Myocardial performance and aortic elasticity are impaired in patients with ankylosing spondylitis

A meta-analysis of left ventricular dysfunction in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine, presenting a considerable morbidity risk. Although evidence consistently indicates an elevated risk of ischemic heart disease among AS patients, debates persist regarding the likelihood of these patients developing left ventricular dysfunction (LVD). Our investigation aimed to determine whether individuals with AS face a greater risk of LVD compared to the general population. To accomplish this, we identified studies exploring LVD in AS patients across five major databases and Google Scholar. Initially, 431 studies were identified, of which 30 met the inclusion criteria, collectively involving 2933 participants. Results show that AS patients had: (1) poorer Ejection Fraction (EF) [mean difference (MD): -0.92% (95% CI: -1.25 to -0.59)], (2) impaired Early (E) and Late (atrial-A) ventricular filling velocity (E/A) ratio [MD: -0.10 m/s (95% CI: -0.13 to -0.08)], (3) prolonged deceleration time (DT) [MD: 12.30 ms (95% CI: 9.23-15.36)] and, (4) a longer mean isovolumetric relaxation time (IVRT) [MD: 8.14 ms (95% CI: 6.58-9.70)] compared to controls. Though AS patients show increased risks of both systolic and diastolic LVD, we found no significant differences were observed in systolic blood pressure [MD: 0.32 mmHg (95% Confidence Interval (CI): -2.09 to 2.73)] or diastolic blood pressure [MD: 0.30 mmHg (95% CI: -0.40 to 1.01)] compared to the general population. This study reinforces AS patients' susceptibility to LVD without a notable difference in HTN risk.

Association of ankylosing spondylitis with cardiovascular disease: a bidirectional two-sample mendelian randomization study

Backgrounds

Current observational investigations hint at a potential linkage between ankylosing spondylitis and cardiovascular wellness. However, the nature of this causality remains to be elucidated. Consequently, this study is designed to evaluate the causal interconnection between ankylosing spondylitis and cardiovascular-related conditions utilizing a bidirectional two-sample Mendelian Randomization (MR) methodology.

Methods

In this study, we conducted Mendelian randomization (MR) analyses using genome-wide association study (GWAS) data. The fixed-effects inverse variance weighted (IVW) model was used as the primary analysis method, and MR-Egger regression and the weighted median method were employed as supplementary approaches. Horizontal pleiotropy and heterogeneity were evaluated using various statistical tests, including MR-PRESSO global test, MR-Egger intercept, and Cochran's Q test.

Results

The MR result demonstrated an increased risk of heart failure in individuals with ankylosing spondylitis (OR: 1.0132, 95% CI = 1.0043-1.0221, p = 0.003). The MR analysis results did not demonstrate a causal relationship between ankylosing spondylitis and other cardiovascular diseases, such as atrial fibrillation, coronary artery disease, ischemic stroke, myocardial infarction, and valvular heart disease (all p > 0.05). No evidence of reverse causality was found between ankylosing spondylitis and mentioned cardiovascular diseases in reverse MR analyses. Sensitivity analysis verified the reliability of the results.

Conclusion

Our MR study indicates a relationship between ankylosing spondylitis and an increased risk of heart failure. Further research is needed to confirm these findings and elucidate the underlying mechanisms involved.

No evidence of a causal relationship between ankylosing spondylitis and cardiovascular disease: a two-sample Mendelian randomization study

Objective

Observational studies have suggested an increased risk of cardiovascular disease in individuals with ankylosing spondylitis. However, these studies are prone to confounding factors and reverse causality. To address these limitations, we conducted a Mendelian randomization study to assess the causal relationship between AS and CVD.

Methods

The study population comprises 9,069 individuals with ankylosing spondylitis and 509,093 individuals with either of six common cardiovascular diseases and a related indicator. Causal analysis using summary effect estimates and inverse variance weighting were employed as the main methods.

Results

The CAUSE analysis showed no evidence of a causal relationship between AS and CVD. The odds ratios for total CVD, heart failure, myocardial infarction, valvular heart disease, ischemic heart disease, and venous thromboembolism, Arterial stiffness index, were as follows: OR, 1.01; 95% confidence interval, 0.96-1.05; P = 0.91; OR, 1.03; 95% CI, 0.99-1.08; P = 0.50; OR, 0.94; 95% CI, 0.86-1.03; P = 0.53; OR, 0.99; 95% CI, 0.94-1.04; P = 0.99; OR, 0.98; 95% CI, 0.91-1.04; P = 0.94; OR, 0.98; 95% CI, 0.91-1.04; P = 0.99; β, -0.0019; 95% CI, 0.97-1.01; P = 0.99. The IVW and weighted median methods also yielded consistent results, and no heterogeneity or pleiotropy was found. Likewise, a reverse Mendelian randomization analysis did not uncover a heritable causal relationship between AS and CVD.

Conclusion

This Mendelian randomization study does not support a causal relationship between AS and CVD. Further research is needed to confirm this association.

Ankylosing spondylitis is associated with increased prevalence of valvular heart diseases: a cross-sectional population-based study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis primarily affecting the sacroiliac joint and axial skeleton with associated extra-articular involvement including cardiovascular system disease including aortic valve disease with variable reported prevalence. The aim of this study is to determine the prevalence of heart valve disorders in AS patients.

