Traditional cardiovascular risk factors and residual disease activity are associated with atherosclerosis progression in rheumatoid arthritis patients

Association between syndecan-4 and subclinical atherosclerosis in ankylosing spondylitis

BACKGROUND

Despite advances in the diagnosis and treatment of ankylosing spondylitis (AS), the risk of cardiovascular complications in AS patients is still higher than in the general population. Macrophages are at the intersection of the basic pathogenetic processes of AS and atherosclerosis. Although syndecan-4 (SDC4) mediates a variety of biological processes, the role of SDC4 in macrophage-mediated atherogenesis in AS patients remains unclear. Herein, we aimed to investigate the role of SDC4 in subclinical atherosclerosis in AS patients.

METHODS

Subjects were selected from eligible AS patients and control subjects without a prior history of AS who were referred to the rheumatology outpatient clinics. All participants' past medical records and clinical, and demographic characteristics were scanned. In addition, carotid intima-media thickness (CIMT) measurement and disease activity index measurement were applied to all patients.

RESULTS

According to our data, serum SDC4 level was significantly higher among AS patients compared with the control group (6.7 [1.5-35.0] ng/mL vs 5.1 [0.1-12.5] ng/mL, P < .001). The calculated CIMT was also significantly higher in AS patients than in the control group (0.6 [0.3-0.9] mm vs 0.4 (0.2-0.7), P < .001]. Additionally, serum C-reactive protein level and SDC4 level were independent predictors of AS and strongly associated with CIMT. Linear regression analysis showed that serum SDC4 level was the best predictor of CIMT (P = .004).

CONCLUSION

Our data indicate that serum SDC4 levels provide comprehensive information about the clinical activity of the disease and subclinical atherosclerosis in AS patients.

Newly developed cardiovascular risk factors in rheumatoid arthritis patients initiating biologic treatment

Introduction

Rheumatoid arthritis (RA) is a risk factor (RF) for cardiovascular (CV) disease, a leading cause of mortality in RA patients.

Material and methods

Consecutive records of RA patients with high disease activity screened upon biologic therapy initiation were reviewed between January 2001 and 2018. Patients with at least 6-month follow-up and baseline disease activity scores were enrolled (n = 353) and stratified into manifest CV disorder ("overt CVD"), any traditional CV risk factor ("atCVrisk") and no CV risk factor ("vlCVrisk") groups.

Results

Overall, mean (SD) patient age was 51.4 (±12.2) years, and 291 (82.4%) subjects were female. Median follow-up was 41.9 (IQR 18.6, 80) months. Overall, 89 (25.2%) individuals developed at least one new CV RF, of which 65 (18.4%) acquired one and 24 (6.8%) two or more. Incident lipid disorders (42, 11.9%), followed by hypertension (14, 4%), atrial fibrillation (17, 4.8%) and venous thromboembolism (VTE) (16, 4.5%), were common. Incident major adverse cardiac events (MACE) were not reported in the vlCVrisk group, in contrast to atCVrisk (n = 8, 4.2%) or overt CVD (n = 4, 18.2%). Age was a significant predictor of incident CV risk factor (HR 1.04, 95% CI: 1.02-1.07; p < 0.01). In age-adjusted analyses, only baseline body mass index (BMI) (HR 1.11, 95% CI: 1.04-1.18; p < 0.01), but not ever smoking (p = 0.93), male sex (p = 0.26), positive RF (p = 0.24), positive ACPA (p = 0.90), or baseline disease activity (p = 0.19), were independent predictor of incident CV risk factors.

Conclusions

Patients with RA initiating biologics should be screened for cardiometabolic risk factors, especially at an older age. The presence of at least one risk factor may be linked to a worse long-term prognosis.

