Cardiovascular disease in patients with rheumatoid arthritis

Effect of biologic agents and inflammation on lipid levels and cardiovascular risk in rheumatoid arthritis patients

BACKGROUND

Cardiovascular disease (CVD) is the main cause of mortality in Rheumatoid Arthritis (RA).

OBJECTIVE

To investigate the effect of biologic disease modifying anti-rheumatic drugs (bDMARDs) on lipids and CVD risk and evaluate associations with changes in systemic inflammation.

METHODS

Patients with RA initiating a bDMARD were evaluated at baseline, 3 and 6 months later. Longitudinal mixed effects models examined the association of individual biologics with changes in lipid levelsm Reynolds Risk Score (RRS) and Framingham risk score. Mediation by CRP, clinical disease activity index (CDAI) or swollen joint count on lipid changes were modeled using structural equation models. The correlation between CRP changes and LDL changes was estimated. Changes of LDL-C at 6 months among patients with low baseline LDL-C (<90 mg/dl) vs higher baseline LDL-C(90-130, and >130 mg/dl) were compared. The association between LDL-C changes across baseline LDL-C groups and disease activity improvement was evaluated.

RESULTS

1698 bDMARD initiations were analyzed. Patients initiating tocilizumab had a significant increase in lipid levels but RRS at 3 and 6 months was similar across all biologics. Framingham risk score increased for patients treated with tocilizumab. Mediator analyses were statistically significant for the effects of CRP on lipid levels. Increases in LDL-C from baseline were independent of clinical response. An association of changes from baseline CRP and LDL-C were observed across all of the bDMARDs studied.

CONCLUSION

Moderate increases in lipid levels on bDMARD treatment were not associated with an increased CVD risk by RRS regardless of the bDMARD initiated. Changes in CRP were significantly associated with changes in lipids in a mediator analysis.

Subclinical left ventricular dysfunction in rheumatoid arthritis: findings from the prospective Porto-RA cohort

AIM

Patients with rheumatoid arthritis (RA) have an increased risk of cardiac dysfunction and heart failure (HF) due to a pro-inflammatory state. Detecting cardiac dysfunction in RA is challenging as these patients often present preserved ejection fraction (EF) but may have subclinical ventricular dysfunction. Echocardiographic strain analysis is a promising tool for early detection of subclinical left ventricular systolic dysfunction (LVSD). This study assesses the prognostic role of strain analysis in RA.

METHODS AND RESULTS

Prospective study of 277 RA patients without known heart disease and preserved EF, categorized by left ventricular global longitudinal strain (GLS): normal GLS (≤ - 18%) vs. subclinical LVSD (> - 18%). Primary outcome was a composite of myocardial infarction, HF hospitalization, stroke, or cardiovascular death (MACE). Mean age was 57 years, 79% female. Although mean GLS was within normal (- 20 ± 3%), subclinical LVSD was observed in 24% of patients (n = 67) and was positively correlated with older age (OR 1.54 per 10 years; p < 0.001) and comorbid conditions, such as dyslipidemia (OR 2.27; p = 0.004), obesity (OR 2.29; p = 0.015), and chronic kidney disease (OR 8.39; p = 0.012). Subclinical LVSD was independently associated with a 3.9-fold higher risk of MACE (p = 0.003) and a 3.4-fold higher risk of HF hospitalization/cardiovascular death (p = 0.041). A GLS threshold of > - 18.5% provided optimal sensitivity (78%) and specificity (74%) in identifying patients at elevated MACE risk (AUC = 0.78; p < 0.001).

CONCLUSION

Subclinical LVSD, identified by reduced GLS, was strongly associated with adverse cardiovascular events in RA. Whether these findings have therapeutic implications is worth exploring in clinical trials.

Interleukin-receptor antagonist and tumour necrosis factor inhibitors for the primary and secondary prevention of atherosclerotic cardiovascular diseases

BACKGROUND

Atherosclerotic cardiovascular disease (ACVD) is worsened by chronic inflammatory diseases. Interleukin receptor antagonists (IL-RAs) and tumour necrosis factor-alpha (TNF) inhibitors have been studied to see if they can prevent cardiovascular events.

OBJECTIVES

The purpose of this study was to assess the clinical benefits and harms of IL-RAs and TNF inhibitors in the primary and secondary prevention of ACVD.

SEARCH METHODS

The Cochrane Heart Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, EBSCO CINAHL plus, and clinical trial registries for ongoing and unpublished studies were searched in February 2024. The reference lists of relevant studies, reviews, meta-analyses and health technology reports were searched to identify additional studies. No limitations on language, date of publication or study type were set.

SELECTION CRITERIA

RCTs that recruited people with and without pre-existing ACVD, comparing IL-RAs or TNF inhibitors versus placebo or usual care, were selected. The primary outcomes considered were all-cause mortality, myocardial infarction, unstable angina, and adverse events.

DATA COLLECTION AND ANALYSIS

Two or more review authors, working independently at each step, selected studies, extracted data, assessed the risk of bias and used GRADE to judge the certainty of evidence.

MAIN RESULTS

We included 58 RCTs (22,053 participants; 21,308 analysed), comparing medication efficacy with placebo or usual care. Thirty-four trials focused on primary prevention and 24 on secondary prevention. The interventions included IL-1 RAs (anakinra, canakinumab), IL-6 RA (tocilizumab), TNF-inhibitors (etanercept, infliximab) compared with placebo or usual care. The certainty of evidence was low to very low due to biases and imprecision; all trials had a high risk of bias. Primary prevention: IL-1 RAs The evidence is very uncertain about the effects of the intervention on all-cause mortality(RR 0.33, 95% CI 0.01 to 7.58, 1 trial), myocardial infarction (RR 0.71, 95% CI 0.04 to 12.48, I² = 39%, 2 trials), unstable angina (RR 0.24, 95% CI 0.03 to 2.11, I² = 0%, 2 trials), stroke (RR 2.42, 95% CI 0.12 to 50.15; 1 trial), adverse events (RR 0.85, 95% CI 0.59 to 1.22, I² = 54%, 3 trials), or infection (rate ratio 0.84, 95% 0.55 to 1.29, I² = 0%, 4 trials). Evidence is very uncertain about whether anakinra and cankinumab may reduce heart failure (RR 0.21, 95% CI 0.05 to 0.94, I² = 0%, 3 trials). Peripheral vascular disease (PVD) was not reported as an outcome. IL-6 RAs The evidence is very uncertain about the effects of the intervention on all-cause mortality (RR 0.68, 95% CI 0.12 to 3.74, I² = 30%, 3 trials), myocardial infarction (RR 0.27, 95% CI 0.04 to1.68, I² = 0%, 3 trials), heart failure (RR 1.02, 95% CI 0.11 to 9.63, I² = 0%, 2 trials), PVD (RR 2.94, 95% CI 0.12 to 71.47, 1 trial), stroke (RR 0.34, 95% CI 0.01 to 8.14, 1 trial), or any infection (rate ratio 1.10, 95% CI: 0.88 to 1.37, I2 = 18%, 5 trials). Adverse events may increase (RR 1.13, 95% CI 1.04 to 1.23, I² = 33%, 5 trials). No trial assessed unstable angina. TNF inhibitors The evidence is very uncertain about the effects of the intervention on all-cause mortality (RR 1.78, 95% CI 0.63 to 4.99, I² = 10%, 3 trials), myocardial infarction (RR 2.61, 95% CI 0.11 to 62.26, 1 trial), stroke (RR 0.46, 95% CI 0.08 to 2.80, I² = 0%; 3 trials), heart failure (RR 0.85, 95% CI 0.06 to 12.76, 1 trial). Adverse events may increase (RR 1.13, 95% CI 1.01 to 1.25, I² = 51%, 13 trials). No trial assessed unstable angina or PVD. Secondary prevention: IL-1 RAs The evidence is very uncertain about the effects of the intervention on all-cause mortality (RR 0.94, 95% CI 0.84 to 1.06, I² = 0%, 8 trials), unstable angina (RR 0.88, 95% CI 0.65 to 1.19, I² = 0%, 3 trials), PVD (RR 0.85, 95% CI 0.19 to 3.73, I² = 38%, 3 trials), stroke (RR 0.94, 95% CI 0.74 to 1.2, I² = 0%; 7 trials), heart failure (RR 0.91, 95% 0.5 to 1.65, I² = 0%; 7 trials), or adverse events (RR 0.92, 95% CI 0.78 to 1.09, I² = 3%, 4 trials). There may be little to no difference between the groups in myocardial infarction (RR 0.88, 95% CI 0.0.75 to 1.04, I² = 0%, 6 trials). IL6-RAs The evidence is very uncertain about the effects of the intervention on all-cause mortality (RR 1.09, 95% CI 0.61 to 1.96, I² = 0%, 2 trials), myocardial infarction (RR 0.46, 95% CI 0.07 to 3.04, I² = 45%, 3 trials), unstable angina (RR 0.33, 95% CI 0.01 to 8.02, 1 trial), stroke (RR 1.03, 95% CI 0.07 to 16.25, 1 trial), adverse events (RR 0.89, 95% CI 0.76 to 1.05, I² = 0%, 2 trials), or any infection (rate ratio 0.66, 95% CI 0.32 to 1.36, I² = 0%, 4 trials). No trial assessed PVD or heart failure. TNF inhibitors The evidence is very uncertain about the effect of the intervention on all-cause mortality (RR 1.16, 95% CI 0.69 to 1.95, I² = 47%, 5 trials), heart failure (RR 0.92, 95% 0.75 to 1.14, I² = 0%, 4 trials), or adverse events (RR 1.15, 95% CI 0.84 to 1.56, I² = 32%, 2 trials). No trial assessed myocardial infarction, unstable angina, PVD or stroke. Adverse events may be underestimated and benefits inflated due to inadequate reporting.