METHODS

This was a retrospective, population-based, cross-sectional study that retrieved data from the Clalit Health Services registry. Cases were defined as having AS, whereas controls were frequency matched by age and sex in a ratio of 5:1. The prevalence of valvular heart diseases was compared between the two groups; a multivariate logistic regression model was applied to estimate the association after controlling for potential confounders.

RESULTS

We included 4082 AS patients and 20 397 controls frequency matched by age and sex. AS patients had a significantly higher prevalence of cardiovascular risk factors (P < .001) and a higher prevalence of valvular heart disease. In the multivariate logistic regression model, adjusting for multiple confounding factors, AS was independently associated with aortic stenosis [odds ratio (OR): 2.25, 95% confidence interval (CI): 1.57-3.23, P < 0.001], aortic insufficiency (OR: 2.44, 95% CI: 1.50-3.94, P < 0.001), and mitral insufficiency (OR: 1.75, 95% CI: 1.17-2.61, P < 0.001) but not mitral stenosis (OR: 1.31, 95% CI: 0.60-2.70, P = 0.47).

CONCLUSIONS

Our study reports the increased risk of valvular heart diseases in patients with AS, possibly due to the inflammatory milieu associated with the disease process and the result of biomechanical stress affecting the enthesis-like valvular structures.

Mitral valve disease in ankylosing spondylitis: an autoimmune disease manifestation? A case report

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease of primarily the joints of the spine. In the literature, AS is known to have cardiac manifestations. Most frequently, this is aortic regurgitation. However, in rare cases also mitral valve (MV) disease is observed in AS patients. The extent and mechanism of this involvement are still unclear. We aim to describe a histologically validated case report to add understanding on this topic.

Case summary

We show the case of a 51-year-old male who suffered since his youth from back pain and uveitis, which was later diagnosed as AS. After a first presentation with combined heart valve disease, the patient recovered on cardiac medical therapy and biologic treatment for AS. Four years later, cardiac complaints worsened mainly due to severe MV stenosis. Surgical treatment was performed with histopathologic analysis of the excised MV validating involvement of AS.

Discussion

Histopathologic analysis showed chronic fibro inflammatory thickening of the MV leaflets and subvalvular apparatus. These pathological features could fit with the inflammatory nature of AS. Since this is a rare case, the recognition of fibro inflammatory thickening leading to commissural fusion and stenosis may contribute to better understanding of heart valve disease in AS to create a base for better cardiac management in this specific patient group.

Multimodality Evaluation of Aortic Insufficiency and Aortitis in Rheumatologic Diseases

Aortic insufficiency is commonly observed in rheumatologic diseases such as ankylosing spondylitis, systemic lupus erythematosus, antiphospholipid syndrome, Behçet's disease, granulomatosis with polyangiitis, and Takayasu arteritis. Aortic insufficiency with an underlying rheumatologic disease may be caused by a primary valve pathology (leaflet destruction, prolapse or restriction), annular dilatation due to associated aortitis or a combination of both. Early recognition of characteristic valve and aorta morphology on cardiac imaging has both diagnostic and prognostic importance. Currently, echocardiography remains the primary diagnostic tool for aortic insufficiency. Complementary use of computed tomography, cardiac magnetic resonance imaging and positron emission tomography in these systemic conditions may augment the assessment of underlying mechanism, disease severity and identification of relevant non-valvular/extracardiac pathology. We aim to review common rheumatologic diseases associated with aortic insufficiency and describe their imaging findings that have been reported in the literature.

Echocardiographic and Electrocardiographic Findings in Patients with Ankylosing Spondylitis without Cardiovascular Risk Factors

Background: Ankylosing spondylitis (AS) is a chronic inflammatory condition associated with more cardiac manifestations than those in the normal population. In this study, we sought to determine the prevalence of cardiac involvement in patients suffering from AS without cardiovascular risk factors.

Methods: The present case-control study, conducted in 2 university hospitals in Tehran from January 2016 to December 2017, recruited 67 patients with AS and 40 age- and sex-matched healthy controls. The diagnosis of AS was based on the classification criteria of the Assessment of SpondyloArthritis International Society. All the participants were examined using transthoracic echocardiography and a standard 12-lead ECG. Baseline characteristics, echocardiographic findings, and ECG features were compared between the AS and control groups using univariate analyses.

Results: The median age was 33.5 (IQR_25-75%: 20.5–59) years in the AS group and 35 (IQR_25-75%: 26–59) years in the control group (P=0.301). The number of patients with left ventricular systolic and diastolic dysfunction was significantly higher in the patients with AS than in the controls (7.5% vs. 20.9%; P=0.067, and 22.9% vs. 5.0%; P=0.026, respectively). The number of individuals with a left-axis deviation and a left anterior fascicular block was significantly higher in the patients suffering from AS than in the control group. The number of patients with aortic valve involvement was comparable between the groups (P=0.332).

Conclusion: The most common cardiac involvement in our patients with AS was left ventricular dysfunction, followed by rhythm disturbances and aortic valve insufficiency. These findings were independent of age, AS severity, and disease duration. Therefore, the implementation of cardiovascular screening can be recommended for patients with AS.