Exploration of Inflammatory Biomarkers and Psychological Cardiovascular Disease Risk Factors Among Community Dwelling Adults: A Gender Comparison Study

Patients with rheumatic disease (RD) are at high risk for cardiovascular disease (CVD), which is the leading non-communicable chronic disease cause of death worldwide. Inflammatory biomarkers and psychological health status are reliable predictors of CVD in patients with RD. The primary aim of this study was to compare the inflammatory biomarkers and psychological CVD risk factors (CRFs) between a group of community-dwelling adults with RD and CRFs and a group of their peers with CRFs only. The secondary aim of this study was to analyze and compare the collected data by gender in the RD group. Data were collected and analyzed from 355 participants, with the 135 participants with physician-diagnosed RD assigned to the RD group and the remainder (n = 220) assigned to the comparison group. The measures used included a demographic datasheet, medical information, serum homocysteine (Hcy) levels, high sensitive C-reactive protein (hs-CRP) levels, and depression and global sleep-quality scale scores. The RD group had higher ratios of hypertension and depression diagnoses than the comparison group. The gender analysis of the RD group found significantly more-severe sleep disturbances in women than men and a significantly higher mean value of Hcy in men than women. The women in the RD group were significantly older, less educated, and less employed than their male counterparts and thus may be presumed to at higher risk of health illiteracy. Gender-tailored interventions to modify the risk factors of CVD identified in this study for patients with RD are recommended.

Accelerated Atherosclerosis and Management of Cardiovascular Risk in Autoimmune Rheumatic Diseases: An Updated Review

Even though diagnosis and management pathways have been substantially improved over the last years, autoimmune rheumatic diseases (AIRDs) such as rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren's syndrome, and systemic vasculitides have been linked to elevated rates of cardiovascular morbidity and mortality, primarily secondary to accelerated atherosclerosis. This phenomenon can be partially attributed to the presence of established cardiovascular risk factors but may also be a result of other inflammatory and autoimmune mechanisms that are enhanced in AIRDs. According to the current guidelines, the recommendations regarding cardiovascular disease prevention in patients with AIRDs are not significantly different from those applied to the general population. Herein, we present a review of the current literature on the risk of accelerated atherosclerosis in AIRDs and provide a summary of available recommendations for the management of cardiovascular risk in rheumatic diseases.

GM-CSF receptor/SYK/JNK/FOXO1/CD11c signaling promotes atherosclerosis

Atherosclerosis complicates chronic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus, suggesting that a shared physiological pathway regulates inflammatory responses in these diseases wherein spleen tyrosine kinase (SYK) is involved. We aimed to identify a shared therapeutic target for atherosclerosis and inflammatory diseases. We used Syk-knockout atherosclerosis-prone mice to determine whether SYK is involved in atherosclerosis via the inflammatory response and elucidate the mechanism of SYK signaling. The Syk-knockout mice showed reduced atherosclerosis in vivo, and macrophages derived from this strain showed ameliorated cell migration in vitro. CD11c expression decreased on Syk-knockout monocytes and macrophages; it was upregulated by forkhead box protein O1 (FOXO1) after stimulation with granulocyte-macrophage colony-stimulating factor (GM-CSF), and c-Jun amino-terminal kinase (JNK) mediated SYK signaling to FOXO1. Furthermore, FOXO1 inhibitor treatment mitigated atherosclerosis in mice. Thus, GM-CSF receptor/SYK/JNK/FOXO1/CD11c signaling in monocytes and macrophages and FOXO1 could be therapeutic targets for atherosclerosis and inflammatory diseases.

Carotid atherosclerosis in the first five years since rheumatoid arthritis diagnosis: a cross sectional study

BACKGROUND

Systemic inflammation, documented before rheumatoid arthritis (RA) diagnosis, is associated with accelerated atherosclerosis. We aimed to compare the prevalence of carotid plaque (CP) in RA patients in the first five years since diagnosis and healthy controls, and to determine disease characteristics associated with the presence of subclinical atherosclerosis in RA patients.

METHODS

This was a cross-sectional study. We recruited 60 RA patients in the first five years since diagnosis and 60 matched healthy controls. Carotid ultrasound was performed to detect the presence of CP and measure carotid-intima media thickness (cIMT). Subclinical atherosclerosis was considered as the presence of CP and/or increased cIMT. Distribution was evaluated with the Kolmogorov-Smirnov test. Comparisons were made with Chi-square or Fisher's exact test for qualitative variables and Student's t or Mann-Whitney's U test for quantitative variables. A p-value < 0.05 was considered significant.