AUTHORS' CONCLUSIONS

This Cochrane review assessed the benefits and harms of using interleukin-receptor antagonists and tumour necrosis factor inhibitors for primary and secondary prevention of atherosclerotic diseases compared with placebo or usual care. However, the evidence for the predetermined outcomes was deemed low or very low certainty, so there is still a need to determine whether these interventions provide clinical benefits or cause harm from this perspective. In summary, the different biases and imprecision in the included studies limit their external validity and represent a limitation to determining the effectiveness of the intervention for both primary and secondary prevention of ACVD.

Antirheumatic drug leflunomide attenuates atherosclerosis by regulating lipid metabolism and endothelial dysfunction via DHODH/AMPK signaling pathway

The probability of cardiovascular events has been reported lower in rheumatoid arthritis (RA) patients treated with leflunomide. However, the anti-atherosclerotic and cardiovascular protective effects and metabolism of leflunomide are not explored. In this study, we assessed the potential benefits of leflunomide on atherosclerosis and revealed the underlying mechanism. ApoE-/- mice were fed a western diet (WD) alone or supplemented with leflunomide (20 mg/kg, oral gavage, once per day) for 12 weeks. Samples of the aorta, heart, liver, serum, and macrophages were collected. We found that leflunomide significantly reduced lesion size in both en-face aortas and aortic root in WD-fed ApoE-/- mice. Leflunomide also obviously improved dyslipidemia, reduced hepatic lipid content, and improved disorders of glucose and lipid metabolism in vivo. RNA-Seq results showed that leflunomide effectively regulated the genes' expression involved in the lipid metabolism pathway. Importantly, leflunomide significantly increased the phosphorylation levels of AMPKα and acetyl-CoA carboxylase (ACC) in vivo. Furthermore, leflunomide and its active metabolite teriflunomide suppressed lipid accumulation in free fatty acid (FFA)-induced AML12 cells and improved endothelial dysfunction in palmitic acid (PA)-induced HUVECs through activating AMPK signaling and inhibiting dihydroorotate dehydrogenase (DHODH) signaling pathway. We present evidence that leflunomide and teriflunomide ameliorate atherosclerosis by regulating lipid metabolism and endothelial dysfunction. Our findings suggest a promising use of antirheumatic small-molecule drugs leflunomide and teriflunomide for the treatment of atherosclerosis and related cardiovascular diseases (CVDs).

The Multifaceted Nature of Macrophages in Cardiovascular Disease

As the leading cause of mortality worldwide, cardiovascular disease (CVD) represents a variety of heart diseases and vascular disorders, including atherosclerosis, aneurysm, ischemic injury in the heart and brain, arrythmias, and heart failure. Macrophages, a diverse population of immune cells that can promote or suppress inflammation, have been increasingly recognized as a key regulator in various processes in both healthy and disease states. In healthy conditions, these cells promote the proper clearance of cellular debris, dead and dying cells, and provide a strong innate immune barrier to foreign pathogens. However, macrophages can play a detrimental role in the progression of disease as well, particularly those inflammatory in nature. This review will focus on the current knowledge regarding the role of macrophages in cardiovascular diseases.

Phosphate as an adjunct to calcium in promoting coronary vascular calcification in chronic inflammatory states

Bone releases calcium and phosphate in response to pro-inflammatory cytokine-mediated inflammation. The body develops impaired urinary excretion of phosphate with age and chronic inflammation given the reduction of the kidney protein Klotho, which is essential to phosphate excretion. Phosphate may also play a role in the development of the resistance of the parathyroid calcium-sensing receptor (CaSR) to circulating calcium thus contributing to calcium retention in the circulation. Phosphate can contribute to vascular smooth muscle dedifferentiation with manifestation of osteoblastogenesis and ultimately endovascular calcium phosphate precipitation. Thus phosphate, along with calcium, contributes to the calcification and inflammation of atherosclerotic plaques and the origin of these elements is likely the bone, which serves as storage for the majority of the body's supply of extracellular calcium and phosphate. Early cardiac evaluation of patients with chronic inflammation and attempts at up-regulating the parathyroid CaSR with calcimimetics or introducing earlier anti-resorptive treatment with bone active pharmacologic agents may serve to delay onset or reduce the quantity of atherosclerotic plaque calcification in these patients.

Rheumatoid arthritis and cardiovascular complications during delivery: a United States inpatient analysis

BACKGROUND AND AIMS

Persons with rheumatoid arthritis (RA) have an increased risk of obstetric-associated complications, as well as long-term cardiovascular (CV) risk. Hence, the aim was to evaluate the association of RA with acute CV complications during delivery admissions.

METHODS

Data from the National Inpatient Sample (2004-2019) were queried utilizing ICD-9 or ICD-10 codes to identify delivery hospitalizations and a diagnosis of RA.

RESULTS

A total of 12 789 722 delivery hospitalizations were identified, of which 0.1% were among persons with RA (n = 11 979). Individuals with RA, vs. those without, were older (median 31 vs. 28 years, P < .01) and had a higher prevalence of chronic hypertension, chronic diabetes, gestational diabetes mellitus, obesity, and dyslipidaemia (P < .01). After adjustment for age, race/ethnicity, comorbidities, insurance, and income, RA remained an independent risk factor for peripartum CV complications including preeclampsia [adjusted odds ratio (aOR) 1.37 (95% confidence interval 1.27-1.47)], peripartum cardiomyopathy [aOR 2.10 (1.11-3.99)], and arrhythmias [aOR 2.00 (1.68-2.38)] compared with no RA. Likewise, the risk of acute kidney injury and venous thromboembolism was higher with RA. An overall increasing trend of obesity, gestational diabetes mellitus, and acute CV complications was also observed among individuals with RA from 2004-2019. For resource utilization, length of stay and cost of hospitalization were higher for deliveries among persons with RA.

CONCLUSIONS

Pregnant persons with RA had higher risk of preeclampsia, peripartum cardiomyopathy, arrhythmias, acute kidney injury, and venous thromboembolism during delivery hospitalizations. Furthermore, cardiometabolic risk factors among pregnant individuals with RA rose over this 15-year period.

Changes of peripheral blood α-L-fucosidase activity in patients with rheumatoid arthritis: a cross-sectional study

Background

Rheumatoid arthritis (RA), a systemic autoimmune disease with approximately 1% prevalent population worldwide, which the etiology is still unclear. RA cannot be completely cured at present, which seriously affects the quality of life of patients. This study is to compare the peripheral blood α-L-fucosidase (AFU) between RA and healthy persons.

Methods

A cross-sectional study was performed using total of 96 patients with RA served as case group and another 94 age-matched healthy volunteers served as a control group. AFU assay is detected by continuous monitoring method using Toshiba TBA-120FR (Tokyo, Japan) fully automatic biochemical analyzer in Japan, and the reagent is purchased from Zhejiang Quark Biological Company (Zhejiang, China). Statistical analysis was performed using SPSS 24.0 (SPSS, Inc., Chicago, IL, USA).

Results

AFU activity in peripheral blood of RA patients were lower than healthy controls. The higher AFU activity, the shorter the course of disease (r=-0.2790, P=0.0065). The activity of lactate dehydrogenase in patients with RA is higher than that of healthy control, but the activity of acetylcholinesterase is lower than that of normal people. Finally, AFU activity was negatively correlated with the activity of lactate dehydrogenase (r=-0.2381, P=0.0208) and positively correlated with the activity of acetylcholinesterase (r=0.2985, P=0.0035).

Conclusions

Changes of peripheral blood AFU activity might be associated with progression of disease in RA patients. The changes of AFU activity may lead to disturbances in glucose and lipid metabolism.

JAK-Inhibitors - A Story of Success and Adverse Events

Rheumatoid arthritis (RA) is a systemic, chronic, immune-mediated inflammatory condition. Treatments options encompass conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), biologic disease-modifying antirheumatic drugs (bDMARDs) like tumor necrosis factor (TNF) inhibitors (TNFis) and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) including Janus Kinase inhibitors (JAKinibs). Orally administered JAKinibs have demonstrated comparable or, in specific cases, superior efficacy compared to bDMARDs in inflammatory conditions. However, the escalating clinical utilization has been accompanied by the emergence of serious adverse effects, including major adverse cardiac events (MACE), malignancies and venous thrombotic episodes (VTE), leading to regulatory restrictions imposed by health authorities in both the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA).

Resolvin T4 enhances macrophage cholesterol efflux to reduce vascular disease

While cardiovascular disease (CVD) is one of the major co-morbidities in patients with rheumatoid arthritis (RA), the mechanism(s) that contribute to CVD in patients with RA remain to be fully elucidated. Herein, we observe that plasma concentrations of 13-series resolvin (RvT)4 negatively correlate with vascular lipid load in mouse inflammatory arthritis. Administration of RvT4 to male arthritic mice fed an atherogenic diet significantly reduces atherosclerosis. Assessment of the mechanisms elicited by this mediator demonstrates that RvT4 activates cholesterol efflux in lipid laden macrophages via a Scavenger Receptor class B type 1 (SR-BI)-Neutral Cholesterol Ester Hydrolase-dependent pathway. This leads to the reprogramming of lipid laden macrophages yielding tissue protection. Pharmacological inhibition or knockdown of macrophage SR-BI reverses the vasculo-protective activities of RvT4 in vitro and in male mice in vivo. Together these findings elucidate a RvT4-SR-BI centered mechanism that orchestrates macrophage responses to limit atherosclerosis during inflammatory arthritis.