Unexpected increase of aortic stiffness in juvenile Spondyloarthropathies

Juvenile spondyloarthropathy is an umbrella term for a group of childhood rheumatic diseases that can cause chronic arthritis extending to the axial skeleton before the age of 16. Although ankylosing spondylitis has aortic involvement as one of its most important effects, this relationship has not been extensively studied in children with juvenile spondyloarthropathy. Here, a cross-sectional study of the elastic properties of the aorta of 43 patients with juvenile spondyloarthropathy and 19 healthy controls is reported. Aortic stiffness assessed by echocardiography was used to predict the presence of aortitis, supplemented by pulsed-wave tissue Doppler indices. The right ventricular fractional area change was found to be significantly lower in the patients with juvenile spondyloarthropathy than in the healthy controls; aortic strain and distensibility were also significantly lower, and aortic stiffness index β was significantly higher; and the aortic root diameter change was significantly lower. According to HLA-B27 positivity, there was no difference in the stiffness parameters between the two groups. There was a significant correlation between juvenile Ankylosing Spondylitis Disease Activity Index and aortic diameter change, between juvenile Ankylosing Spondylitis Disease Activity Index and aortic stiffness. Thus, juvenile spondyloarthropathy is linked to high aortic stiffness parameters.

Biomechanical Properties of Common Carotid Arteries Assessed by Circumferential 2D Strain and β Stiffness Index in Patients With Ankylosing Spondylitis

OBJECTIVE

Ankylosing spondylitis (AS) is associated with an elevated risk of cardiovascular disease (CVD) related to atherosclerosis, preceded by arterial stiffness. We aimed to examine common carotid artery (CCA) biomechanical properties using ultrasound to calculate β stiffness index (indicating arterial stiffness) and, a more recently developed technique, 2-dimensional (2D) speckle tracking strain (indicating arterial motion and deformation, strain) to (1) compare with age- and sex-matched controls, and (2) analyze relationships between strain and stiffness with disease characteristics and traditional risk factors for CVD in patients with AS.

METHODS

In this cross-sectional study, a cohort of 149 patients with AS, mean age 55.3 ± 11.2 years, 102 (68.5%) men, and 146 (98%) HLA-B27-positive, were examined. Bilateral CCA were examined for circumferential 2D strain and β stiffness index. A subgroup of 46 patients was compared with 46 age- and sex-matched controls, both groups without hypertensive disease, diabetes, myocardial infarction, or stroke.

RESULTS

Mean bilateral circumferential 2D strain was lower in AS patients compared with controls (7.9 ± 2.6% vs 10.3 ± 1.9%, P < 0.001), whereas mean bilateral β stiffness index was higher (13.1 ± 1.7 mmHg/mm vs 12.3 ± 1.3 mmHg/mm, P = 0.02). In multivariable linear regression analyses, strain was associated with age, erythrocyte sedimentation rate, history of anterior uveitis, and treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARD) and/or biological DMARD (R² 0.33), while stiffness was associated with age (R² 0.19).

CONCLUSION

Both CCA circumferential 2D strain and β stiffness index differed between patients with AS and controls. Strain was associated with AS-related factors and age, whereas only age was associated with stiffness, suggesting that the obtained results reflect different pathogenic vascular processes.

Cardiac Arrhythmias in Autoimmune Diseases

Autoimmune diseases (ADs) affect approximately 10% of the world's population. Because ADs are frequently systemic disorders, cardiac involvement is common. In this review we focus on typical arrhythmias and their pathogenesis, arrhythmia-associated mortality, and possible treatment options among selected ADs (sarcoidosis, systemic lupus erythematosus, scleroderma, type 1 diabetes, Graves' disease, rheumatoid arthritis, ankylosing spondylitis [AS], psoriasis, celiac disease [CD], and inflammatory bowel disease [IBD]). Rhythm disorders have different underlying pathophysiologies; myocardial inflammation and fibrosis seem to be the most important factors. Inflammatory processes and oxidative stress lead to cardiomyocyte necrosis, with subsequent electrical and structural remodeling. Furthermore, chronic inflammation is the pathophysiological basis linking AD to autonomic dysfunction, including sympathetic overactivation and a decline in parasympathetic function. Autoantibody-mediated inhibitory effects of cellular events (i.e., potassium or L-type calcium currents, M₂muscarinic cholinergic or β₁-adrenergic receptor signaling) can also lead to cardiac arrhythmia. Drug-induced arrhythmias, caused, for example, by corticosteroids, methotrexate, chloroquine, are also observed among AD patients. The most common arrhythmia in most AD presentations is atrial arrhythmia (primarily atrial fibrillation), expect for sarcoidosis and scleroderma, which are characterized by a higher burden of ventricular arrhythmia. Arrhythmia-associated mortality is highest among patients with sarcoidosis and lowest among those with AS; there are scant data related to mortality in patients with psoriasis, CD, and IBD.

Ankylosing Spondylitis Is Associated With Risk of New-Onset Obstructive Sleep Apnea: A Nationwide Population-Based Cohort Study

Objectives: Investigating the risk of obstructive sleep apnea(OSA) among ankylosing spondylitis (AS) patients based on administrative healthcare databases.

