Rheumatoid spondylitis and aortic insufficiency

The Prevalence of Cardiac Diseases in a Contemporary Large Cohort of Dutch Elderly Ankylosing Spondylitis Patients-The CARDAS Study

Objectives: The aim of the present study was to determine the prevalence of specific cardiac manifestations, i.e., conduction disorders, valvular disease and diastolic left ventricular (LV) dysfunction, in a large cross-sectional controlled cohort of elderly ankylosing spondylitis (AS) patients. Methods: This cross-sectional study assessed the prevalence of valvular disease, conduction disorders and LV dysfunction in 193 randomly selected AS patients compared with 74 osteoarthritis (OA) controls aged 50–75 years. Patients underwent conventional and tissue Doppler echocardiography in combination with clinical and laboratory assessments. Multivariate regression analyses were performed to compare the odds of mitral valve regurgitation (MVR) and aortic valve regurgitation (AVR) between AS patients and OA controls. Results: The prevalence of diastolic dysfunction was trivial and comparable in AS patients compared to controls (respectively, 4% and 3%) and had no further clinical relevance. In addition, the prevalence of conduction disturbances was similar in both groups, with little clinical relevance, respectively 23% vs. 24%. The prevalence of AVR was significantly higher in AS patients compared to the controls, respectively 23% (9% trace, 12% mild, 1% moderate, 1% severe, 1% prosthesis) vs. 11%, p = 0.04. After correcting for age, sex and CV risk factors, AS patients had an odds ratio of 4.5 (95% CI 1.1–13.6) for AVR compared to the controls. In contrast, the prevalence values of MVR were similar and mostly not clinically relevant in AS patients and controls, respectively 36% and 32% and p = 0.46. Conclusion: The prevalence of diastolic LV dysfunction and conduction disorders was mostly not clinically relevant, and similar in AS patients and controls. However, AS patients had an up to five times increased odds to develop AVR compared to controls. Therefore, echocardiographic screening of elderly (50–75 years) AS patients should be considered.

Spondyloarthropathy identified as the etiology of Nubian erosive arthritis

Slight variation in manifestation of different diseases may allow a single individual with one disease to mimic the "classic" appearance of another, as evidenced by the frequent confusion of spondyloarthropathy with rheumatoid arthritis. Analysis of population occurrence of arthritis (rather than isolated skeletons) facilitates more precise diagnosis. Northeast Africans living around 2,000 years before present were clearly afflicted with a form of spondyloarthropathy. Lack of inclusion of spondyloarthropathy in the differential diagnosis of erosive arthritis led to past misclassification of Nubians as having rheumatoid arthritis. While evidence of spondyloarthropathy abounds in the literature of human skeletal disease, pre-Columbian Old World rheumatoid arthritis is still elusive. The current study further documents the absence of rheumatoid arthritis in Nubians, supporting the hypothesis that rheumatoid arthritis began in the New World.

The microscopic features of inflammatory abdominal aortic aneurysms: discriminant analysis

Up to 15% of abdominal aortic aneurysms are designated as inflammatory. They are characterized by marked fibrous thickening of the aneurysmal wall, with the fibrosis extending into the adjacent retroperitoneum. Thirty-five abdominal aortic aneurysms were studied, 15 inflammatory and 20 atherosclerotic. Of the inflammatory group, 10 were symptomatic and five asymptomatic. For each resection specimen, 59 microscopic features (variables) were scored semi-quantitatively. Discriminant function analysis showed that endarteritis obliterans, fibrosis around nerves or ganglia at the outer margin of mural fibrosis, and the thickness of the combined fibrotic media and adventitia gave a satisfactory high discrimination between atherosclerotic and inflammatory aneurysms. When these three variables are used together, a histological diagnosis of inflammatory aneurysm can be made with an expected accuracy in excess of 80%.

Complete heart block in rheumatoid arthritis

We report 8 cases of complete heart block (CHB) occurring in patients with rheumatoid arthritis and review 20 similar patients previously reported. Complete heart block occurs generally in patients with established erosive nodular rheumatoid disease. It usually appears to be sudden and permanent, but progression from minor conduction delays is not uncommon. The characteristic histopathological finding is a rheumatoid granuloma in or near the AV node or bundle of His. If syncope or Stokes-Adams attacks occur, the treatment of choice is the insertion of a permanent pacemaker. The prognosis is good provided no other cardiac lesions occur, whether pericardial, valvular, or myocardial.

Ankylosing spondylitis: an important cause of severe disturbances of the cardiac conduction system. Prevalence among 223 pacemaker-treated men

The cause of severe disturbances of the cardiac conduction system is seldom possible to establish clinically at pacemaker implantation, apart from cases of acute myocardial infarction or digitalis intoxication and in relatively rare cases of inflammatory disorders such as sarcoidosis and systemic sclerosis. Since cardiac manifestations, mainly conduction disturbances, occur in patients with ankylosing spondylitis, the prevalence of this disease was determined using radiologic screening for sacroiliitis in a population of 223 men who had permanently implanted pacemakers. Sacroiliitis was found in 19 men (8.5 percent), 15 of whom fulfilled the diagnostic criteria for ankylosing spondylitis. In six patients, sacroiliitis was asymptomatic and two of the patients were completely free of symptoms other than those originating from their heart manifestations. In seven of the 15 patients with ankylosing spondylitis and in the four patients with sacroiliitis without clinical criteria of ankylosing spondylitis, the diagnosis was previously unknown. Uveitis and aortic regurgitation occurred in five patients each, while peripheral arthritis was twice as common. The prevalence of sacroiliitis and ankylosing spondylitis of 8.5 and 6.7 percent, respectively, differ significantly (p less than 0.01) from the frequencies found in general Caucasian populations of 1 to 2 and 0.1 to 0.5 percent, respectively. HLA B27 was present in more than 80 percent of the patients with sacroiliitis and/or ankylosing spondylitis, compared with 8 to 10 percent in the general population. This strong association is in accordance with previous studies of patients with symptomatic sacroiliitis and/or ankylosing spondylitis. Thus sacroiliitis, diagnosed by x-ray, can be considered a marker for this relatively common rheumatic cause of severe disturbances of the cardiac conduction system.