Prediction of Major Adverse Cardiovascular Events by Triglyceride Glucose Index in Predominantly Male Patients with Rheumatoid Arthritis

Background

Rheumatoid arthritis (RA) is a systemic and chronic autoimmune disease that is characterized by persistent joint inflammation. RA patients experience a considerably increased risk of cardiovascular-related morbidity and mortality. The current study investigated the association between triglyceride glucose (TyG) index and major adverse cardiovascular events (MACEs) in a predominantly male cohort of RA patients.

Methods

A total of 1613 RA patients (81.53% male) were selected from the Kailuan study. The TyG index was calculated as the logarithmic product of fasting blood triglyceride and fasting blood glucose divided by two. MACEs were defined as the composite of non-fatal myocardial infarctions and non-fatal strokes. Cox proportional hazards analysis was performed to study the association between the TyG index and MACEs.

Results

A total of 59 MACEs occurred during the median follow-up time of 5.32 years. Following adjustment for age and gender, analysis by multivariable Cox proportional hazards (model 1) showed that an elevated TyG index was associated with an increased risk of MACEs (quartile 2, hazard ratio (HR): 2.741, 95% confidence interval (CI): 1.220-6.157, p = 0.015; quartile 4, HR: 2.521, 95% CI: 1.074-5.917, p = 0.034). After adjustment for other variables, Cox proportional hazards analysis (model 2) showed that an elevated TyG index was independently associated with an increased risk of MACEs (quartile 2, HR: 2.348, 95% CI: 1.009-5.465, p = 0.048). In addition, subgroup analysis showed a higher TyG index was significantly linked to an increased risk of MACEs in patients aged more than 65 years (quartile 2, HR: 6.048, 95% CI: 1.311-27.908, p = 0.021; quartile 4, HR: 12.074, 95% CI: 1.438-101.358, p = 0.022).

Conclusions

The TyG index was associated with an increased risk of MACEs in a predominantly male cohort of RA patients. This index may be helpful for the prediction of MACEs in male patients with RA.

Clinical Trial Registration

Registration number in the Chinese clinical trial registry: ChiCTR-TNRC-11001489.

Tumor Necrosis Factor Alpha Inhibitors and Cardiovascular Risk in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by an increased risk of cardiovascular events, due to the complex interplay between traditional and disease-related risk factors. Chronic inflammation and persistent disease activity are the key determinants of this risk, but despite great improvement in the disease management and prognosis, cardiovascular events are still the main cause of morbidity and mortality in RA cohorts1. In the last decades, the advent of new biological and targeted-synthetic DMARDs was accompanied by an improvement in disease activity control, but the role of each class of drugs on CVD risk is still a matter a debate. Since their approval for RA treatment, tumor necrosis factor alpha (TNFα) inhibitors have been widely investigated to better understand their effects on cardiovascular outcomes. The hypothesis that the reduction of chronic inflammation with any treatment may reduce the cardiovascular risk has been recently confuted by the direct comparison of TNFα-inhibitors and JAK inhibitors in patients with RA and coexisting risk factors for cardiovascular disease. The aim of this literature review is to add to the available evidence to analyze the relationship between TNFα-inhibitors and CVD risk in patients with RA and also provide some clinical scenarios to better explain the treatment dilemmas. In particular, while data on major cardiovascular events and thromboembolism seem consistent with an inflammation-mediated benefit with TNFα-inhibitors, there remain concerns about the use of this class of bDMARDs in patients with chronic heart failure.

Meta-analysis of risk factors for cardiovascular disease in patients with rheumatoid arthritis

BACKGROUND

Cardiovascular disease (CVD) is a common complication of rheumatoid arthritis (RA). We aimed to explore the risk factors for cardiovascular disease in patients with rheumatoid arthritis and provide a scientific basis on effective prevention and treatments for CVD in RA patients.

METHODS

We searched for a combination of the subject words and free words involved arthritis, rheumatoid, CVD, heart disease, vascular disease, risk factors, etc. from China Knowledge Network, Wanfang, Vip, China Biomedical Literature Database, Pubmed, Embase, Web of Science, Cochrane and other databases for documents published in public in 2000-October 2022.RevMan 5.3 and Stata14.0 analysis software was used to perform a meta-analysis of case-control and cohort studies on risk factors of CVDs in patients with RA published from 2000 to 2022.The Egger method was used to determine whether there was publication bias.

RESULTS

Seventeen pieces of literature were included in this meta-analysis. We explored the associations between CVD and different clinical characters such as DAS28 score, rheumatoid factor, triglyceride, age, sex, C-reactive protein, total cholesterol (TC), hypertension, and D dimer. High serum levels of C-reactive protein, TC, and D-dimer, as well as hypertension, are the main risk factors for CVD in patients with RA. The OR and 95% CI of C-reactive protein were 2.06 (1.91-2.23), RR and 95% CI of TC were 1.7 (1.49-1.93), RR and 95% CI of hypertension were 3.58 (2.37-5.40), as well as OR and 95% CI of D dimer were 2.83 (1.48-5.40).Our results performed by the meta-analysis were reliable, with low publication bias existed.

CONCLUSION

C-reactive protein, TC, hypertension, and D dimer are the main risk factors for CVD in patients with RA. No protective factors were found.

4-Octyl itaconate inhibits inflammation to attenuate psoriasis as an agonist of oxeiptosis

Psoriasis is a highly prevalent chronic disease associated with a substantial social and economic burden. Oxeiptosis is a programmed cell death that occurs when cells are in a state of high oxidative stress, which has a potent anti-inflammatory effect. However, there is still no research on oxeiptosis in psoriasis, and the agonists or antagonists of oxeiptosis remain an unclear field. Here, we found that oxeiptosis of keratinocytes was inhibited in psoriasis lesions. KEAP1, as the upstream molecular component of oxeiptosis, is highly expressed in psoriasis lesions. Knockdown of KEAP1 in HaCaT cells caused oxeiptosis in the condition of M5 cocktail stimulation. Next, we found that the cell-permeable derivative of itaconate, 4-octylitaconate (OI) promoted oxeiptosis of keratinocytes by inhibiting KEAP1 and then activating PGAM5 which are two upstream molecular components of oxeiptosis. At the same time, OI can reduce the expression of inflammatory cytokines induced by M5 cocktail stimulation in vitro. Similarly, we found that OI can alleviate IMQ-induced psoriatic lesions in mice and downregulate the levels of inflammatory cytokines in psoriatic lesions. In summary, our findings suggest that oxeiptosis of keratinocytes was inhibited in psoriasis and OI can significantly inhibit inflammation and alleviate psoriasis as an agonist of oxeiptosis, indicating that oxeiptosis may be involved in regulating the progression of psoriasis, which may provide new therapeutic targets for psoriasis treatment.

Clinical prediction models of rheumatoid arthritis and its complications: focus on cardiovascular disease and interstitial lung disease

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease of unknown etiology with erosive, symmetric polyarthritis as the main clinical manifestations. Its basic pathological changes are the formation of synovitis, and patients gradually develop destruction of articular cartilage destruction and bone erosion, which eventually leads to joint deformity, disability, and various extra-articular manifestations. Clinical prediction models (CPMs), also known as risk prediction models or risk scores, are mathematical formulas used to estimate the probability that a given individual will have a disease or an outcome in the future. The models are mainly divided into two categories: diagnostic models and prognostic models, which can be used to provide information on disease diagnosis or prognosis to help make better medical decisions. Currently, there is no cure for RA, but effective early diagnosis and treatment are crucial for limiting the severity of the disease and preventing the occurrence and development of complications. This paper reviews the CPMs associated with RA and its related complications, including cardiovascular disease (CVD) and interstitial lung disease (ILD), in order to provide reference and evidence for the early diagnosis and treatment of these diseases and personalized medicine for patients. In addition, the possible pathogenesis and risk factors of these comorbidities are summarized, and possible directions for future related research are prospected.

Relationship of Blood Inflammatory Composite Markers with Cardiovascular Risk Factors and Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis

The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammatory index (SIRI, neutrophils × monocytes/lymphocytes) have been described as potential blood-derived inflammatory biomarkers in several diseases. Rheumatoid arthritis is an inflammatory disease that has been related to an increased risk of cardiovascular (CV) disease. In the present work, we analyze how these hematological composite scores of inflammation are related to classic CV risk factors and subclinical atherosclerosis in patients with RA. In this cross-sectional study that included 430 patients with RA, the NLR, MLR, PLR, and SIRI scores were calculated. Multivariable analysis was performed to examine the relationships of these composite blood scores with subclinical carotid atherosclerosis and with traditional cardiovascular factors, producing a complete profile of lipid molecules and insulin resistance or indices of beta-cell function, and a Systematic Coronary Risk Assessment (SCORE2) calculation. C-reactive protein and disease activity were significantly and positively associated with the four blood composite scores. SCORE2 was significantly associated with higher values of SIRI, NLR, and MLR, but not PLR. These relationships were maintained when SCORE 2 was considered categorical; patients in the very high CV risk category had higher values in all hematological composite scores, except PLR. In the multivariable analysis, SIRI and NLR were independently associated with higher levels of beta cell dysfunction. In conclusion, SCORE2 and the values of the hematological composite scores were positively correlated in patients with RA. In addition, there were some relationships of these scores with traditional CV risk factors, with their association with beta cell dysfunction being the most consistent.