Methods: We conducted a nationwide cohort study by using the Taiwan National Health Insurance Research Database with 1997–2013 claim records. The AS cohort included 2,210 patients who were newly diagnosed between 2003 and 2013. Randomly selected non-AS controls were matched at a 1:4 ratio. The endpoint was set as OSA occurrence or the end of 2013. Cumulative incidences, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, comorbidities, and co-medication. Multivariate analyses were performed using the Cox proportional hazards model. Due to the violation of the proportionality assumption, landmark analysis was conducted to explore the risk of OSA during specific follow-up periods.

Results: The adjusted HR (aHR) of OSA in the AS group was 2.826 (95% C.I. = 1.727–4.625) compared to the control group. On landmark analysis, aHR was 7.919 (95% C.I. = 3.169–19.792) for the AS group 0–24 months from the index date and decreased to 1.816 (95% C.I. = 0.944–3.494) at ≥ 24 months from the index date. The increased risks of OSA in the AS group compared to the control group were found for both males and females (aHRs were 4.533 and 2.672). On age-stratified analysis, a significant risk only for the 40–59 age group with aHR of 3.913 (95% C.I. = 1.890–8.102).

Conclusions: A higher risk of developing OSA was found among newly diagnosed AS cohort during the maximum 11-year follow-up period, especially within 2 years after newly diagnosed AS and in the 40–59 age group.

Thoracic Manifestations of Ankylosing Spondylitis, Inflammatory Bowel Disease, and Relapsing Polychondritis

Ankylosing spondylitis, inflammatory bowel disease (IBD), and relapsing polychondritis are immune-mediated inflammatory diseases with variable involvement of lungs, heart and the chest wall. Ankylosing spondylitis is associated with anterior chest wall pain, restrictive lung disease, obstructive sleep apnea, apical fibrosis, spontaneous pneumothorax, abnormalities of cardiac valves and conduction system, and aortitis. Patients with IBD can develop necrobiotic lung nodules that can be misdiagnosed as malignancy or infection. Relapsing polychondritis involves large airways in at least half of the patients. Relapsing polychondritis can mimic asthma in some patients. Medications used to treat these inflammatory conditions can cause pulmonary complications such as infections, pneumonitis, and rarely serositis.

Subclinical cardiac disease in ankylosing spondylitis

OBJECTIVES

To investigate aortic stiffness and subclinical left ventricular systolic dysfunction in ankylosing spondylitis (AS) patients.

METHODS

A cross-sectional study of 55 AS patients being treated with antitumor necrosis factor alpha (anti-TNF-α) biological agents, conventional synthetic disease-modifying antirheumatic drugs (csDMARDS), and non steroidal anti-inflammatory drugs (NSAIDs) and 20 controls matched for conventional cardiovascular risk factors. Aortic stiffness, ejection fraction, and left ventricular global longitudinal strain (LVGLS) were evaluated using transthoracic echocardiography and 2D Doppler echocardiography.

RESULTS

Aortic stiffness was higher in AS patients when compared to controls (P = 0.009). Stiffness increased in those being treated with csDMARDs when compared to the control group and those on anti-TNF-α biologics (P ˂0.001). AS patients' LVGLS values were worse than those of the control group (P < 0.001) and also worse in patients on csDMARDs and anti-TNF-α biologics when compared to those being treated with NSAIDs (P < 0.001).

CONCLUSIONS

Subclinical cardiac dysfunction occurs in AS patients despite well controlled musculoskeletal disease. Aortic stiffness and LVGLS increases in AS patients. Anti-TNF biological agents may somewhat protect arterial compliance. We believe that all AS patients should be investigated for cardiac dysfunction and followed up accordingly.

Assessment of left atrial function using speckle tracking echocardiography in ankylosing spondylitis: a case-control study

The aim of this study is to assess the left atrium (LA) deformation parameters by using 2D speckle tracking echocardiography (2D-STE) in ankylosing spondylitis (AS) patients and to evaluate the relationship between these parameters and AS clinical indexes. 30 patients with AS (22 males, 8 females) and 30 healthy individuals (19 males, 11 females) were enrolled in this study. Transthoracic echocardiography was performed to both groups. Besides the conventional echocardiographic parameters, the LA strain parameters; including systolic-reservoir (LA S-S), early diastolic-conduit (LA S-E), late diastolic-contraction (LA S-A) were measured. No significant difference was found between two groups in terms of conventional echocardiographic parameters except mean deceleration time (DT). Mean DT was prolonged in the AS patients compare with the control group (173.5 ± 22.5 vs. 155.3 ± 36.7, p = 0.025). In the AS patients, LA S-S (48.3 ± 9.4 vs. 56.9 ± 10.1, p = 0.001), LA S-E (26.4 ± 6.4 vs. 31.6 ± 7.3, p = 0.005) and LA S-A (21.9 ± 4.7 vs. 25.4 ± 5.7, p = 0.013) values were statistically lower than the control group. Also a negative correlation was observed between the Bath Ankylosing Spondylitis Metrology Index (BASMI) and LA S-S (r = - 0.509, p = 0.004), LA S-E (r = - 0.501, p = 0.005). Our study demonstrated that 2D-STE is a useful method to determine the left atrial involvement in AS patients without the clinical evident of cardiovascular disease.