RESULTS

There were no differences in the demographic characteristics between RA patients and controls. The mean disease duration was 2.66 ± 1.39 years. A higher prevalence of CP (30.0% vs. 11.7%, p = 0.013), bilateral CP (18.3% vs. 3.3%, p = 0.008), increased cIMT (30.0% vs. 6.7%, p = 0.001), and subclinical atherosclerosis (53.3% vs. 18.3%, p = < 0.001) was found in RA patients. RA patients with subclinical atherosclerosis were older (56.70 years vs. 50.00 years, p = 0.002), presented a higher prevalence of dyslipidemia (53.1% vs. 14.3%, p = 0.002), and higher prevalence of classification in moderate-high disease activity category measured by DAS28-CRP (68.8% vs. 35.7%, p = 0.010). The latter variable persisted independently associated with subclinical atherosclerosis in the binary logistic regression (OR 6.11, 95% CI 1.51-24.70, p = 0.011).

CONCLUSIONS

In the first five years since diagnosis, higher prevalence of subclinical atherosclerosis, including CP was found in RA patients. Carotid ultrasound should be considered part of the systematic CVR evaluation of RA at the time of diagnosis.

Subclinical Carotid Atherosclerosis in Patients with Rheumatoid Arthritis at Low Cardiovascular Risk

OBJECTIVE

To evaluate the rate of subclinical carotid atherosclerosis and clinical significance of immunoinflammatory markers in patients with rheumatoid arthritis (RA) at low cardiovascular risk.

MATERIALS AND METHODS

The study included 275 RA patients and a control group of 100 participants without autoimmune diseases. All study participants were at low cardiovascular risk, calculated by the QRISK3 scale (<20%), and free of cardiovascular disease. Ultrasound examination of carotid arteries was performed to measure cIMT and to detect atherosclerotic plaques (ASP) in carotid arteries. sIСАМ-1, sVСАМ, and sCD40L levels were determined by enzyme immunoassay.

RESULTS

Carotid ASP was observed more frequently in RA patients (27%) than in the control group (17%), p = 0.03. The frequency of ASP in RA patients did not depend on the disease's stage or activity. There was a significant correlation between cIMT and age, cardiovascular risk determined by QRISK3, level of total cholesterol, LDL, and blood pressure in RA patients, p < 0.05 in all cases. No correlation between cIMT and blood levels of sCD40L, sVCAM, and sICAM was found. In RA patients, a higher concentration of sVCAM was detected in the carotid ASP group compared to the non-atherosclerotic group. sCD40L was associated with cIMT and total cholesterol in the ASP group and with total cholesterol and blood pressure in non-atherosclerotic patients.

CONCLUSIONS

Subclinical atherosclerotic lesions of the carotid arteries were observed significantly more frequently in RA patients with low cardiovascular risk than in the control group. The results of the study demonstrate the association between cIMT, traditional cardiovascular risk factors, and immunoinflammatory markers in RA patients.

Subclinical atherosclerosis profiles in rheumatoid arthritis and primary Sjögren's syndrome: the impact of BAFF genetic variations

OBJECTIVES

RA and primary SS carry increased atherosclerotic risk, while B-cell activating factor holds a vital role in disease pathogenesis and atherosclerosis. We aimed to compare subclinical atherosclerosis profiles between the two clinical entities and define whether BAFF genetic variants alter atherosclerotic risk.

METHODS

DNA from 166 RA, 148 primary SS patients and 200 healthy controls of similar age and sex distribution was subjected to PCR-based assay for the detection of five single nucleotide polymorphisms of the BAFF gene (rs1224141, rs12583006, rs9514828, rs1041569 and rs9514827). Genotype and haplotype frequencies were determined by SNPStats software and statistical analysis was performed by SPSS and Graphpad Software. Subclinical atherosclerosis was defined by the presence of carotid/femoral plaque formation and arterial wall thickening.