Arterial Stiffness as a Surrogate Marker of Cardiovascular Disease and Atherosclerosis in Patients with Arthritides and Connective Tissue Diseases: A Literature Review

The increased cardiovascular (CV) risk among patients with autoimmune rheumatic diseases, such as arthritides and connective tissue diseases, has been extensively documented. From a pathophysiological standpoint, systemic inflammation in the context of the disease can lead to endothelial dysfunction, accelerated atherosclerosis, and structural changes in vessel walls, which, in turn, are associated with exaggerated CV morbidity and mortality. In addition to these abnormalities, the increased prevalence of traditional CV risk factors, such as obesity, dyslipidemia, arterial hypertension, and impaired glucose metabolism, can further worsen the status of and overall prognosis for CV in rheumatic patients. However, data on appropriate CV screening methods for patients with systemic autoimmune diseases are scarce, and traditional algorithms may lead to an underestimation of the true CV risk. The reason for this is that these calculations were developed for the general population and thus do not take into account the effect of the inflammatory burden, as well as other chronic-disease-associated CV risk factors. In recent years, different research groups, including ours, have examined the value of different CV surrogate markers, including carotid sonography, carotid-femoral pulse wave velocity, and flow-mediated arterial dilation, in the assessment of CV risk in healthy and rheumatic populations. In particular, arterial stiffness has been thoroughly examined in a number of studies, showing high diagnostic and predictive value for the occurrence of CV events. To this end, the present narrative review showcases a series of studies examining aortic and peripheral arterial stiffness as surrogates of all-cause CV disease and atherosclerosis in patients with rheumatoid and psoriatic arthritis, as well as in systemic lupus erythematosus and systemic sclerosis. Moreover, we discuss the associations of arterial stiffness with clinical, laboratory, and disease-specific parameters.

Subclinical atherosclerosis in primary Sjögren's syndrome: comparable risk with diabetes mellitus

OBJECTIVES

It has been found that the risk of subclinical atherosclerosis in some connective tissue diseases (CTDs) was equivalent to type 2 diabetes mellitus (T₂DM). There is no clinical study focusing on the differences of subclinical atherosclerosis between primary Sjögren's syndrome (pSS) and T₂DM. Our aim is to investigate the prevalence of subclinical atherosclerosis in pSS patients, compare the differences in subclinical atherosclerosis between pSS and T₂DM patients, and determine the risk factors of subclinical atherosclerosis.

METHOD

A retrospective case-control study of 96 patients with pSS, 96 age- and sex-matched T₂DM patients and healthy individuals underwent evaluation, including clinical data and carotid ultrasound examination. Univariate and multivariate models were used to explore the related factors of carotid intima-media thickness (IMT) and carotid plaque.

RESULTS

Increased IMT scores were detected in patients with pSS and T₂DM compared to controls. The percentages of carotid IMT were detected in 91.7% of pSS and 93.8% of T₂DM patients versus 81.3% in the controls. Carotid plaques were detected in 82.3%, 82.3% and 66.7% of pSS, T₂DM, and controls, respectively. Age and the presence of pSS and T₂DM emerged as risk factors for IMT (adjusted OR = 1.25, 4.40, and 9.92, respectively). In addition, age, total cholesterol, and the presence of pSS and T₂DM emerged as risk factors for carotid plaque (adjusted OR = 1.14, 1.50, 4.18, and 3.79, respectively).

CONCLUSIONS

The prevalence of subclinical atherosclerosis in pSS patients was increased, which was comparable to that in T₂DM patients. The presence of pSS is associated with subclinical atherosclerosis. Key Points • The prevalence of subclinical atherosclerosis is higher in primary Sjögren' s syndrome. • The risk of subclinical atherosclerosis is similar in primary Sjögren's syndrome and diabetes mellitus patients. • Advanced age was an independent predictor of carotid IMT and plaque formation in primary Sjögren's syndrome. • Primary Sjögren's syndrome and diabetes mellitus are associated with atherosclerosis.

Signaling pathways in rheumatoid arthritis: implications for targeted therapy

Rheumatoid arthritis (RA) is an incurable systemic autoimmune disease. Disease progression leads to joint deformity and associated loss of function, which significantly impacts the quality of life for sufferers and adds to losses in the labor force. In the past few decades, RA has attracted increased attention from researchers, the abnormal signaling pathways in RA are a very important research field in the diagnosis and treatment of RA, which provides important evidence for understanding this complex disease and developing novel RA-linked intervention targets. The current review intends to provide a comprehensive overview of RA, including a general introduction to the disease, historical events, epidemiology, risk factors, and pathological process, highlight the primary research progress of the disease and various signaling pathways and molecular mechanisms, including genetic factors, epigenetic factors, summarize the most recent developments in identifying novel signaling pathways in RA and new inhibitors for treating RA. therapeutic interventions including approved drugs, clinical drugs, pre-clinical drugs, and cutting-edge therapeutic technologies. These developments will hopefully drive progress in new strategically targeted therapies and hope to provide novel ideas for RA treatment options in the future.

Role of reactive oxygen species and mitochondrial damage in rheumatoid arthritis and targeted drugs

Rheumatoid arthritis (RA) is an autoimmune disease characterized by synovial inflammation, pannus formation, and bone and cartilage damage. It has a high disability rate. The hypoxic microenvironment of RA joints can cause reactive oxygen species (ROS) accumulation and mitochondrial damage, which not only affect the metabolic processes of immune cells and pathological changes in fibroblastic synovial cells but also upregulate the expression of several inflammatory pathways, ultimately promoting inflammation. Additionally, ROS and mitochondrial damage are involved in angiogenesis and bone destruction, thereby accelerating RA progression. In this review, we highlighted the effects of ROS accumulation and mitochondrial damage on inflammatory response, angiogenesis, bone and cartilage damage in RA. Additionally, we summarized therapies that target ROS or mitochondria to relieve RA symptoms and discuss the gaps in research and existing controversies, hoping to provide new ideas for research in this area and insights for targeted drug development in RA.

In RA patients without prevalent CVD, incident CVD is mainly associated with traditional risk factors: A 20-year follow-up in the CARRÉ cohort study

OBJECTIVES

To extend our investigation of cardiovascular diseases (CVD) in rheumatoid arthritis (RA) patients to a follow up of more than 20 years, with a special focus on patients without prevalent CVD.

METHODS

The CARRÉ study is an ongoing prospective cohort study on CV endpoints in RA patients. Results were compared to those of a reference cohort (n = 2484) enriched for type 2 diabetes mellitus (DM). Hazard ratios (HR) for RA and DM patients compared to non-RA/-DM controls were calculated with cox proportional hazard models, and adjusted for baseline SCORE1 (estimated 10-year CVD mortality risk based on CV risk factors).

RESULTS

238 RA patients, 117 DM patients and 1282 controls, without prevalent CVD at baseline were included. Analysis of events in these patients shows that after adjustment, no relevant 'RA-specific' risk remains (HR 1.16; 95%CI 0.88 - 1.53), whereas a 'DM-specific' risk is retained (1.73; 1.24 - 2.42). In contrast, adjusted analyses of all cases confirm the presence of an 'RA-specific' risk (1.50; 1.19 - 1.89).

CONCLUSIONS

In RA patients without prevalent CVD the increased CVD risk is mainly attributable to increased presence of traditional risk factors. After adjustment for these factors, an increased risk attributable to RA only was thus preferentially seen in the patients with prevalent CVD at baseline. As RA treatment has improved, this data suggests that the 'RA-specific' effect of inflammation is preferentially seen in patients with prevalent CVD. We suggest that with modern (early) treatment of RA, most of the current increased CVD risk is mediated through traditional risk factors.

Correlation Between Total Bilirubin, Total Bilirubin/Albumin Ratio with Disease Activity in Patients with Rheumatoid Arthritis

Purpose

Rheumatoid arthritis (RA) is a systemic inflammatory disorder with unknown etiology. Oxidative stress and immune imbalance play a critical role in the pathogenesis of rheumatoid arthritis. Bilirubin has recently been recognized as a potent antioxidant as well as an immunomodulatory agent of physiological importance. The aim of this study was to explore whether increased bilirubin concentrations are correlated with good clinical prognosis of rheumatoid arthritis.

Patients and Methods

In this cross-sectional study, we included 197 healthy individuals and 197 RA patients in the Affiliated Hospital of North Sichuan Medical College from October 2020 to February 2022. The latter were classified into three classes of disease activity according to DAS28-ESR: remission and low (DAS28-ESR<3.2), moderate (3.2≤DAS28-ESR≤5.1), and high (DAS28ESR>5.1). Based on the clinical and laboratory data, we evaluated the association of bilirubin levels with disease activity in RA using multivariable ordered logistic regression.

Results

The levels of total bilirubin and total bilirubin/albumin ratio were significantly lower (P < 0.001; P < 0.001) in RA patients compared with healthy controls. In RA patients, Spearman's rank correlation analysis revealed that bilirubin and total bilirubin/albumin ratio were negatively correlated with disease activity and inflammatory marker (C-reactive protein, erythrocyte sedimentation rate, Interleukin-6). In multivariable ordered logistic regression, higher total bilirubin (OR=0.77, 95% CI: 0.67-0.89, p<0.001) independently predicted lower disease activity.

Conclusion

Bilirubin levels remain associated with a reduction of disease activity, suggesting that bilirubin may be a protective factor for RA aggravation.

Vascular dysfunction in juvenile idiopathic arthritis: a systematic review and meta-analysis

We performed a systematic review and meta-analysis of studies evaluating vascular function in patients with JIA. Relevant literature published from 1st January 1965 to 1st March 2022 was searched systematically utilizing PubMed, Web of Science, and Embase databases. Observational studies were included-patients with JIA (classified according to the International League of Associations for Rheumatology criteria) were included as cases (study population) and age/sex-matched healthy participants as controls (comparator group). Outcome measures were differences in non-invasive parameters of vascular function. Online Population, Intervention, Comparison, Outcomes Portal was used for deduplication of studies and data extraction. Review Manager, Comprehensive Meta-analysis, and Meta-Essential softwares were used for data synthesis/analysis (encompassing data pooling and evaluation of heterogeneity and publication bias). Newcastle-Ottawa Scale and GRADEpro GDT software were utilized to assess study quality and certainty of evidence, respectively. Of 338 citations, 17 observational studies with 1423 participants (cases = 757, controls = 666) were included. Carotid intima-media thickness (CIMT) was higher [mean difference (MD) 0.02 mm {95% confidence interval (CI) 0.01-0.04}, p = 0.0006, I² = 69%] in patients with JIA. Besides, decreased flow-mediated dilatation (FMD) [MD - 2.18% {95%CI - 3.69- - 0.68}, p = 0.004, I² = 73%] was also observed. Results of studies assessing pulse wave velocity or arterial stiffness could not be pooled due to significant methodological variations. A 'very low' certainty of evidence suggests the presence of vascular dysfunction in JIA. Future longitudinal studies are required to determine whether altered CIMT and FMD in patients with JIA translate to an enhanced risk of (adverse) clinical cardiovascular events. PROSPERO (CRD42022323752).