Recommendations for the prescription of physical exercise for patients with spondyloarthritis

OBJECTIVE

To develop expert-based recommendations on physical activity and exercise for patients with spondyloarthritis (SpA).

METHODS

Two discussion groups, one of physical therapists, rehabilitation physicians, and professionals of physical activity and sports, and another of rheumatologists interested in SpA, were held to discuss the results of a survey of rheumatologists on exercise and two focus groups with patients on barriers to exercise. Preliminary recommendations were drafted. These were submitted to the opinion of the experts in both groups according to a two round Delphi methodology.

RESULTS

Twenty one recommendations covering general aspects of exercise, adaptation to patient, how to deliver messages, pain management, and type of exercise and monitoring were issued. The level of agreement varied slightly between expert groups but it was high overall. Items with poor agreement were removed from the consensus.

CONCLUSIONS

We present recommendations on when and how to prescribe and monitor exercise in patients with SpA based on the opinion of experts in exercise and in SpA. We must now test whether these recommendations are useful for clinical practice and have an effect on patients with SpA seen by rheumatologists.

Left ventricular non-compaction in a patient with ankylosing

A 58 years old male with a long-standing history of HLA-B27 positive ankylosing spondylitis presented with increasing fatigue and dyspnea on exertion. He had left ventricular dysfunction and enlargement, flail right coronary leaflet of aortic valve with severe eccentric aortic insufficiency along with left ventricular non-compaction in echocardiography. The most common cardiac manifestations of ankylosing spondylitis are aortic insufficiency and conduction disturbances. Involvement of myocardium, in the form of dilated cardiomyopathy and restrictive cardiomyopathy, has also been reported. This case presents a very rare association of ankylosing spondylitis with non-compaction cardiomyopathy.

Cardiac Involvement in Ankylosing Spondylitis

Ankylosing spondylitis is one of the subgroup of diseases called “seronegative spondyloarthropathy”. Frequently, it affects the vertebral colon and sacroiliac joint primarily and affects the peripheral joints less often. This chronic, inflammatory and rheumatic disease can also affect the extraarticular regions of the body. The extraarticular affections can be ophthalmologic, cardiac, pulmonary or neurologic. The cardiac affection can be 2-10% in all patients. Cardiac complications such as left ventricular dysfunction, aortitis, aortic regurgitation, pericarditis and cardiomegaly are reviewed.

Targeting inflammation in the prevention of cardiovascular disease in patients with inflammatory arthritis

Patients with inflammatory arthritis have increased risk of cardiovascular diseases (CVDs) compared with the general population. Subclinical carotid atherosclerosis and increased arterial stiffness are also common in these patients, which may serve as surrogate end points for cardiovascular (CV) events in clinical trials. Although exact mechanisms are still unclear, persistent systemic inflammation in patients with inflammatory arthritis may contribute to the development of CVD. Dysregulated innate immunity pathways in these patients may also play a role in accelerating atherosclerosis. During the last decade, effective suppression of inflammation by biological disease-modifying antirheumatic drugs has improved the disease outcome dramatically in patients with inflammatory arthritis. Growing evidence suggests that antitumor necrosis factor (TNF) therapy may prevent CVD in patients with rheumatoid arthritis. Nonetheless, data on non-TNF biologics are limited. Whether anti-TNF therapy may prevent CVD in patients with spondyloarthritis also remained unclear. In this review, we summarized the effect of both anti-TNF and non-TNF biologics on the CV system, including traditional CVD risk factors, endothelial function, arterial stiffness, subclinical atherosclerosis, and clinical CVD in patients with inflammatory arthritis.

Subclinical Atherosclerosis Is Not Accelerated in Patients with Ankylosing Spondylitis with Low Disease Activity: New Data and Metaanalysis of Published Studies

OBJECTIVE

Chronic inflammatory rheumatic diseases are associated with accelerated atherosclerosis, but data in ankylosing spondylitis (AS) are limited and the relative contribution of inflammation versus classical cardiovascular (CV) risk factors remains a matter of controversy. We addressed this in an original study and a metaanalysis of previous studies.

METHODS

Atheromatic plaques in carotid and femoral arteries, carotid hypertrophy [intima-media thickness (IMT), cross-sectional area], and carotid stiffness by ultrasound, as well as aortic stiffness by pulse wave velocity, were examined in consecutive nondiabetic, CV disease (CVD)-free patients with AS. Healthy individuals carefully matched 1:1 with patients for age, sex, smoking habits, hyperlipidemia, and hypertension served as controls. A metaanalysis of original studies that examined subclinical atherosclerosis in patients with AS versus controls with comparable CVD risk factors was also performed.