RESULTS

Atherosclerotic plaque formation was more frequently detected in the RA vs primary SS group (80.7% vs 62.2%, P-value <0.001), along with higher rates of family CVD history, current steroid dose and serum inflammatory markers. The TT genotype of the rs1224141 variant was more prevalent in RA but not primary SS patients with plaque and arterial wall thickening vs their counterparts without. Regarding the rs1014569 variant, among RA patients the TT genotype increased the risk for plaque formation while in primary SS patients the AT genotype conferred increased risk. Haplotype GTTTT was protective in the RA cohort, while TATTT and TTCTT haplotypes increased susceptibility for arterial wall thickening in the primary SS cohort.

CONCLUSIONS

Increased inflammatory burden, higher steroid doses and distinct BAFF gene variations imply chronic inflammation and B-cell hyperactivity as key contributors for the augmented atherosclerotic risk among autoimmune patients.

Increased Risk of Cardiovascular Diseases in Rheumatoid Arthritis: A Systematic Review

Rheumatoid arthritis (RA) is an autoimmune condition in which the body's joints are attacked by the immune system, leaving the patient disabled in severe cases, with irreversible joint damage and a lower quality of life. RA patients are more likely to develop cardiovascular (CV) disease, which increases their risk of morbidity and mortality. This study systematically reviews various CV diseases that might occur with RA including heart failure (HF), coronary artery disease, acute coronary syndrome, ischemic heart disease, stroke, cardiac death, venous thromboembolism, and valvular diseases. The relation between these complications and RA is specifically assessed. Systematic search was carried out on literature reporting the risk of each of the CV diseases in RA patients from databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases searched were MEDLINE (through PubMed) and Google Scholar using a combination of keywords and medical subject headings (MeSH). Our keywords were mainly "cardiovascular diseases" and "arthritis and rheumatoid". We found a total of 33 articles reporting each CV comorbidity. Interestingly, a wide spectrum of CV diseases is reported in patients with RA. Many tools were implemented in the diagnosis of each disease such as carotid intima-media thickness for atherosclerosis and echocardiography for HF. We confirmed that RA is associated with an increased risk of different CV events, and prophylactic measures should be implemented.

Serum sulfatide as a biomarker of carotid atherosclerosis in patients with rheumatoid arthritis

PURPOSE

Rheumatoid arthritis (RA) patients have accelerated atherosclerosis (AS) leading to excess cardiovascular morbidity and mortality, but traditional risk factors for cardiovascular disease (CVD) are invalid to explain the problem. Sulfatides, as major components of serum lipoproteins, are synthesized in the liver. These molecules are reported to play an important role in the development of AS, thrombogenesis, and inflammation. However, it is unclear whether sulfatides are responsible for such issue. To elucidate the possible association between serum sulfatide and the accelerated progress of AS, evaluated by carotid intima-media thickness (CIMT), and ascertain the related mechanism underlying the correlation in RA cases.

METHODS

We performed an observational study of 144 patients with RA and 120 sex and age-matched controls. Meanwhile, 107 patients (of the 144 RA patients enrolled at baseline) were invited to undergo a second measurement after 12 months. Serum sulfatide levels of all the enrolled subjects were quantified by mass spectrometry after they were converted into lysosulfatides (LS), and then calculated as the sum of the levels of seven LS molecular species. Serum oxidative stress marker, malondialdehyde (MDA) was detected by ELISA. We subsequently statistically analyzed the causalities between carotid AS and clinical parameters, and the association of serum sulfatide with other variables. Multivariable logistic regression analysis was finally employed by taking all factors to identify independent determinant for carotid atherosclerotic plaque and serum sulfatide level.

RESULTS

A gradual declined trend in serum sulfatide levels was observed in control subjects, non-plaque group, and the plaque group (8.56 ± 1.37 nmol/mL, 5.63 ± 1.57 nmol/mL, 3.18 ± 1.32 nmol/mL, respectively, p < 0.01), along with an increased value of CIMT (0.63 ± 0.07 mm, 0.92 ± 0.14 mm, 1.43 ± 0.22 mm, respectively, p < 0.01). Meanwhile, a negative linear correlation between CIMT and serum sulfatide was further confirmed by Spearman's analysis (r = -0.622, p < 0.01). Eventually, multivariate logistic regression analysis identified serum MDA as the only independent factor for the abnormal level of serum sulfatide, and serum sulfatide was detected as a significant protective factor for the occurrence of carotid plaques in RA cases (p < 0.01), which was confirmed repeatedly by our cross-sectional and longitudinal studies.