Early detection of aortic dilatation in ankylosing spondylitis using echocardiography

Aortic root abnormalities including cusp thickening, subvalvular stenosis, and mild aortic root dilatation are the most common cardiac complications in patients with long standing ankylosing spondylitis (AS). Twenty-three patients with definite idiopathic AS (New York Criteria 1966) and twenty-two matched controls were studied with M-mode echocardiography. Only one of the AS patients had clinical aortic incompetence. Six of the AS patients had mildly dilated aortic roots (normal less than 3.7 cm) with a mean diameter of 3.9 cm (range 3.8 to 4.00 cm). None of the twenty-two controls matched for age, sex and blood pressure had dilated aortic roots, with a mean diameter of 3.3 cm (range 2.9 to 3.6 cm). No correlation existed between aortic dilatation and severity of disease estimated by acute phase proteins--caerulo plasmin, alpha 1-antitrypsin, alpha 1 acid glycoprotein, ferritin and C Reactive protein. Contrary to a previous report, mild aortic root dilatation occurs in long standing cases of AS. Although it is a non-specific finding, it does not appear to be related to age or blood pressure and may therefore be the forerunner of aortic incompetence.

Aortic valve incompetence and replacement in rheumatoid arthritis

Five cases of aortic incompetence and nodular seropositive rheumatoid arthritis are presented. Four cases underwent aortic valve replacement. Two of these had granulomatous involvement of the aortic cusps similar to subcutaneous rheumatoid nodules, and another showed a nonspecific fibrosis. One case had definite coincidental rheumatic aortic and mitral heart disease. Two patients had undergone pericardectomy previously for constrictive pericarditis. Good results were obtained in all four operated cases and cardiac surgery enabled continuation of rehabilitation for the rheumatoid arthritis, including major orthopaedic procedures. A review of 22 cases from the literature with rheumatoid granulomata within the aortic valve shows that they are associated with mitral valve granulomata in 63-6%. Congestive cardiac failure was found in 75%. Macroscopical evidence of aortic incompetence was seen in 36-8% and of aortic stenosis in 15-8%. Associated pericarditis occurred in 59-1%, which was severe or complicated in 13.6%. The associated arthritis was severe in 77-8% with subcutaneous nodules (71-5%), rheumatoid factor (83-6%), and episcleritis (66-6%). From these cases and a review of the literature the following points are emphasized. (1) Both the granulomatous and nonspecific aortic valvulitis of rheumatoid arthritis may result in significant haemodynamic abnormality. (2) The valve lesions found are often clinically and macroscopically indistinguishable from rheumatic valve lesions. (3) Granulomata, when present, are usually found in the valve cusp or ring and only occasionally in the aortic wall. (4) Associated joint disease, although usually severe, may be mild. (5) The valve lesion may be accompanied by a severe pericardial involvement--either tamponade or constriction. (6) Aortic valve replacement for aortic incompetence in rheumatoid arthritis is both feasible and worthwile, despite severe joint disease.

Ankylosing spondylitis and aortic regurgitation. Description of the characteristic cardiovascular lesion from study of eight necropsy patients

Clinical and cardiovascular necropsy findings are described in eight patients with combined ankylosing spondylitis and aortic regurgitation. All were men (aged 34-55 years), each had peripheral arthritis in addition to spondylitis, all had severe congestive failure, and six had conduction disturbances. In three patients aortic regurgitation was present before distinctive radiologic changes of ankylosing spondylitis were apparent and only two patients had advanced arthritic changes of ankylosing spondylitis. Thus, cardiac dysfunction may be present before signs of spondylitis are apparent, and aortic regurgitation may be severe when signs of spondylitis are minimal. A characteristic cardiovascular morphologic abnormality was present in each patient. The aortic valve cusps and the aorta behind and immediately above the sinuses of Valsalva were thickened, the latter by dense adventitial scar tissue and by intimal fibrous proliferation. In each patient the scar tissue in the root of aorta extended below the base of aortic valve to produce a subaortic fibrous ridge. The subaortic bump involves the base of anterior mitral leaflet and may cause mitral regurgitation. Extension of the fibrous scar into ventricular septum may cause heart block. The distinctive cardiovascular morphologic findings in patients with ankylosing spondylitis clearly separate this condition from syphilis and other entities associated with aortic regurgitation.

Inflammatory aneurysms of the abdominal aorta

Two hundred and seventeen patients presenting with abdominal aneurysms in the Department of Surgery at the Manchester Royal Infirmary between the years 1958–69 were surveyed retrospectively.

One hundred and eighty-seven of the patients underwent operation for resection of their aneurysms; of these, 19 (10 per cent) showed excessive thickening of the aneurysm walls and perianeurysmal adhesions at operation.

Subsequent histological examination of the walls of these unusual aaneurysms showed extensive active chronic inflammatory changes, including plasma-cell infiltration.

This group of patients whose aneurysms we describe as ‘inflammatory’ presented with different clinical features in comparison with the atherosclerotic group.

Retrospective investigation has not yet revealed any aetiological factors. We feel that ‘inflammatory’ aneurysms are a discrete entity with significant differences from atherosclerotic aneurysms and previously described arteritis.