RESULTS

Carotid and femoral atheromatic plaques were slightly less prevalent compared with controls in a contemporary cohort consisting of 67 patients with AS (82% men), aged 47.5 ± 12.5 years (mean ± SD), with a median disease duration of 12 years and a Bath AS Disease Activity Index (BASDAI) of 1.8 (interquartile range 0.4-3.6), of whom 66% were receiving anti-tumor necrosis factor (TNF) treatment. Carotid hypertrophy and stiffness, as well as aortic stiffness, were similar between patients and their matched controls. Metaanalysis of all published studies revealed a significantly increased carotid IMT, but not plaque burden, in AS versus controls. Notably, however, increased IMT was not evident in studies involving patients with low disease activity (mean BASDAI < 4) or in those studies that included > 50% of patients treated with anti-TNF.

CONCLUSION

Low AS disease activity is not associated with accelerated atherosclerosis.

Ankylosing spondylitis: A state of the art factual backbone

Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects 1% of the general population. As one of the most severe types of spondyloarthropathy, AS affects the spinal vertebrae and sacroiliac joints, causing debilitating pain and loss of mobility. The goal of this review is to provide an overview of AS, from the pathophysiological changes that occur as the disease progresses, to genetic factors that are involved with its onset. Considering the high prevalence in the population, and the debilitating life changes that occur as a result of the disease, a strong emphasis is placed on the diagnostic imaging methods that are used to detect this condition, as well as several treatment methods that could improve the health of individuals diagnosed with AS.

Can suppression of inflammation by anti-TNF prevent progression of subclinical atherosclerosis in inflammatory arthritis?

OBJECTIVE

It remains a matter of debate whether TNF-a antagonists have favourable effects on the cardiovascular (CV) system. This systematic review evaluates the effect of TNF-a blockers on the progression of subclinical atherosclerosis and arterial stiffness in patients with inflammatory arthritis.

METHODS

A search of the MEDLINE and Web of Knowledge databases was conducted to identify studies into the effect of TNF-a antagonists on subclinical atherosclerosis and arterial stiffness in patients with RA, AS and PsA. Carotid intimamedia thickness (cIMT) was used to assess subclinical atherosclerosis. Two methods were used to assess arterial stiffness: pulse wave velocity (PWV) and aortic augmentation index (AIx). Twenty-three studies matching the search criteria were included for analysis.

RESULTS

TNF-a blockers probably are effective in preventing (7/13 studies) or even reversing (5/13 studies) the progression of IMT in patients with RA, AS and PsA who are responding to treatment. With regard to arterial stiffness, PWV was either significantly reduced (7/13 studies) or remained unchanged (6/13 studies) following TNF-a antagonist treatment. Nonetheless, most studies in RA (7/10) reported significant improvement of PWV. AIx remained unchanged in 10 of 13 studies.

CONCLUSION

The balance of evidence suggests that TNF-a antagonists may have a beneficial effect on preventing the progression of subclinical atherosclerosis and arterial stiffness. It remains unknown whether this effect is specific to TNF-a antagonists or relates to better control of inflammation irrespective of the disease modification strategy by which this is achieved.

Frequency of fragmented QRS in ankylosing spondylitis : a prospective controlled study

OBJECTIVES

Since inflammatory diseases may also cause fibrosis, we hypothesized that patients with ankylosing spondylitis (AS) may have frequent fragmented QRS complexes (fQRS) when compared to a control group.

PATIENTS AND METHODS

In this prospective study, 71 patients with AS (group 1) were compared with 42 age- and gender-matched individuals without rheumatic disease (group 2, control). fQRS was described as the presence of an additional R wave (R') or R or S wave bridging, or the presence of fragmentation on two consecutive derivations that correspond to the major coronary artery regions.

RESULTS

The mean ages of groups 1 and 2 were 37.67 ± 9.17 and 40.43 ± 11.09 years, respectively (p = 0.270). fQRS was detected in 23 AS patients (32.4%), whereas 3 patients in the control group had fQRS (7.14%). Age, gender, medication, and echocardiography results were comparable. The disease duration score was 101.37 ± 59.96 months in fQRS(+) patients; in contrast, it was 57.93 ± 30.95 months in fQRS(-) patients. This difference was of statistical significance (p = 0.046). A statistically significant difference was not determined between the fQRS(+) and fQRS(-) groups when evaluated in terms of HLAB27 (p = 0.739). In the fQRS(+) group, the mean lumbar Schober score was 2.91 ± 1.52; in patients without fQRS, it was 4.10 ± 1.40. The mean thoracic expansion test scores in the fQRS(+) and fQRS(-) groups were 1.44 ± 0.66 and 2.69 ± 1.22, respectively.

CONCLUSION

Given the higher frequency of fQRS detected in electrocardiography studies in AS patients than in the control group, cardiac fibrosis is thought to be more likely to occur in AS patients without cardiovascular disease. The presence of fQRS may be a simple and cost-effective method for predicting cardiac fibrosis in AS patients. fQRS can be a predictive marker for fibrosis in patients with AS.

Impaired distensibility of ascending aorta in patients with HIV infection

Background

Our aim was to investigate the aortic distensibility (AD) of the ascending aorta and carotid artery intima-media thickness (c-IMT) in HIV-infected patients compared to healthy controls.

Methods

One hundred and five HIV-infected patients (86 males [82%], mean age 41 ± 0.92 years), and 124 age and sex matched HIV-1 uninfected controls (104 males [84%], mean age 39.2 ± 1.03 years) were evaluated by high-resolution ultrasonography to determine AD and c-IMT. For all patients and controls clinical and laboratory factors associated with atherosclerosis were recorded.