CONCLUSION

Excessive abnormal levels of oxidative stress decreased serum sulfatide levels, followed by a high occurrence of AS in RA patients. Serum sulfatide level might be useful as a predictor (biomarker) for the progression of AS in RA cases.

Association of atherogenic indices with C-reactive protein and risk factors to assess cardiovascular risk in rheumatoid arthritis patient at Tikur Anbessa Specialized Hospital, Addis Ababa

Background

Rheumatoid arthritis (RA) is an autoimmune systemic chronic inflammatory disorder, which is characterized by joint stiffness, damage, and destruction of bone. In RA patients, the risk of cardiovascular disease is increased by 2–3 folds as compared to the general population. The major burden of RA is the development of cardiovascular diseases, including congestive heart failure, stroke, and myocardial infarction.

Objectives

Assessment of the association of atherogenic indices with C-reactive protein to evaluate CVD risk was one of the purposes of this study. In addition, the association of atherogenic indices with elevated levels of cardiovascular risk factors (LDL-C and TG) was another aim of this study.

Methods

The preferred study design for this study was a hospital based comparative cross-sectional study method. Data were cleaned, coded, and entered into Epi Data version 4.6 software, and exported to SPSS version 20 for further analysis of atherogenic indices, C-reactive protein, and risk factors. The comparison of atherogenic indices and other variables among the case and control groups was estimated by the independent t-test statistical analysis method. All variables with a p-value less than 0.2 during binary linear regression analysis were selected for multinomial logistic regression analysis. The association of atherogenic indices with C-reactive protein and risk factors was computed using multiple logistic regressions. The data were presented using tables and figures for clarification of the study.

Results

The levels of atherogenic indices were computed for both RA patients and the control group. The values of atherogenic indices were significantly associated with cardiovascular risk factor (CRP ≥ 2mg/L). Atherogenic index of plasma (AIP) and TC/HDL-C ratio had a statistically significant association with an elevated levels of triglycerides (P<0.01). The TC/HDL-Cratio value of the patient had 2.38 folds more likely to have an elevated low density lipoprotein level. In addition, AIP of RA patients had 57.51 and 23.65 folds more to have elevated low density lipoprotein and triglycerides respectively.

Conclusions

The result of this study showed that TC/HDL-C, LDL/HDL-C ratio values, and atherogenic index of plasma had a statistically significant association with elevated level of low density lipoprotein and triglycerides. In addition to this, they have a statistically significant association with the level of C-reactive protein. There was a highly significant statistical association between atherogenic indices, elevated low density lipoprotein, and triglycerides values. Therefore, the result of this finding confirmed that atherogenic indices have a potential role in the prediction and management of CVD risk in RA patients.

Macrophage Dysfunction in Autoimmune Rheumatic Diseases and Atherosclerosis

One of the problems of modern medical science is cardiovascular pathology caused by atherosclerotic vascular lesions in patients with autoimmune rheumatic diseases (ARDs). The similarity between the mechanisms of the immunopathogenesis of ARD and chronic low-grade inflammation in atherosclerosis draws attention. According to modern concepts, chronic inflammation associated with uncontrolled activation of both innate and acquired immunity plays a fundamental role in all stages of ARDs and atherosclerotic processes. Macrophage monocytes play an important role among the numerous immune cells and mediators involved in the immunopathogenesis of both ARDs and atherosclerosis. An imbalance between M1-like and M2-like macrophages is considered one of the causes of ARDs. The study of a key pathogenetic factor in the development of autoimmune and atherosclerotic inflammation-activated monocyte/macrophages will deepen the knowledge of chronic inflammation pathogenesis.

