Association of non-invasive hemodynamics with arterial stiffness in rheumatoid arthritis

Circulating microvesicles across a population with various degree of cardiovascular burden are associated with systolic blood pressure

Circulating microvesicles (MVs) have been studied in heterogeneous, divergent, and rather small patient populations with cardiovascular risk . Therefore, we measured endothelial (EMVs), platelet (PMVs) and erythrocyte (RMVs) MVs in patients with divergent cardiovascular risk. We then compared them to coronary artery disease (CAD) and healthy subjects and identified independent MVs' predictors. We enrolled consecutive patients from our Cardiology, Hypertension, Diabetic, Rheumatic, and Nephrology Outpatient Units with MVs measurements. Central blood pressure (BP) was measured by either applanation tonometry or Mobil-O-graph device, while MVs by a standardized flow cytometry protocol. We studied 369 participants with increased cardiovascular risk: 63 with high cardiovascular risk (47 diabetes mellitus type II/DM and 16 end-stage renal disease/ESRD), 92 with chronic inflammatory disorders and 73 with untreated essential hypertension/UEH. We further included 53 subjects with CAD and 87 otherwise healthy individuals. All MVs were lower in patients with increased cardiovascular risk compared to CAD, showing predictive value with high sensitivity and specificity. Furthermore, PMVs and EMVs were increased in patients with cardiovascular risk compared to healthy individuals. DM and ESRD patients had increased EMVs versus UEH and chronic inflammatory disorders. In the whole study population, RMVs were associated only with history of essential hypertension. In multivariate analysis, systolic BP predicted PMVs. Aage, systolic BP, and DM predicted EMVs. In a large population of patients with divergent cardiovascular risk, MVs are independently associated with systolic blood pressure.

Circulating levels of galectin-3 and coronary microvascular perfusion in rheumatoid arthritis patients with suppressed inflammation

OBJECTIVE

Cardiovascular manifestations are the leading cause of mortality in rheumatoid arthritis (RA). Galectin-3, a lectin protein with major role in cellular, inflammatory, and fibrotic processes, has been introduced as a novel cardiac biomarker. We hypothesized that patients with RA present increased levels of galectin-3, and investigated potential associations with arterial stiffness and coronary microvascular dysfunction.

METHODS

This cross-sectional study enrolled RA patients and non-RA individuals without cardiovascular comorbidities. Galectin-3 and high-sensitivity C-reactive protein (hsCRP) were measured with enzyme-linked immunosorbent assay (ELISA) in serum samples. Subendocardial viability ratio (SEVR), an index of microvascular myocardial perfusion, and pulse wave velocity (PWV), the gold-standard measure of vascular stiffness, were estimated with applanation tonometry.

RESULTS

Cardiovascular risk factors and hsCRP were comparable between patients (n = 24) and controls (n = 24). However, galectin-3 was increased [6.9 (6.7) vs 4.6 (4.7)] ng/dl, p = 0.015], and coronary microvascular perfusion was decreased (142.6 ± 22.8 vs 159.7 ± 23.2%, p = 0.028) in RA patients compared to controls, whereas PWV did not significantly differ. Galectin-3 correlated with both PWV and SEVR in univariate analysis. However, after adjustment for cardiovascular risk factors and subclinical inflammation, these associations were rendered non-significant.

CONCLUSION

Galectin-3 appears increased in RA, even among patients with suppressed inflammation in the absence of cardiovascular comorbidities. The observed association of galectin-3 with coronary microvascular perfusion in our study was non-significant after adjustment for cardiovascular risk factors and inflammation. The potential role of galectin-3 as a cardiac biomarker in RA warrants further investigation. Key Points • Galectin-3 has emerged as a novel cardiac biomarker but remains understudied in RA. • Patients with RA present elevated levels of galectin-3 and impaired coronary microvascular perfusion compared to non-RA individuals. • These differences were observed in patients with suppressed inflammation, even in the absence of CVD. • The association of galectin-3 with coronary microvascular impairment in RA warrants further investigation.

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.