Results

HIV- infected patients had reduced AD compared to controls: 2.2 ± 0.01 vs. 2.62 ± 0.01 10^-6 cm² dyn^-1, respectively (p < 0.001). No difference was found in c-IMT between the two groups. In multiadjusted analysis, HIV infection was independently associated with decreased distensibility (beta –0.45, p < 0.001). Analysis among HIV-infected patients showed that patients exposed to HAART had decreased AD compared to HAART-naïve patients [mean (SD): 2.18(0.02) vs. 2.28(0.03) 10^-6 cm² dyn^-1, p = 0.01]. In multiadjusted analysis, increasing age and exposure to HAART were independently associated with decreased AD.

Conclusion

HIV infection is independently associated with decreased distensibility of the ascending aorta, a marker of subclinical atherosclerosis. Increasing age and duration of exposure to HAART are factors further contributing to decreased AD.

Patients with ankylosing spondylitis have evidence of left ventricular asynchrony

OBJECTIVES

Ankylosing spondylitis (AS) is a chronic inflammatory disease that often leads to cardiovascular complications including aortic regurgitation and conduction disturbances. Left ventricular (LV) systolic asynchrony is defined as loss of the simultaneous peak contraction of corresponding cardiac segments. The aim of this study was to evaluate LV systolic asynchrony noninvasively in patients with AS by using tissue synchrony imaging (TSI).

METHODS

Asynchrony was evaluated in 77 AS patients (61 male, mean age 36.4 ± 10 years) and 40 controls (35 male, mean age 39.1 ± 8.2 years). All study population underwent a comprehensive echocardiographic evaluation including TSI. The time to regional peak systolic velocity (Ts) during the ejection phase in LV was measured from TSI images by the six-basal and six-midsegmental model, and four TSI parameters of systolic asynchrony were computed.

RESULTS

The baseline demographic and echocardiographic characteristics were similar between the patients enrolled and controls. All TSI parameters of LV asynchrony were prolonged in patients with AS compared to controls: the standard deviation (SD) of the 12 LV segments Ts (39.6 ± 19.6 vs. 24.7 ± 11.6, P < 0.001); the maximal difference in Ts between any 2 of the 12 LV segments (122.1 ± 52.9 vs. 82.2 ± 38.6, P < 0.001); the SD of the six basal LV segments (33.5 ± 20.2 vs. 23 ± 13.3, P = 0.008); and the maximal difference in Ts between any two of the six basal LV segments (84.6 ± 48.1 vs. 60.4 ± 34.6, P = 0.008). The asynchrony parameters were significantly correlated with index of myocardial performance (Tei index) and peak systolic mitral annular velocity.

CONCLUSION

TSI showed presence of LV systolic asynchrony in patients with AS which may account for the cardiovascular complications of AS.

Severe main coronary artery disease in a young woman with ankylosing spondylitis

Patients with ankylosing spondylitis (AS) have an approximately two-fold increased death rate compared to the general population, which is predominately caused by increased cardiovascular risk. The prevalence rate for myocardial infarction is approximately 2-3 fold increased as compared with the general population. The inflammatory process appears to have an important role in causing this excess cardiovascular risk. In this paper, we present a case of severe coronary artery disease which could be demonstrated clearly by computer tomography in a 27-year-old woman who is being followed with AS.

Exercise programs in trials for patients with ankylosing spondylitis: do they really have the potential for effectiveness?

OBJECTIVE

To evaluate if exercise programs in trials for patients with ankylosing spondylitis (AS) have the potential for effectiveness.

METHODS

A systematic literature search was performed and randomized trials examining the effectiveness of exercise programs for AS patients were analyzed according to 3 elements: whether the exercise programs were designed according to the American College of Sports Medicine (ACSM) recommendations for developing cardiorespiratory fitness, muscular strength, and flexibility; whether physiologic responses were properly measured; and whether adherence to programs was monitored.

RESULTS

Twelve trials with a total of 826 AS patients were evaluated. Five trials included cardiorespiratory exercise as a part of the exercise programs. One of these met the ACSM recommendations for intensity, duration, frequency, and length of the exercise period. This trial showed the greatest within-group improvement in aerobic capacity (effect size [ES] 2.19). Five trials included muscular strength training, but none measured the physiologic responses nor met the recommendations for improving muscular strength. Eleven trials included flexibility training, but the programs were poorly described overall. Small improvements in spinal mobility (ES range 0.02-0.67) were reported in all trials. Finally, 4 trials reported on participants' adherence to the exercise programs, but only 1 provided sufficient information to evaluate the possible influence of the adherence.

CONCLUSION

The quality of interventions in exercise trials for patients with AS can be improved. Future trials should also focus on measuring and reporting physiologic responses and adherence to exercise interventions.