Estimated 10-year cardiovascular risk in a large Italian cohort of rheumatoid arthritis patients: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group

BACKGROUND

Several cardiovascular (CV) risk algorithms are available to predict CV events in the general population. However, their performance in patients with rheumatoid arthritis (RA) might differ from the general population. This cross-sectional multicentre study aimed to estimate the 10-year CV risk using two different algorithms in a large RA cohort and in patients with osteoarthritis (OA).

METHODS

In a consecutive series of RA patients and matched OA controls without prior CV events, clinical and serologic data and traditional CV risk factors were recorded. The 10-year CV risk was assessed with the Systematic COronary Risk Evaluation (SCORE) and the "Progetto Cuore" algorithms.

RESULTS

1,467 RA patients and 342 OA subjects were included. RA patients were more frequently diabetic (9.9% vs 6.4%; p=0.04) and smokers (20.4% vs 12.5%; p=0.002) but had lower prevalence of obesity (15% vs 21%; p=0.003). Dyslipidaemia was more prevalent in OA (32.5% vs 21.7%; p<0.0001). The 10-year estimated CV risk was 1.6% (95%CI 1.3-1.9) in RA and 1.4% (95%CI 1.3-1.6) in OA (p=0.002) according to SCORE and 6.5% (95%CI 6.1-6.9) in RA and 4.4% (95%CI 3.9-5.1) in OA (p<0.001) according to "Progetto Cuore". Regardless of the score used, RA patients had a 3- to-4-fold increased 10-year risk of CV events compared to OA subjects.

CONCLUSION

RA patients have a significantly higher 10-year risk of CV events than OA subjects. In addition to effective disease control and joint damage prevention, specific protective measures targeting modifiable traditional CV risk factors should be implemented in RA.

Application of cardiovascular risk scales to identify carotid atherosclerosis in patients with rheumatoid arthritis

Aim. To evaluate the cardiovascular risk (CVR) and analyze its relationship with detection of early carotid artery atherosclerotic lesion in patients with rheumatoid arthritis (RA). Materials and methods. One hundred and nine RA patients aged 45 to 60 without established cardiovascular diseases (CVD) were included in the study. The median age was 52 [48; 54] years, duration of RA was 120 [36; 204] months, DAS28 was 4.7 [3.5; 5.6] points. CVD risk was calculated with mSCORE, Reynolds Risk Score (RRS), ASSIGN, QRISK3, ERS-RA scales and Carotid Artery Doppler Ultrasound Exam was performed for all patients. Results. High risk was found in 5, 5, 14, 6, and 38% of patients according to mSCORE, RRS, ASSIGN, QRISK3, ERS-RA scales, respectively. Atherosclerotic plaques of carotid arteries were found in 30% of patients. It was found that carotid intima-media thickness is correlated to all CVR calculators, age, systolic and diastolic blood pressure, cholesterol, erythrocyte sedimentation rate, interleukin-6 levels. The sensitivity and specificity of the CVR algorithms in prognostication of atherosclerotic carotid artery lesions were 73 and 67% for mSCORE, 64 and 63% for RRS, 64 and 56% for ASSIGN, 73 and 49% for QRISK3, respectively, p0.05 in all cases, 67 and 50% for ERS-RA, p=0.06. Conclusion. RRS, mSCORE, ASSIGN, QRISK3 calculators equally predict atherosclerotic carotid artery damage in RA patients. The optimal ratio of specificity and sensitivity is shown for the mSCORE scale. Stratification of CVR in RA patients should include assessment of the carotid intima-media thickness. To identify CVR in RA patients, the most informative methods are mSCORE calculation and carotid intima-media thickness determination.

Do individuals with autoimmune disease have increased risk of subclinical carotid atherosclerosis and stiffness?