Association of IL-10 and CRP with Pulse Wave Velocity in Patients with Abdominal Aortic Aneurysm

Background: Markers of inflammation and arterial stiffness are predictors of cardiovascular morbidity and events, but their roles in the mechanisms and progression of abdominal aortic aneurysm (AAA) in males have not been fully investigated. This study explored possible associations between inflammatory marker levels and arterial stiffness in males with AAA. Methods: A total of 270 males (191 AAA and 79 controls) were included in the study. Arterial stiffness was assessed using non-invasive applanation tonometry to measure the regional pulse wave velocity between the carotid and femoral arteries and the carotid and radial arteries. Blood samples were obtained, and interleukin-10 (IL-10) and CRP levels were analysed. Results: Subjects with an AAA had higher levels of IL-10 (21.5 ± 14.0 ng/mL versus 16.6 ± 9.3 ng/mL) compared to controls (p = 0.007). In the AAA cohort, subjects with T2DM showed higher levels of IL-10 (26.4 ± 17.3 versus 20.4 ± 13.0, p = 0.036). We observed a positive correlation between PWVcf and CRP in the control group (r = 0.332) but not the AAA group. PWVcf and CRP were negatively correlated (r = 0.571) in the T2DM subjects treated with metformin in the AAA group. Conclusion: Arterial stiffness is related to the degree of inflammation reflected by CRP and IL-10 levels in males with an AAA. IL-10 is negatively correlated with arterial stiffness in these subjects. This finding suggests that IL-10 may decrease arterial stiffness in males with AAA. The negative correlation between CRP and PWVcf in males with T2DM treated with metformin may indicate that metformin influences the arterial wall to decrease stiffness in subjects with AAA.

Cardiovascular Diseases Diagnosis by Impedance Cardiography

Cardiovascular disease (CVD) represents the leading cause of mortality worldwide. In order to diagnose CVDs, there are a range of detection methods, among them, the impedance cardiography technique (ICG). It is a non-invasive and low-cost method. In this paper, we highlight recent advances and developments of the CDVs diagnosis mainly by the ICG method. We considered papers published during the last five years (from 2017 until 2022). Based on this study, we expressed the need for an ICG database for the different CDVs.

Aortic Stiffness: Epidemiology, Risk Factors, and Relevant Biomarkers

Aortic stiffness (AoS) is a maladaptive response to hemodynamic stress and both modifiable and non-modifiable risk factors, and elevated AoS increases afterload for the heart. AoS is a non-invasive marker of cardiovascular health and metabolic dysfunction. Implementing AoS as a diagnostic tool is challenging as it increases with age and varies amongst races. AoS is associated with lifestyle factors such as alcohol and smoking, as well as hypertension and comorbid conditions including metabolic syndrome and its components. Multiple studies have investigated various biomarkers associated with increased AoS, and this area is of particular interest given that these markers can highlight pathophysiologic pathways and specific therapeutic targets in the future. These biomarkers include those involved in the inflammatory cascade, anti-aging genes, and the renin-angiotensin aldosterone system. In the future, targeting AoS rather than blood pressure itself may be the key to improving vascular health and outcomes. In this review, we will discuss the current understanding of AoS, measurement of AoS and the challenges in interpretation, associated biomarkers, and possible therapeutic avenues for modulation of AoS.

Endothelial dysfunction and vascular complications after allogeneic hematopoietic cell transplantation: an expert analysis

Allogeneic hematopoietic cell transplantation (alloHCT) is the standard of care for many diseases. However, survivors often present with serious complications resulting from acute and chronic toxicities and it is crucial to increase consciousness from treating physicians. We performed a comprehensive review of the literature and critically examined recent available data, mostly using the PubMed and Medline search engines for original articles published over the last decade. Better understanding of many alloHCT-related disorders has shown that endothelial injury and vascular damage plays a critical role. The most widely studied endothelial injury syndromes (EIS) are veno-occlusive disease/sinusoidal obstruction syndrome (SOS/VOD), graft-versus-host-disease (GVHD), and transplant-associated thrombotic microangiopathy (TA-TMA). TA-TMA, frequently underdiagnosed, needs to be clarified using certain criteria and, as a life-threatening condition, requires immediate and intensive treatment. The first-in-class complement inhibitor eculizumab has significantly improved outcomes in both the pediatric and adult population. Cardiovascular (CV) events are the second major cause of morbidity and mortality of alloHCT survivors, after GVHD. Long-term monitoring and management of CV risk is expected to also incorporate patient stratification with CV risk prediction models, early markers of vascular dysfunction or procoagulant activity, subclinical target organ damage, arterial stiffness, and subclinical atherosclerosis.

Arterial stiffness, the hidden face of cardiovascular risk in autoimmune and chronic inflammatory rheumatic diseases

BACKGROUND AND OBJECTIVE

Cardiovascular diseases (CVD) are the leading causes of death in chronic inflammatory rheumatic diseases and are not solely explained by the increased prevalence of cardiovascular (CV) risk factors in this population. Arterial stiffness, assessed primarily by pulse wave velocity (PWV) and more indirectly by augmentation index (AIx), is a surrogate marker of CVD that should be considered. The objective of this review was to investigate the relationship between arterial stiffness and chronic inflammatory and/or autoimmune diseases.