Cardiopulmonary manifestations of ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory condition that usually affects young men. Cardiac dysfunction and pulmonary disease are well-known and commonly reported extra-articular manifestation, associated with ankylosing spondylitis (AS). AS has also been reported to be specifically associated with aortitis, aortic valve diseases, conduction disturbances, cardiomyopathy and ischemic heart disease. The pulmonary manifestations of the disease include fibrosis of the upper lobes, interstitial lung disease, ventilatory impairment due to chest wall restriction, sleep apnea, and spontaneous pneumothorax. They are many reports detailing pathophysiology, hypothesized mechanisms leading to these derangements, and estimated prevalence of such findings in the AS populations. At this time, there are no clear guidelines regarding a stepwise approach to screen these patients for cardiovascular and pulmonary complications.

Work disability in patients with ankylosing spondylitis in Norway

OBJECTIVE

To report the prevalence of work disability (WD) in a cross-sectional study of a large population of patients with ankylosing spondylitis (AS) and the associated demographic and clinical characteristics, including extraspinal features, that contribute to WD.

METHODS

Patients with AS registered in a hospital database were invited to participate. A total of 360 patients took part. The survey period was 1998 to 2002. During an extended outpatient visit, data were collected according to a predefined data form. Demographic data were collected and a physical examination performed.

RESULTS

After 22.6 years of disease duration, the cumulative prevalence of WD reached 43.6%, and an additional 8.9% of patients were nonparticipants in the labor force. Significant odds ratios indicating an independent association with WD were found for history of polyarthritis (9.6), coronary heart disease (CHD; 7.8), female sex (3.4), having children with spondyloarthritis (2.9), changing profession (2.8), lower level of education (1.4), mean score of the Bath AS Functional Index (1.2), increasing age (1.05), and increasing finger-to-floor distance (1.02).

CONCLUSION

The longterm prevalence of WD among Norwegian patients with AS is considerably higher than in reports from other countries. Earlier polyarthritis and CHD were the strongest independent risk factors for WD.

Assessment of subclinical vascular disease associated with ankylosing spondylitis

OBJECTIVE

Studies indicate that ankylosing spondylitis (AS), as well as rheumatoid arthritis, may be associated with accelerated atherosclerosis and vascular disease. We assessed endothelial dysfunction, carotid atherosclerosis, and aortic stiffness in AS in context with clinical and laboratory measurements.

METHODS

Forty-three patients with AS and 40 matched healthy controls were studied. We assessed common carotid intima-media thickness (ccIMT), flow-mediated vasodilation (FMD), and pulse-wave velocity (PWV) in association with age, disease duration, smoking habits, body mass index, patient's assessment of pain and disease activity, Bath AS Disease Activity Index, Bath AS Functional Index (BASFI), metric measurements, erythrocyte sedimentation rate, C-reactive protein, and HLA-B27 status.

RESULTS

We found impaired FMD (6.85 ± 2.98% vs 8.30 ± 3.96%; p = 0.005), increased ccIMT (0.65 ± 0.15 vs 0.54 ± 0.15 mm; p = 0.01), and higher PWV (8.64 ± 2.44 vs 8.00 ± 1.46 m/s; p = 0.03) in patients with AS compared to controls, respectively. We also found that ccIMT negatively correlated with FMD (r = -0.563; p = 0.0001) and positively correlated with PWV (r = 0.374; p = 0.018). Both ccIMT and PWV correlated with disease duration (r = 0.559; p = 0.013 and r = 0.520; p = 0.022, respectively), BASFI (r = 0.691; p = 0.003 and r = 0.654; p = 0.006), decreased lumbar spine mobility (r = -0.656; p = 0.006 and r = -0.604; p = 0.013), chest expansion (r = -0.502; p = 0.047 and r = -0.613; p = 0.012), and increased wall-occiput distance (r = 0.509; p = 0.044 and r = 0.614; p = 0.011).

CONCLUSION

In this well characterized AS population, impaired FMD and increased ccIMT and PWV indicate abnormal endothelial function and increased atherosclerosis and aortic stiffness, respectively. The value of noninvasive diagnostic tools needs to be further characterized.

The relationship between disease-related characteristics and conduction disturbances in ankylosing spondylitis

OBJECTIVES

Ankylosing spondylitis (AS) is associated with an increased cardiovascular (CV) risk. Conduction disturbances (CD) may explain the CV burden, as they are independently associated with cardiac disease. The aim of this study was (i) to determine the prevalence of CD in AS, and (ii) to evaluate the relationship between CD and demographic and AS-related characteristics.

METHODS

A rheumatological evaluation assessing demographic and AS-related characteristics and a resting standard 12-lead electrocardiogram (ECG) were performed in 131 consecutive AS patients.

RESULTS

A first-degree atrioventricular (AV) block was found in six (4.6%) patients. One (0.8%) patient suffered from a complete right bundle branch block (RBBB) and one (0.8%) patient had a left anterior hemiblock. A prolonged QRS (pQRS) interval was observed in 38 (29.2%) patients, including those with a complete or incomplete BBB. Age, disease duration, and body mass index (BMI) were significantly associated with the PR interval, and male gender, disease duration, and the Bath Ankylosing Spondylitis Metrology Index (BASMI) with the QRS interval. In multivariate analyses, disease duration remained independently associated with both the PR and the QRS intervals.

CONCLUSION

Intraventricular CD is highly prevalent in AS, particularly in patients with long-standing disease. Further research is needed to determine whether intraventricular CD contribute to the increased CV risk and long-term CV mortality in AS.