To explore the role of chronic inflammation inherent to autoimmune diseases in the development of subclinical atherosclerosis and arterial stiffness, this study recruited two population-based samples of individuals with and without autoimmune disease (ratio 1:5) matched by age, sex, and education level and with a longstanding (≥6 years) diagnosis of autoimmune disease. Common carotid intima-media thickness (IMT) and arterial distensibility and compliance were assessed with carotid ultrasound. Multivariable linear and logistic regression models were adjusted for 10-year cardiovascular risk. In total, 546 individuals with and without autoimmune diseases (91 and 455, respectively) were included. The mean age was 66 years (standard deviation 12), and 240 (43.9%) were women. Arterial stiffness did not differ according to the presence of autoimmune diseases. In men, the diagnosis of autoimmune diseases significantly increased common carotid IMT [beta-coefficient (95% confidence interval): 0.058 (0.009; 0.108); p value = 0.022] and the percentage with IMT ≥ 75th percentile [1.012 (0.145; 1.880); p value = 0.022]. Women without autoimmune disease were more likely to have IMT ≥ the 75th percentile [-2.181 (-4.214; -0.149); p value = 0.035], but the analysis of IMT as a continuous variable did not yield significant results. In conclusion, subclinical carotid atherosclerosis, but not arterial stiffness, was more common in men with autoimmune diseases. Women did not show significant differences in any of these carotid features. Sex was an effect modifier in the association between common carotid IMT values and the diagnosis of autoimmune diseases.

The Key Comorbidities in Patients with Rheumatoid Arthritis: A Narrative Review

Comorbidities in patients with rheumatoid arthritis (RA) are often associated with poor health outcomes and increased mortality. Treatment decisions should take into account these comorbidities due to known or suspected associations with certain drug classes. In clinical practice, it is critical to balance potential treatment benefit against the possible risks for comorbidities as well as the articular manifestations of RA. This review summarises the current literature relating to prevalence and risk factors for the important comorbidities of cardiovascular disease, infections, lymphomas and nonmelanoma skin cancers in patients with RA. The impact on patient outcomes and the interplay between these comorbidities and the therapeutic options currently available, including tumour necrosis factor inhibitors and newer biological therapies, are also explored. As newer RA therapies are developed, and patients gain wider and earlier access to advanced therapies, in part due to the emergence of biosimilars, it is important to consider the prevention or treatment of comorbidities as part of the overall management of RA.

Patterns of multimorbidity and their effects on adverse outcomes in rheumatoid arthritis: a study of 5658 UK Biobank participants

OBJECTIVE

To investigate how the type and number of long-term conditions (LTCs) impact on all-cause mortality and major adverse cardiovascular events (MACE) in people with rheumatoid arthritis (RA).

DESIGN

Population-based longitudinal cohort study.

SETTING

UK Biobank.

PARTICIPANTS

UK Biobank participants (n=502 533) aged between 37 and 73 years old.

PRIMARY OUTCOME MEASURES

Primary outcome measures were risk of all-cause mortality and MACE.

METHODS

We examined the relationship between LTC count and individual comorbid LTCs (n=42) on adverse clinical outcomes in participants with self-reported RA (n=5658). Risk of all-cause mortality and MACE were compared using Cox's proportional hazard models adjusted for lifestyle factors (smoking, alcohol intake, physical activity), demographic factors (sex, age, socioeconomic status) and rheumatoid factor.

RESULTS

75.7% of participants with RA had multimorbidity and these individuals were at increased risk of all-cause mortality and MACE. RA and >4 LTCs showed a threefold increased risk of all-cause mortality (HR 3.30, 95% CI 2.61 to 4.16), and MACE (HR 3.45, 95% CI 2.66 to 4.49) compared with those without LTCs. Of the comorbid LTCs studied, osteoporosis was most strongly associated with adverse outcomes in participants with RA compared with those without RA or LTCs: twofold increased risk of all-cause mortality (HR 2.20, 95% CI 1.55 to 3.12) and threefold increased risk of MACE (HR 3.17, 95% CI 2.27 to 4.64). These findings remained in a subset (n=3683) with RA diagnosis validated from clinical records or medication reports.

CONCLUSION

Those with RA and other LTCs, particularly comorbid osteoporosis, are at increased risk of adverse outcomes, although the role of corticosteroids could not be evaluated in this study. These results are clinically relevant for the monitoring and management of RA across the healthcare system, and future clinical guidelines for RA should acknowledge the importance of multimorbidity.