Metabolic Abnormalities, Cardiovascular Disease, and Metabolic Syndrome in Adult Rheumatoid Arthritis Patients: Current Perspectives and Clinical Implications

AIM

Rheumatoid arthritis is a prevalent worldwide disease, associated with an increased risk of multiple metabolic abnormalities that generate a higher disease burden.

OBJECTIVE

To gather the available evidence on the epidemiology, pathophysiology, current perspectives, clinical implications and prognosis of metabolic abnormalities in patients with rheumatoid arthritis.

METHODS

This is a narrative literature review. Search was conducted in PubMed, OVID, and Taylor & Francis databases, using the following MeSH terms: "Arthritis Rheumatoid", "Metabolic Diseases", and "Metabolic Syndrome".

RESULTS

This study describes the main metabolic manifestations of rheumatoid arthritis. Research has recognized that rheumatoid arthritis and metabolic abnormalities share pathophysiological mechanisms with an additive effect that increases cardiovascular risk. In that context, appropriate antirheumatic treatment can also impact on cardiovascular risk.

CONCLUSION

There are metabolic abnormalities in rheumatoid arthritis patients that increase cardiovascular risk. Therefore, it is crucial to evaluate cardiovascular risk to provide appropriate comprehensive management to reduce morbidity and mortality in patients with this disease.

To eat or not to eat—an exploratory randomized controlled trial on fasting and plant-based diet in rheumatoid arthritis (NutriFast-Study)

Background

Fasting is beneficial in many diseases, including rheumatoid arthritis (RA), with lasting effects for up to 1 year. However, existing data dates back several decades before the introduction of modern therapeutic modalities.

Objective

This exploratory RCT compares the effects of a 7-day fast followed by a plant-based diet (PBD) to the effects of the dietary recommendations of the German society for nutrition (Deutsche Gesellschaft für Ernährung, DGE) on RA disease activity, cardiovascular (CV) risk factors, and well-being.

Methods

In this RCT we randomly assigned 53 RA patients to either a 7-day fast followed by an 11-week PBD or a 12-week standard DGE diet. The primary endpoint was the group change from baseline to 12 weeks on the Health Assessment Questionnaire Disability Index (HAQ-DI). Further outcomes included other disease activity scores, body composition, and quality of life.

Results

Of 53 RA patients enrolled, 50 participants (25 per group) completed the trial and were included into the per-protocol analysis. The primary endpoint was not statistically significant. However, HAQ-DI improved rapidly in the fasting group by day 7 and remained stable over 12 weeks (Δ-0.29, p = 0.001), while the DGE group improved later at 6 and 12 weeks (Δ-0.23, p = 0.032). DAS28 ameliorated in both groups by week 12 (Δ-0.97, p < 0.001 and Δ-1.14, p < 0.001; respectively), with 9 patients in the fasting but only 3 in the DGE group achieving ACR50 or higher. CV risk factors including weight improved stronger in the fasting group than in the DGE group (Δ-3.9 kg, p < 0.001 and Δ-0.7 kg, p = 0.146).

Conclusions

Compared with a guideline-based anti-inflammatory diet, fasting followed by a plant-based diet showed no benefit in terms of function and disability after 12 weeks. Both dietary approaches had a positive effect on RA disease activity and cardiovascular risk factors in patients with RA.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03856190, identifier: NCT03856190.

TNF-α Inhibitors and Other Biologic Agents for the Treatment of Immune Checkpoint Inhibitor-Induced Myocarditis

With anti-PD-1 antibodies serving as a representative drug, immune checkpoint inhibitors (ICIs) have become the main drugs used to treat many advanced malignant tumors. However, immune-related adverse events (irAEs), which might involve multiple organ disorders, should not be ignored. ICI-induced myocarditis is an uncommon but life-threatening irAE. Glucocorticoids are the first choice of treatment for patients with ICI-induced myocarditis, but high proportions of steroid-refractory and steroid-resistant cases persist. According to present guidelines, tumor necrosis factor alpha (TNF-α) inhibitors are recommended for patients who fail to respond to steroid therapy and suffer from severe cardiac toxicity, although evidence-based studies are lacking. On the other hand, TNF-α inhibitors are contraindicated in patients with moderate-to-severe heart failure. This review summarizes real-world data from TNF-α inhibitors and other biologic agents for ICI-induced myocarditis to provide more evidence of the efficacy and safety of TNF-α inhibitors and other biologic agents.

Psoriasis and coronary heart disease-not as severe as predicted

BACKGROUND

Psoriasis is a systemic disorder involved in several disease processes, including cancer, metabolic syndrome and cardiovascular disease (CVD). Previous studies showed that psoriasis is most likely an independent risk factor for CVD, yet the extent of its impact on CVD and the extent of coronary artery disease (CAD) remains unclear. We investigated the correlation of psoriasis to the severity of CAD in age and gender-matched patients with CAD with and without psoriasis.

METHODS

This is a retrospective, case-control study of 59 patients with psoriasis who underwent coronary angiography were matched using a computer software to 59 patients without psoriasis according to age, gender, smoking status, hyperlipidemia, hypertension and diabetes. CAD severity was defined according to number of affected vessels (single vs. multiple) and location of lesions (proximal vs. distal).

RESULTS

CAD severity was significantly higher in the control group compared to the psoriasis group (P = 0.038). Among patients with psoriasis, 20.3% were disease free or with low severity (42.4%), while only 37.3% had severe CAD. Among patients without psoriasis, the majority had severe CAD (57.6%), followed by low severity (30.5%) or disease free (11.9%). We did not find an association of prior treatment with anti-inflammatory medications and the severity of CAD.

CONCLUSIONS

Our results show that although psoriasis may be a risk factor for CAD, psoriatic patients have a less severe CAD compared to the general population. The use of anti-inflammatory medications does not explain this finding.

MicroRNAs (miRNAs) in Cardiovascular Complications of Rheumatoid Arthritis (RA): What Is New?

Rheumatoid Arthritis (RA) is among the most prevalent and impactful rheumatologic chronic autoimmune diseases (AIDs) worldwide. Within a framework that recognizes both immunological activation and inflammatory pathways, the exact cause of RA remains unclear. It seems however, that RA is initiated by a combination between genetic susceptibility, and environmental triggers, which result in an auto-perpetuating process. The subsequently, systemic inflammation associated with RA is linked with a variety of extra-articular comorbidities, including cardiovascular disease (CVD), resulting in increased mortality and morbidity. Hitherto, vast evidence demonstrated the key role of non-coding RNAs such as microRNAs (miRNAs) in RA, and in RA-CVD related complications. In this descriptive review, we aim to highlight the specific role of miRNAs in autoimmune processes, explicitly on their regulatory roles in the pathogenesis of RA, and its CV consequences, their main role as novel biomarkers, and their possible role as therapeutic targets.

Cardiovascular Implications of Immune Disorders in Women

Immune responses differ between men and women, with women at higher risk of developing chronic autoimmune diseases and having more robust immune responses to many viruses, including HIV and hepatitis C virus. Although immune dysregulation plays a prominent role in chronic systemic inflammation, a key driver in the development of atherosclerotic cardiovascular disease (ASCVD), standard ASCVD risk prediction scores underestimate risk in populations with immune disorders, particularly women. This review focuses on the ASCVD implications of immune dysregulation due to disorders with varying global prevalence by sex: autoimmune disorders (female predominant), HIV (male-female equivalent), and hepatitis C virus (male predominant). Factors contributing to ASCVD in women with immune disorders, including traditional risk factors, dysregulated innate and adaptive immunity, sex hormones, and treatment modalities, are discussed. Finally, the need to develop new ASCVD risk stratification tools that incorporate variables specific to populations with chronic immune disorders, particularly in women, is emphasized.

Is calcium a link between inflammatory bone resorption and heart disease?

Several epidemiologic studies associate bone-resorbing chronic inflammatory conditions with increased risk of atherosclerotic heart disease. These include post-menopausal osteoporosis, spinal cord injury, rheumatoid arthritis, and osteoarthritis. Additional studies have noted that the use of anti-resorptive agents following hip fracture, during rheumatoid arthritis, and prior to intensive care management have resulted in reduced overall mortality and mortality from cardiovascular disorders. The careful study of burn patients has allowed us to detect that children and adolescents have a mechanism that protects them from the entry of calcium into the circulation following inflammatory bone resorption. That is, they respond to pro-inflammatory cytokines by up-regulating the parathyroid calcium-sensing receptor (CaSR) with consequent development of hypocalcemic hypoparathyroidism and hypercalciuria. As extracellular calcium appears to exacerbate and/or prolong the inflammatory response, this responsiveness of the CaSR to inflammatory cytokines may be the factor that reduces cardiovascular morbidity and mortality. In adults with chronic inflammatory conditions, the ability of the CaSR to respond to pro-inflammatory cytokines is lost, suggesting that the calcium that enters the circulation following inflammatory bone resorption may persist in the circulation, entering the small coronary blood vessels and favoring the formation of coronary artery calcification, inflammation, and consequent cardiovascular disease.

