (36 patients with ulcerative colitis [UC] and 36 Crohn's disease [CD]) were registered. Each subject was evaluated after a minimum 15-day attack-free period. For the control group, 36 age- and sex-matched healthy volunteers were included into the study. IBD clinical disease activity in UC was assessed by the Truelove-Witts Index (TWAS) and in CD by the Crohn's Disease Activity Index (CDAI). In each subject, CFR was measured through transthoracic Doppler echocardiography.

RESULTS

Compared to the controls, the CD group and UC group had significantly higher high-sensitivity C-reactive protein (hs-CRP) and erythrocyte sedimentation rate. Baseline diastolic peak flow velocity (DPFV) of the left anterior descending artery (LAD) was significantly higher in the IBD group (24.1±3.9 vs. 22. 4±2.9, p<0.05), and hyperemic DPFV (56.1±12.5 vs. 70.6±15.3, p<0.05) and CFR (2.34±0.44 vs. 3.14±0.54, p<0.05) were significantly lower in the IBD group than in the control group. In stepwise linear regression analysis, hs-CRP and lateral Em/Am ratio were independently correlated with CFR.

CONCLUSION

CFR, reflecting coronary microvascular function, is impaired in patients with IBD. CFR and left ventricular diastolic function parameters are well correlated with hs-CRP.

Endothelial dysfunction in chronic inflammatory diseases

Chronic inflammatory diseases are associated with accelerated atherosclerosis and increased risk of cardiovascular diseases (CVD). As the pathogenesis of atherosclerosis is increasingly recognized as an inflammatory process, similarities between atherosclerosis and systemic inflammatory diseases such as rheumatoid arthritis, inflammatory bowel diseases, lupus, psoriasis, spondyloarthritis and others have become a topic of interest. Endothelial dysfunction represents a key step in the initiation and maintenance of atherosclerosis and may serve as a marker for future risk of cardiovascular events. Patients with chronic inflammatory diseases manifest endothelial dysfunction, often early in the course of the disease. Therefore, mechanisms linking systemic inflammatory diseases and atherosclerosis may be best understood at the level of the endothelium. Multiple factors, including circulating inflammatory cytokines, TNF-α (tumor necrosis factor-α), reactive oxygen species, oxidized LDL (low density lipoprotein), autoantibodies and traditional risk factors directly and indirectly activate endothelial cells, leading to impaired vascular relaxation, increased leukocyte adhesion, increased endothelial permeability and generation of a pro-thrombotic state. Pharmacologic agents directed against TNF-α-mediated inflammation may decrease the risk of endothelial dysfunction and cardiovascular disease in these patients. Understanding the precise mechanisms driving endothelial dysfunction in patients with systemic inflammatory diseases may help elucidate the pathogenesis of atherosclerosis in the general population.

Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies

OBJECTIVE

Patients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial.

DESIGN

We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD.

RESULTS

33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67-2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91-1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78-3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95-3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19-1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78-6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93-1.14).

CONCLUSION

The risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia.