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Nygaard L, Polcwiartek C, Nelveg-Kristensen KE, Carlson N, Kristensen S, Torp-Pedersen C, Gregersen JW. Increased risk of cardiovascular disease preceding diagnosis of incident ANCA-associated vasculitis: a Danish nationwide study. Rheumatology (Oxford) 2024; 63:1313-1321. [PMID: 37481712 DOI: 10.1093/rheumatology/kead377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/30/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE To examine whether patients with ANCA-associated vasculitis (AAV) have an increased risk of cardiovascular disease in the months prior to diagnosis of AAV. METHODS Using a nested case-control framework, patients with granulomatosis with polyangiitis and microscopic polyangiitis were identified through the Danish Nationwide Registries from 1996 to 2021 and matched 1:3 with age- and sex-matched controls without AAV. Each control was assigned the same index date (date of AAV diagnosis) as their corresponding case. Conditional logistic regression was used to compute adjusted hazard ratios (HRs) for major adverse cardiovascular events (MACE), ischaemic heart disease, coronary angiogram, heart failure, venous thromboembolism, atrial fibrillation, ischaemic stroke, pericarditis and ventricular arrhythmias/implantable cardioverter defibrillator implantation/cardiac arrest (VA/ICD/CA) within 12 months, 6 months, 3 months, 2 months and 1 month before index date. RESULTS A total of 2371 patients with AAV (median age 63 years, 53.7% male) were matched with 7113 controls. The prevalence of any cardiovascular outcome and MACE within 12 months preceding index date were 10.3% and 2.4% for AAV, compared with 3.8% [HR 3.05 (95% CI 2.48-3.75)] and 1.3% [HR 1.98 (95% CI 1.39-2.82)] of controls. The risk of cardiovascular outcomes was similarly increased in temporal proximity to the diagnosis, with the highest HR at 1 month prior to index date: any cardiovascular outcome [HR 10.73 (95% CI 7.05-16.32)] and MACE [HR 5.78 (95% CI 2.67-12.52)]. In individual analysis, a significantly higher rate was observed for all outcomes (excluding VA/ICD/CA). CONCLUSIONS AAV disease is associated with an increased risk of cardiovascular disease in the months preceding diagnosis, which underlines the importance of early clinical vigilance towards cardiovascular disease.
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Affiliation(s)
- Louis Nygaard
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- SLE and Vasculitis Clinic, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christoffer Polcwiartek
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital, Copenhagen, Denmark
- Research Department, The Danish Heart Foundation, Copenhagen, Denmark
| | - Salome Kristensen
- SLE and Vasculitis Clinic, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jon Waarst Gregersen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- SLE and Vasculitis Clinic, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Vegting Y, Penne EL, Hilhorst ML, Hoekstra T, Bemelman FJ, Vogt L, Voskuyl AE, Pagnoux C, Houben E. Traditional and disease-related cardiovascular risk factors in ANCA-associated vasculitis: A prospective, two-centre cohort study. Joint Bone Spine 2023; 90:105540. [PMID: 36758893 DOI: 10.1016/j.jbspin.2023.105540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/27/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES ANCA-associated vasculitis (AAV) has been associated with increased risk of cardiovascular (CV) events. The aim was to assess traditional and disease-related CV risk determinants in a two-centre prospective cohort of AAV patients. METHODS Patients were recruited from centres in the Netherlands and Canada. A comprehensive CV risk assessment was performed at inclusion. Subjects were followed up yearly for 3-5 years until the first CV event, death or end of follow-up. Cox proportional hazards analyses were performed to relate baseline characteristics to the first CV event. RESULTS A total of 144 patients were included (mean age 62 years, female sex 44%, median Framingham risk score 14.3%). Insulin resistance was present in 73% of patients tested at inclusion, independent of concurrent prednisone therapy. After a median follow-up of 2.90 years, 16 patients (11%) experienced a CV event (14 non-fatal and 2 fatal). The incidence of CV events was 5.45 per 100 patient-years. Age, Framingham risk score, HbA1c level, Diabetes Mellitus (DM), and previous CV event were significantly associated with CV events. Other factors, such as sex, impaired renal function, dyslipidemia, hypertension, smoking history and microalbuminuria, or disease-specific variables, like ANCA serotype or disease activity, were not significantly related to CV events in univariable or age-adjusted cox regression analysis. CONCLUSIONS Determinants of an increased CV risk were identified. Disease-related factors and treatments can further modify individual risk factors, such as for steroids causing chronic insulin resistance and DM. Treatment of risk factors is essential to optimize long-term outcomes in AAV patients.
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Affiliation(s)
- Yosta Vegting
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands; Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands; Amsterdam institute for Infection and Immunity, Inflammatory diseases, Amsterdam, The Netherlands.
| | - Erik L Penne
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Marc L Hilhorst
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands
| | - Tiny Hoekstra
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederike J Bemelman
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Christian Pagnoux
- Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada
| | - Eline Houben
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands; Department of Internal Medicine, Section of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Khan S, Rizvi TA, Velaga ST, Ling JC, Makhoul Wahbah G, Asogwa N, Ahmed M, Lafferty JC. A Rare Case of High-Grade Atrioventricular Block in Granulomatosis With Polyangiitis. Cureus 2023; 15:e34774. [PMID: 36909020 PMCID: PMC10004416 DOI: 10.7759/cureus.34774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2023] [Indexed: 02/10/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is an autoimmune disease that affects small and medium-sized vessels. It is classically known to present with renal and respiratory tract symptoms. However, the disease can manifest in other organ systems, especially cardiovascular involvement. Though there are multiple reports of cardiac involvement in GPA, it is not commonly evaluated and is often overlooked in patients with GPA. Heart disease in GPA has a wide range of presentations ranging from subacute and silent to severe abnormalities, which can prove fatal if not identified and treated appropriately. Identifying cardiac involvement early in patients with no apparent signs can help with prevention strategies and follow-up to avoid significant complications. Pericarditis is the most common pathology noted in GPA, followed by cardiomyopathy, coronary artery disease, valvular disease, and conduction abnormality. In our report, we present a case of GPA in a young male with asymptomatic conduction abnormality of the heart. Although it was silent at the presentation, identifying the initial electrocardiogram (ECG) changes prompted us to admit him to the telemetry floor. Continuous telemetry monitoring helped us identify the progression of the conduction abnormality, which otherwise could have been missed. This led us to correlate to his symptoms which he later developed during his admission course. His symptoms subsided after prompt treatment. If not identified early, these cardiac abnormalities can delay management, leading to increased disease burden and morbidity. Hence, essential cardiac work with at least ECG and continuous telemetry monitoring is recommended.
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Affiliation(s)
- Shahkar Khan
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Taqi A Rizvi
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Saran Teja Velaga
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Joanne C Ling
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | | | - Nnedindu Asogwa
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Mustafa Ahmed
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - James C Lafferty
- Cardiology, Northwell Health/Staten Island University Hospital, Staten Island, USA
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Nygaard L, Polcwiartek C, Nelveg-Kristensen KE, Carlson N, Kristensen S, Torp-Pedersen C, Gregersen JW. Long-term cardiovascular outcomes and temporal trends in patients diagnosed with ANCA-associated vasculitis: a Danish nationwide registry study. Rheumatology (Oxford) 2023; 62:735-746. [PMID: 35788270 DOI: 10.1093/rheumatology/keac386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/25/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To examine long-term cardiovascular outcomes and temporal trends among patients with ANCA-associated vasculitis (AAV) using Danish nationwide registries. METHODS Using a cohort design, we examined patients with granulomatosis with polyangiitis (ICD-10: DM31.3) and microscopic polyangiitis (ICD-10: DM3.17) in Denmark from 1996-2018. Hazard ratios (HRs) of cardiovascular outcomes were compared between patients with AAV and age and gender-matched controls. Counterfactual G-estimation of HRs was performed to estimate 5-year absolute risks. Temporal trends were obtained by grouping cohorts into evenly distributed tertiles according to inclusion year. RESULTS A total of 2306 patients with AAV (median age: 62.9yrs, 52.6% male) were matched with 6918 controls. Median follow-up was 9.5yrs. Patients with AAV had a higher rate of ischaemic heart disease [HR 1.86 (1.62-2.15)], myocardial infarction [HR 1.62 (1.26-2.09)], coronary angiogram [HR 1.64 (1.37-1.96)], percutaneous coronary intervention [HR 1.56 (1.17-2.07)] and ventricular arrhythmias/implantable-cardioverter-defibrillator (ICD)-implantations [HR 2.04 (1.16-3.57)]. Similarly, an increased rate of heart failure [HR 2.12 (1.77-2.54)], deep vein thrombosis [HR 3.13 (2.43-4.05)], pulmonary embolism [HR 4.04 (3.07-5.32)], atrial fibrillation [HR 2.08 (1.82-2.39)], ischaemic stroke [HR 1.58 (1.31-1.90)] and in-hospital cardiac arrest [HR 2.27 (1.49-3.48)] was observed. The 5-year risk of all outcomes were significantly higher (excluding ventricular arrhythmia/ICD-implantations). For temporal trends among patients with AAV, a decreased 3-year risk of cardiovascular mortality was observed over time. CONCLUSIONS Patients with AAV are at increased risk of heart failure, atrial-/ventricular arrhythmias, venous thrombotic events, ischaemic stroke and myocardial infarction. Furthermore, patients with AAV were more frequently examined with coronary procedures and underwent more coronary revascularizations. No temporal changes in ischaemic cardiovascular outcomes were observed, albeit the cardiovascular mortality has decreased over time.
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Affiliation(s)
- Louis Nygaard
- Department of Nephrology.,SLE and Vasculitis Clinic, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University
| | - Christoffer Polcwiartek
- Department of Clinical Medicine, Aalborg University.,Department of Cardiology, Aalborg University Hospital, Aalborg
| | | | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital, Copenhagen.,Research Department, The Danish Heart Foundation
| | - Salome Kristensen
- SLE and Vasculitis Clinic, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University.,Department of Rheumatology, Aalborg University Hospital, Aalborg
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød.,Department of Public Health, Univerity of Copenhagen, Copenhagen, Denmark
| | - Jon Waarst Gregersen
- Department of Nephrology.,SLE and Vasculitis Clinic, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University
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Dammacco R, Biswas J, Mohanan-Earatt A, Lisch W, Zito FA, Rubini G, Manno C, Cicco S, Alessio G, Dammacco F. The eye is a common site of granulomatosis with polyangiitis. A collaborative study. BMC Ophthalmol 2023; 23:26. [PMID: 36653761 PMCID: PMC9850589 DOI: 10.1186/s12886-022-02743-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/16/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Ocular manifestations of granulomatosis with polyangiitis (GPA) have been reported in a limited number of studies and with largely variable frequency. Here we report on the clinical, diagnostic, and therapeutic features of a cohort of 63 GPA patients, with particular regard to 22 of them with ophthalmic involvement (35%). METHODS Clinical manifestations, results of immunological findings, histopathological pictures, imaging data, Birmingham Vasculitis Activity Score, therapeutic regimens, and outcomes were retrospectively analyzed. At diagnosis, in addition to a structured clinical assessment, all patients underwent a comprehensive ophthalmologic examination. RESULTS The most frequently involved organs were kidneys, lungs, ear/nose/throat, and eyes. Ocular manifestations were bilateral in 32%. The three most commonly diagnosed ophthalmologic manifestations were scleritis (36%), retro-orbital pseudotumor or orbital mass (23%), and episcleritis (13%). Ocular and systemic involvement were simultaneously present at onset in 41% of the patients; systemic involvement was followed by ocular lesions in 36%; ocular inflammation was followed by systemic manifestations in 18%; and an orbital mass in the absence of systemic disease characterized 5%. Glucocorticoids plus cyclophosphamide and glucocorticoids plus rituximab were the combined therapies most frequently employed during remission induction and remission maintenance, respectively. Persistent ophthalmologic and extra-ocular remissions were achieved in 77 and 64% of the patients, respectively. One to three systemic relapses were diagnosed in 7 patients (31.8%). At the last follow-up, a visual outcome 20/40 or better in 31 (70%) of 44 eyes was determined. CONCLUSIONS The eye was involved in over one third of our patients with GPA. Increased awareness, early diagnosis, and multi-specialty collaboration are critical in achieving a favorable outcome of GPA.
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Affiliation(s)
- Rosanna Dammacco
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Jyotirmay Biswas
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Amanda Mohanan-Earatt
- grid.414795.a0000 0004 1767 4984Department of Uveitis and Ocular Pathology, Sankara Nethralaya, Chennai, India
| | - Walter Lisch
- grid.5802.f0000 0001 1941 7111Department of Ophthalmology, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Giuseppe Rubini
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, University of Bari Medical School, Bari, Italy
| | - Carlo Manno
- grid.7644.10000 0001 0120 3326Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplant Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Sebastiano Cicco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Giovanni Alessio
- grid.7644.10000 0001 0120 3326Department of Ophthalmology and Neuroscience, University of Bari “Aldo Moro”, Medical School, Bari, Italy
| | - Franco Dammacco
- grid.7644.10000 0001 0120 3326Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Medical School, Bari, Italy
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