Treatment of Cardiovascular Disease in Rheumatoid Arthritis: A Complex Challenge with Increased Atherosclerotic Risk

Rheumatoid arthritis (RA) carries significant risk for atherosclerotic cardiovascular disease (ASCVD). Traditional ASCVD risk factors fail to account for this accelerated atherosclerosis. Shared inflammatory pathways are fundamental in the pathogenesis of both diseases. Considering the impact of RA in increasing cardiovascular morbidity and mortality, the characterization of therapies encompassing both RA and ASCVD management merit high priority. Despite little progress, several drugs discussed here promote remission and or lower rheumatoid disease activity while simultaneously conferring some level of atheroprotection. Methotrexate, a widely used disease-modifying drug used in RA, is associated with significant reduction in cardiovascular adverse events. MTX promotes cholesterol efflux from macrophages, upregulates free radical scavenging and improves endothelial function. Likewise, the sulfonamide drug sulfasalazine positively impacts the lipid profile by increasing HDL-C, and its use in RA has been correlated with reduced risk of myocardial infraction. In the biologic class, inhibitors of TNF-α and IL-6 contribute to improvements in endothelial function and promote anti-atherogenic properties of HDL-C, respectively. The immunosuppressant hydroxychloroquine positively affects insulin sensitization and the lipid profile. While no individual therapy has elicited optimal atheroprotection, further investigation of combination therapies are ongoing.

Evaluating the Use of Hydroxychloroquine in Treating Patients With Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases present today. Although treatment options may differ among clinicians, a commonly prescribed treatment is hydroxychloroquine (HCQ), alone or in combination with other medications. HCQ has been studied for its immunomodulatory effects as well as its role in treating adverse conditions associated with RA. This systematic review examined the use of HCQ therapy in RA patients. A systematic search for relevant literature through PubMed, National Institute of Informatics, Japan (CiNii), and Science Direct databases were carried out in August 2021. Literature directly related to HCQ therapy for RA patients, RA-associated chronic kidney disease, and cardiovascular disease (including lipid profile) was considered relevant. HCQ associated retinopathic adverse effects were also selected for this review. Thirty-eight articles were found to be relevant, passed quality assessment, and were included in this review. Nine articles discussed HCQ therapy in comparison with other therapies (mainly methotrexate and sulfasalazine), but were contradictory in their outcomes, as were the seven papers that reviewed kidney function in RA patients with and without HCQ. Five articles credited better cardiovascular outcomes to RA patients taking HCQ. Sixteen articles studied the relationship between HCQ and retinal toxicity, providing insights into the risks associated with HCQ therapy. HCQ therapy was found not only to be beneficial in slowing the disease progression in RA patients but enhanced the effects of methotrexate in treating RA as well. Data strongly associates HCQ therapy with the mitigation of RA-related cardiovascular and kidney conditions. However, if HCQ is prescribed, it is imperative to be aware of the possible (although rare) retinopathic adverse effects associated with this therapy.

Impaired Coronary Vasodilator Reserve and Adverse Prognosis in Patients With Systemic Inflammatory Disorders

OBJECTIVES

The purpose of this study was to evaluate the prognostic value of quantitative myocardial blood flow (MBF) and myocardial flow reserve (MFR), reflecting the integrated effects of diffuse atherosclerosis and microvascular dysfunction in patients with systemic inflammatory disorders.

BACKGROUND

Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriasis (PsO) are common inflammatory conditions with excess cardiovascular (CV) risk compared to the general population. Systemic inflammation perturbs endothelial function and has been linked to coronary vasomotor dysfunction. However, the prognostic significance of this vascular dysfunction is not known.

METHODS

This was a retrospective study of patients with RA, SLE, and PsO undergoing clinically indicated rest and stress myocardial perfusion positron emission tomography (PET). Patients with an abnormal myocardial perfusion study or left ventricular dysfunction were excluded. MFR was calculated as the ratio of myocardial blood flow (MBF, ml/min/g) at peak stress compared to that at rest.

RESULTS

Among the 198 patients (median age: 65 years; 80% female), 20.7% had SLE, 31.8% had PsO, and 47.5% had RA. There were no differences in mean MFR between these conditions. Over a median follow-up of 7.8 years, there were 51 deaths and 63 major adverse cardiovascular events (MACE). Patients in the lowest tertile (MFR <1.65) had higher all-cause mortality than the highest tertile, which remained significant after adjusting for age, sex, and the pre-test clinical risk score (hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.05 to 5.4; p = 0.038). Similarly, compared to the highest MFR tertile, those in the lowest tertile had a lower MACE-free survival after adjusting for age, sex, and the pre-test clinical risk score (HR: 3.6; 95% CI: 1.7 to 7.6; p = 0.001).

CONCLUSIONS

In patients with systemic inflammatory disorders, impaired coronary vasodilator reserve was associated with worse cardiovascular outcomes and all-cause mortality.

Risk of Heart Failure in Rheumatoid Arthritis Patients Treated with Tumor Necrosis Factor-α Inhibitors

This is a retrospective cohort study by analyzing a multi-institutional electronic medical records database covering 1.3 million individuals (6% of Taiwan's population) to compare the risk of heart failure (HF) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor-α (TNF-α) inhibitors or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). We included patients with RA aged 20 years and older who had treatment failure with at least 2 different csDMARD regimens and newly switched to another csDMARD regimen or TNFis from 2009 to 2019. We followed patients from initiation of the new therapies to the occurrence of hospitalization for heart failure (hHF), death, to the last clinical visit or December 31, 2020. We performed multivariable Cox proportional hazard models to compare TNF-α inhibitors and csDMARD groups for the risk of hHF, with adjustment for patients' characteristics. A total of 1,278 TNF-α inhibitors and 1,932 csDMARDs treated patients were identified, with 78% being women and having an average age of 55 (SD 13.28) years. The incidence rates of hHF for the TNF-α inhibitors and csDMARD groups were 3.66 and 4.72 per 1,000 person-years, respectively (adjusted hazard ratio (aHR) 0.59; 95% confidence interval (CI) 0.35-0.97), and the results remained consistent in patients both with an HF history (aHR 0.66; 95% CI 0.03-14.46) and without (aHR 0.49; 95% CI, 0.27-0.89). The findings suggest that those who switched to TNF-α inhibitors had a reduced risk of hHF, compared with those who switched to another csDMARD regimen.

Cardiovascular disease prevention in individuals with underlying chronic inflammatory disease

PURPOSE OF REVIEW

Patients with chronic inflammatory disease have an increased risk of cardiovascular disease. This article reviews the current evidence of cardiovascular prevention in three common systemic inflammatory disorders (SIDs): psoriasis, rheumatoid arthritis, and systemic lupus erythematosus.

RECENT FINDINGS

General population cardiovascular risk assessment tools currently underestimate cardiovascular risk and disease-specific risk assessment tools are an area of active investigation. A disease-specific cardiovascular risk estimator has not been shown to more accurately predict risk compared with the current guidelines. Rheumatoid arthritis-specific risk estimators have been shown to better predict cardiovascular risk in some cohorts and not others. Systemic lupus erythematosus-specific scores have also been proposed and require further validation, whereas psoriasis is an open area of active investigation. The current role of universal prevention treatment with statin therapy in patients with SID remains unclear. Aggressive risk factor modification and control of disease activity are important interventions to reduce cardiovascular risk.

SUMMARY

A comprehensive approach that includes cardiovascular risk factor modification, control of systemic inflammation, and increased patient and physician awareness is needed in cardiovascular prevention of chronic inflammation. Clinical trials are currently underway to test whether disease-specific anti-inflammatory therapies will reduce cardiovascular risk.

Asymmetric Dimethylarginine: a Key Player in the Pathophysiology of Endothelial Dysfunction, Vascular Inflammation and Atherosclerosis in Rheumatoid Arthritis?

Patients with rheumatoid arthritis (RA), a chronic and disabling autoimmune condition that is characterized by articular and extra-articular manifestations and a pro-inflammatory and pro-oxidant state, suffer from premature atherosclerosis and excessive cardiovascular disease burden. A key step in the pathogenesis of atherosclerosis is impaired synthesis of the endogenous messenger nitric oxide (NO) by endothelial cells which, in turn, alters local homeostatic mechanisms and favors vascular damage and plaque deposition. While the exact mechanisms of endothelial dysfunction in RA remain to be established, there is good evidence that RA patients have relatively high circulating concentrations of the methylated arginine asymmetric dimethylarginine (ADMA), a potent endogenous inhibitor of endothelial NO synthase (eNOS). This review discusses the biological and pathophysiological role of ADMA, the interplay between ADMA, inflammation and oxidative stress, and the available evidence on the adverse impact of ADMA on endothelial function and atherosclerosis and potential ADMA-lowering therapies in RA patients.

Accelerated atherosclerosis in premenopausal women with rheumatoid arthritis - 15-year follow-up

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased mortality and morbidity due to the higher cardiovascular risk in these patients. Traditional risk factors are not the only answer for the accelerated atherosclerosis. In a long-term prospective study, we investigated the relationship between asymptomatic atherosclerosis and traditional risk factors and inflammatory markers in patients with RA and matched healthy controls. We studied the laboratory test results, the concentrations of inflammatory mediators, matrix metalloproteases (MMP), and inflammation markers in a total of 70 (60 at follow-up) premenopausal healthy women with RA and 40 (34 at follow-up) matched controls. We used the B-mode ultrasound imaging of carotid arteries for the detection of asymptomatic atherosclerosis. Correlation with different factors was evaluated. Statistically significant higher values of inflammatory markers such as selective adhesion molecules ICAM and VCAM, interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and MMP-3 in the patients group were found in the follow-up study. More plaques were found in the patients group (42.4% vs. 12.9%; p=0.005), as compared with the controls group. The patients had also higher values of cIMT (p=0.001). Using bivariate regression analysis only VCAM was found as a prognostic factor for plaque occurrence (r= 0. 341, p=0.016), but not for cIMT (r= -0.130, p=0.327) in premenopausal female patients with RA after the follow-up. Therefore, asymptomatic atherosclerosis is accelerated in premenopausal women with RA. The results of our follow-up study showed the association between inflammation and accelerated atherosclerosis. Furthermore, VCAM was found to have a statistically significant correlation with plaque occurrence in these patients.

Glucocorticoids: Fuelling the Fire of Atherosclerosis or Therapeutic Extinguishers?

Glucocorticoids are steroid hormones with key roles in the regulation of many physiological systems including energy homeostasis and immunity. However, chronic glucocorticoid excess, highlighted in Cushing's syndrome, is established as being associated with increased cardiovascular disease (CVD) risk. Atherosclerosis is the major cause of CVD, leading to complications including coronary artery disease, myocardial infarction and heart failure. While the associations between glucocorticoid excess and increased prevalence of these complications are well established, the mechanisms underlying the role of glucocorticoids in development of atheroma are unclear. This review aims to better understand the importance of glucocorticoids in atherosclerosis and to dissect their cell-specific effects on key processes (e.g., contractility, remodelling and lesion development). Clinical and pre-clinical studies have shown both athero-protective and pro-atherogenic responses to glucocorticoids, effects dependent upon their multifactorial actions. Evidence indicates regulation of glucocorticoid bioavailability at the vasculature is complex, with local delivery, pre-receptor metabolism, and receptor expression contributing to responses linked to vascular remodelling and inflammation. Further investigations are required to clarify the mechanisms through which endogenous, local glucocorticoid action and systemic glucocorticoid treatment promote/inhibit atherosclerosis. This will provide greater insights into the potential benefit of glucocorticoid targeted approaches in the treatment of cardiovascular disease.

Comprehensive Medical Analysis of Clinical Diseases and Syndromes Based on Rheumatoid Factor Interfering Immune Blood Cell Damage

Rheumatoid arthritis bothers people. According to statistics, the prevalence of rheumatoid arthritis represents about 3% of the world's population. Rheumatoid factors can interfere with immune blood cells, which is very harmful to human health. In order to solve the damage of rheumatoid factor to health and study its influence on immune blood cells, this paper constructs a case template through case investigation of rheumatoid arthritis patients and creates damage assessment matrix by using comprehensive quantitative and qualitative analysis. The horizontal coupling degree between rheumatoid factor and interference of blood cell system is investigated, and the relationship between them is studied. The experimental results show that there is a correlation between rheumatoid factor and immune blood cells, the correlation coefficient is 0.87, the presence of rheumatoid factor in blood cells, and the cell system damage rate is about 30% higher than that without rheumatoid factor; the study found that there is a great difference in the age of rheumatoid factor in the population, and the age of patients is generally above 45 years old. This shows that rheumatoid factor can cause great damage to immune blood cell system and affect people's health level.

Cardiovascular Disease in Rheumatoid Arthritis: Risk Factors, Autoantibodies, and the Effect of Antirheumatic Therapies

Objective:

To scope the current published evidence on cardiovascular risk factors in rheumatoid arthritis (RA) focusing on the role of autoantibodies and the effect of antirheumatic agents.

Methods:

Two reviews were conducted in parallel: A targeted literature review (TLR) describing the risk factors associated with cardiovascular disease (CVD) in RA patients; and a systematic literature review (SLR) identifying and characterizing the association between autoantibody status and CVD risk in RA. A narrative synthesis of the evidence was carried out.

Results:

A total of 69 publications (49 in the TLR and 20 in the SLR) were included in the qualitative evidence synthesis. The most prevalent topic related to CVD risks in RA was inflammation as a shared mechanism behind both RA morbidity and atherosclerotic processes. Published evidence indicated that most of RA patients already had significant CV pathologies at the time of diagnosis, suggesting subclinical CVD may be developing before patients become symptomatic. Four types of autoantibodies (rheumatoid factor, anti-citrullinated peptide antibodies, anti-phospholipid autoantibodies, anti-lipoprotein autoantibodies) showed increased risk of specific cardiovascular events, such as higher risk of cardiovascular death in rheumatoid factor positive patients and higher risk of thrombosis in anti-phospholipid autoantibody positive patients.

Conclusion:

Autoantibodies appear to increase CVD risk; however, the magnitude of the increase and the types of CVD outcomes affected are still unclear. Prospective studies with larger populations are required to further understand and quantify the association, including the causal pathway, between specific risk factors and CVD outcomes in RA patients.

Selected clinical parameters and changes in cardiac morphology and function assessed by magnetic resonance imaging in patients with rheumatoid arthritis and ankylosing spondylitis without clinically apparent heart disease

BACKGROUND

The aim of the study was to assess the relationship between the occurrence of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and the cardiac magnetic resonance (CMR) changes in people without clinically overt heart disease.

METHODS

The study group consisted of 74 people (48.81 ± 11.35 years): 29 patients with RA, 23 patients with AS and 22 people from control group. Blood samples were taken to assess laboratory parameters, disease activity was determined using activity scales, and CMR was performed.

RESULTS

It was shown that the factors independently related to higher left ventricular mass index are AS occurrence, human B27 leukocyte antigen occurrence, higher neutrophil gelatinase-associated lipocalin concentration (NGAL) and higher body mass index (BMI). The lower right ventricular ejection fraction is result of an independent effect of RA, AS and higher NGAL. RA presence, methotrexate use, higher rheumatoid factor titer, higher NGAL, older age and higher BMI should be considered independent risk factors for greater left ventricular myocardium water content. RA occurrence, AS occurrence, type 2 diabetes occurrence and a higher C-reactive protein concentration can be independently associated with a higher probability of non-ischemic left ventricular myocardium injury. Larger pericardial fluid volume is result of an independent effect of higher NGAL, higher anti-cyclic citrullinated peptide antibodies titer and higher DAS28 disease activity index. Use of steroids is protective factor against larger volume of pericardial fluid.

CONCLUSIONS

RA and AS in people without clinically apparent heart disease are associated with the occurrence of adverse changes in CMR. Key Points •RA and AS in people without clinically apparent heart disease are associated with the occurrence of adverse changes in CMR.. •The independent risk factors for higher LVEF are AS occurrence, human B27 leukocyte antigen occurrence, higher NGAL concentration and higher BMI.. •RA presence, methotrexate use, higher RF, higher NGAL, older age and higher BMI are independent risk factors for higher LV T2 ratio.. •RA occurrence, AS occurrence, type 2 diabetes occurrence and a higher CRP are independently associated with a higher risk of non-ischemic LV myocardium injury..

Loss of sarcomeric proteins via upregulation of JAK/STAT signaling underlies interferon-γ-induced contractile deficit in engineered human myocardium

The level of circulating interferon-γ (IFNγ) is elevated in various clinical conditions including autoimmune and inflammatory diseases, sepsis, acute coronary syndrome, and viral infections. As these conditions are associated with high risk of myocardial dysfunction, we investigated the effects of IFNγ on 3D fibrin-based engineered human cardiac tissues ("cardiobundles"). Cardiobundles were fabricated from human pluripotent stem cell-derived cardiomyocytes, exposed to 0-20 ng/ml of IFNγ on culture days 7-14, and assessed for changes in tissue structure, viability, contractile force and calcium transient generation, action potential propagation, cytokine secretion, and expression of select genes and proteins. We found that application of IFNγ induced a dose-dependent reduction in contractile force generation, deterioration of sarcomeric organization, and cardiomyocyte disarray, without significantly altering cell viability, action potential propagation, or calcium transient amplitude. At molecular level, the IFNγ-induced structural and functional deficits could be attributed to altered balance of pro- and anti-inflammatory cytokines, upregulation of JAK/STAT signaling pathway (JAK1, JAK2, and STAT1), and reduced expression of myosin heavy chain, myosin light chain-2v, and sarcomeric α-actinin. Application of clinically used JAK/STAT inhibitors, tofacitinib and baricitinib, fully prevented IFNγ-induced cardiomyopathy, confirming the critical roles of this signaling pathway in inflammatory cardiac disease. Taken together, our in vitro studies in engineered myocardial tissues reveal direct adverse effects of pro-inflammatory cytokine IFNγ on human cardiomyocytes and establish the foundation for a potential use of cardiobundle platform in modeling of inflammatory myocardial disease and therapy. STATEMENT OF SIGNIFICANCE: Various inflammatory and autoimmune diseases including rheumatoid arthritis, sepsis, lupus erythematosus, Chagas disease, and others, as well as viral infections including H1N1 influenza and COVID-19 show increased systemic levels of a pro-inflammatory cytokine interferon-γ (IFNγ) and are associated with high risk of heart disease. Here we explored for the first time if chronically elevated levels of IFNγ can negatively affect structure and function of engineered human heart tissues in vitro. Our studies revealed IFNγ-induced deterioration of myofibrillar organization and contractile force production in human cardiomyocytes, attributed to decreased expression of multiple sarcomeric proteins and upregulation of JAK/STAT signaling pathway. FDA-approved JAK inhibitors fully blocked the adverse effects of IFNγ, suggesting a potentially effective strategy against human inflammatory cardiomyopathy.

LncRNA MIAT downregulates IL-1β, TNF-ɑ to suppress macrophage inflammation but is suppressed by ATP-induced NLRP3 inflammasome activation

Cardiovascular disease (CVD) has been identified as the leading cause of premature deaths in rheumatoid arthritis (RA), accounting for about 40 to 50% of all deaths. Macrophage inflammation is regarded as a key point to link to the two diseases. Recently, long non-coding RNAs (lncRNAs) have acknowledged as a regulator of inflammation significantly. Here, we firstly found that lncRNA myocardial infarction associated transcript (lncRNA MIAT), a crucial lncRNA to regulate CVD, expressed increasingly in synovium and myocardial tissues of collagen-induced arthritis (CIA) mice. Besides, we also verified that the increased infiltration of macrophage occurred in those tissues of the CIA. In vitro, we found that macrophage inflammation induced by LPS could up-regulate lncRNA MIAT expression. LncRNA MIAT seemed to inhibit the expression of IL-1β, TNF-ɑ and be suppressed by ATP-induced NLRP3 inflammasome activation pathway. Therefore, these data indicated an anti-inflammatory effect of lncRNA MIAT in macrophage and an original research direction for high cardiovascular risk in RA.

Cardiovascular risk in inflammatory arthritis: rheumatoid arthritis and gout

The increased risk of cardiovascular morbidity and mortality in rheumatoid arthritis and gout has been increasingly acknowledged in past decades, with accumulating evidence that gout, just as with rheumatoid arthritis, is an independent cardiovascular risk factor. Although both diseases have a completely different pathogenesis, the underlying pathophysiological mechanisms in systemic inflammation overlap to some extent. Following the recognition that systemic inflammation has an important causative role in cardiovascular disease, anti-inflammatory therapy in both conditions and urate-lowering therapies in gout are expected to lower the cardiovascular burden of patients. Unfortunately, much of the existing data showing that urate-lowering therapy has consistent beneficial effects on cardiovascular outcomes in patients with gout are of low quality and contradictory. We will discuss the latest evidence in this respect. Cardiovascular disease risk management for patients with rheumatoid arthritis and gout is essential. Clinical guidelines and implementation of cardiovascular risk management in daily clinical practice, as well as unmet needs and areas for further investigation, will be discussed.

Incidence of congestive heart failure in rheumatoid arthritis: a review of literature and meta-regression analysis

AIMS

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disorder that not only affects peripheral joints but also increases the risk for cardiovascular disease (CVD) and mortality. Heart failure (HF) appears to be one of the most important contributors to the excess mortality risk among patients with RA. We assessed the incidence of HF in patients with RA compared with age-matched and sex-matched non-RA subjects, after accounting for traditional cardiovascular risk factors and clinical ischemic heart disease.

METHODS AND RESULTS

We performed an aggregate analysis on three studies of RA patients having listed manifestations of HF. We performed a meta-regression analysis to evaluate the incidence of HF in RA patients with increased age and noted for any gender correlation. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using both fixed-effects and random-effects models. In the cumulative analysis of 5, 220, 883 patients, the incidence of HF was noted to be almost two-fold higher in patients with RA compared with a matched control population (OR 1.78, 95% CI 1.22-2.60, P < 0.003), HTN (OR 1.66, 95% CI 1.24-2.23, P < 0.001), and diabetes (OR 1.57, 95% CI 1.36-1.81, P < 0.001). Women had three-fold higher incidence of HF with RA (OR 3.38, 95% CI 2.59-4.40, P < 0.001). On meta-regression, the incidence of HF increased further with older age (coefficient = 0.12, P = 0.0004).

CONCLUSIONS

Our systematic review that included over 5 million subjects confirms the suspected increased incidence of HF in RA patients. Women have the greatest risk for HF. Our analysis advocates the need for updating the current guidelines to incorporate screening and preventive methods for HF in RA patients.

Genetic risk score associations for myocardial infarction are comparable in persons with and without rheumatoid arthritis: the population-based HUNT study

Persons with rheumatoid arthritis (RA) have increased risk of myocardial infarction (MI). Overlapping associations with MI of weighted genetic risk scores (wGRS) for coronary artery disease (CAD) and RA is unknown in a population-based setting. Data from the prospective Nord-Trøndelag Health Study (HUNT2: 1995–1997 and HUNT3: 2006–2008) were used. wGRS added each participant’s carriage of all risk variants weighted by the coefficient from published association studies. Published wGRS for CAD and RA were analysed in Cox regression with MI as outcome, age as analysis time, and censoring at the first MI, death, or 31.12.2017. 2609 of 61,465 participants developed MI during follow-up (mean 17.7 years). The best-fitting wGRS for CAD and RA included 157 and 27 single-nucleotide polymorphisms, respectively. In multivariable analysis including traditional CAD risk factors, the CAD wGRS was associated with MI [hazard ratio = 1.23 (95% CI 1.18–1.27) for each SD increase, p < 0.0001] in RA patients (n = 433) and controls. The RA wGRS was not significant (p = 0.06). Independently from traditional risk factors, a CAD wGRS was significantly associated with the risk for MI in RA patients and controls, whereas an RA wGRS was not. The captured genetic risk for RA contributed little to the risk of MI.

Use of healthcare resources in a cohort of rheumatoid arthritis patients treated with biological disease-modifying antirheumatic drugs or tofacitinib

Introduction/objectives

The objective of this study is to describe the treatment patterns and use of healthcare resources in a cohort of Colombian patients with rheumatoid arthritis (RA) treated with biological disease-modifying antirheumatic drugs (bDMARDs) or tofacitinib.

Method

This is a descriptive study from a retrospective cohort of patients diagnosed with RA who were treated with bDMARDs or tofacitinib after failure of conventional DMARDs (cDMARDs) or first bDMARD. Patients who were receiving pharmacological treatment between 01 January 2014 and 30 June 2018 were included. The analysis is through the revision of claim database and electronical medical records. Demographic and clinical data were collected. The costs of healthcare resources were estimated from the billing expense of healthcare service provider.

Results

We evaluated 588 RA patients on treatment with bDMARDs (n = 505) or tofacitinib (n = 83), most of them were in combination with cDMARDs (85.4%). The 88.1% were females and mean age was 57.3 ± 12.5 years. The median evolution of RA since diagnosis was 9 years (IQR:4–17.2). The mean duration of use during follow-up of the bDMARDs or tofacitinib was similar, with a mean of 9.8 ± 1.9 months. It was identified that 394 (67.0%) discontinued therapy. The average annual direct cost of care per patient was USD 8997 ± 2172, where 97.2% was due to drug costs. The average annual cost of treatment per patient with bDMARDs was USD 8604 and tofacitinib was USD 6377.

Conclusions

In the face of a first failure of cDMARD, bDMARDs are frequently added. A high frequency of patients do not persist treatment during the first year of follow-up. The pharmacological treatment is the most representative cause of healthcare costs.

Key Points • Rheumatoid arthritis is a disease with a high burden of comorbidities, complications, and worse health-related quality of life and is associated with elevated healthcare costs. • The biological disease-modifying antirheumatic drugs or tofacitinib medications are indicated for those with significant progression of the disease and when there is a need for alternatives to achieve low levels of activity and remission. • Patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs or tofacitinib represent a significant economic burden to the health system, especially in the costs derived from pharmacological treatment.

Bidirectional association between GERD and rheumatoid arthritis: two longitudinal follow-up studies using a national sample cohort

Several previous studies have suggested a relationship between GERD and RA. However, no study has investigated the bidirectional relationship between GERD and RA. This study aimed to evaluate the causal relationships between rheumatoid arthritis (RA) and gastroesophageal reflux disease (GERD). Participants aged ≥ 20 years old in the Korean Health Insurance Review and Assessment Service-National Sample Cohort from 2002 to 2013 were enrolled. In study I, 132,140 GERD participants were 1:2 matched with 264,280 control I participants. In study II, 6615 RA participants were 1:4 matched with 26,460 control II participants. Both control I and control II groups were matched with their study groups for age, sex, income, and region of residence. The occurrence of RA (study I) and GERD (study II) were followed up in both the study and control groups. The hazard ratios (HRs) of GERD for RA (study I) and of RA for GERD (study II) were analysed using stratified Cox-proportional hazards models. In study I, 0.8% (1,034/132,140) of the GERD group and 0.5% (1,290/264,280) of the control I group had RA (P < 0.001). The GERD group demonstrated a 1.49-fold higher adjusted HR than did the control I group (95% confidence interval (95% CI) = 1.37-1.62, P < 0.001). In study II, 22.5% (1,490/6,615) of the RA group and 15.2% (4,034/26,460) of the control II group had GERD (P < 0.001). The RA group showed a 1.46-fold higher adjusted HR than did the control II group (95% CI = 1.38-1.55, P < 0.001). GERD and RA have bidirectional associations in Korean adult population. Key Points • Several previous studies have suggested a relationship between gastroesophageal reflux disease (GERD) and rheumatoid arthritis (RA). • However, no study has investigated the bidirectional relationship between GERD and RA. • This is the first study to present a bidirectional relationship between GERD and RA. • GERD and RA have bidirectional relations with each other.

The relationship between periodontal status and rheumatoid arthritis - systematic review

There have been numerous publications investigating the relationship between periodontitis (PD) and rheumatoid arthritis (RA) so far.

This publication presents the common risk factors for the development of PD and RA. The major impact of the pathological bacterial factor and cigarette smoking with chronic inflammation playing the key role in both diseases has been confirmed by numerous studies in various populations over the years. More research focuses nowadays also on the role of improper diet and obesity. Pathophysiological pathways, such as increased concentration of proinflammatory cytokines, indirectly affecting the cardiovascular complications and coagulation disorders, which has an impact on function disorders of tissue metalloproteinase inhibitors and the plasminogen activation system, were also researched.

This systematic review of current literature has shown numerous discrepancies in previous analyses and the need for further detailed research on the relationship between periodontal status and RA.