METHODS

We performed a systemic literature review of articles published in Medline from January 2012 to April 2020 restricted to English languages and to human adults. We selected relevant articles about the relationship between arterial stiffness and rheumatoid arthritis, systemic lupus erythematosus, psoriasis, Sjogren's syndrome and ankylosing spondylitis. For each selected article, data on PWV and AIx were extracted and factors that may have an impact on arterial stiffness were identified.

RESULTS

A total of 214 references were identified through database searching and 82 of them were retained for analysis. Arterial stiffness is increased in chronic inflammatory and autoimmune diseases. Traditional CV risk factors such as hypertension and dyslipidemia accentuate this relationship. Current data are insufficient to determine whether disease activity significantly influences arterial stiffness, whereas disease duration seems rather critical. TNF-alpha inhibitors and cardiorespiratory fitness tend to decrease arterial stiffness. Finally, increased arterial stiffness leads to diastolic dysfunction, which is the main mechanism of heart failure in chronic inflammatory rheumatic diseases.

CONCLUSION

CV risk assessment in chronic inflammatory and autoimmune diseases should also rely on PWV and AIx.

Aortic Stiffness, Inflammation, and Incidence of Cardiovascular Events in Elderly Participants From the General Population

Low-grade inflammation and arterial stiffness are key factors in the development of vascular aging. However, the interplay between arterial stiffness and inflammation for cardiovascular (CV) disease is unclear. Aortic pulse wave velocity (aPWV) and the inflammatory markers, high-sensitivity C-reactive protein (CRP) and orosomucoid, were measured in 2710 participants (median age: 72 years). These participants were followed up for a mean of 7.6 years for a composite CV disease end point. Per 1 interquartile range increment of CRP and orosomucoid, respectively, aPWV increased by 0.19 m/s (95% CI: 0.07-0.32) and 0.19 m/s (0.11-0.27), after multifactorial adjustment. Mediation analysis showed that aPWV, after multifactorial adjustment, mediated 8% (-4, 20) of the CV disease risk associated with CRP and 8% (-4, 18) of orosomucoid risk. The associated risk increased with combinations of high aPWV and high CRP or orosomucoid. We found no evidence that arterial PWV acted as an important mediator of the relationship between systemic inflammation and CV disease risk in this elderly population. The results instead indicate an additive effect. Our study supports the view that arterial stiffness and chronic inflammation affects CV risk mainly through separate causal pathways.

Endothelial Dysfunction in Patients with Rheumatoid Arthritis: the Role of Hypertension

PURPOSE OF REVIEW

To review the data on the role of endothelial dysfunction and the impact of hypertension as a potent mediator of cardiovascular disease in patients with rheumatoid arthritis (RA).

RECENT FINDINGS

RA represents the most common autoimmune rheumatic disorder and is characterized by chronic systemic inflammation predisposing to cardiovascular complications. Cardiovascular mortality is increased among patients with RA and represents the leading cause of death. Although the exact prevalence is debated, hypertension is increased in RA. Hypertension acts synergistically with chronic inflammation and accounts, at least partially, for the increased cardiovascular morbidity in this group of patients. Endothelial dysfunction is considered a primary process in the pathogenesis of hypertension and cardiovascular diseases and contributes significantly to the development and progression of the associated micro- and macrovascular complications. Even though several studies in patients with RA have shown the presence of endothelial dysfunction with traditional methods, novel biochemical and vascular methods for the evaluation of endothelial dysfunction have been scarcely applied. In addition, it remains unclear whether and to which extent endothelial dysfunction in RA is present regardless of concomitant hypertension, even in well-controlled patients. Hypertension, endothelial dysfunction, and chronic systemic inflammation appear as a mutually reinforcing triad aggravating cardiovascular risk in patients with RA. Detection of endothelial dysfunction in patients with RA in the early stages further aiming at the development of novel therapeutic targets might contribute to prevention of cardiovascular complications and remains under investigation.

Hypertension in rheumatic diseases: prevalence, awareness, treatment, and control rates according to current hypertension guidelines

Hypertension is a major modifiable risk factor for cardiovascular disease. Autoimmune rheumatic diseases confer increased cardiovascular risk, which is at least partially mediated by traditional cardiovascular risk factors. We examined the prevalence, awareness, treatment, and control rates of hypertension in a large cohort of patients with rheumatic diseases. Consecutive patients attending the Rheumatology Οutpatient Clinics were studied. Hypertension was defined by both the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA). In a total of 622 individuals, hypertension prevalence reached 54.5% according to the 2018 ESH/ESC guideline, with the highest rates observed in patients with osteoarthritis (69.6%), rheumatoid arthritis (60.9%), and psoriatic arthritis (57.8%). Among hypertensive individuals, 21.7% were unaware of high blood pressure levels, while 67.2% were treated. Only 48.6% of treated hypertensives reached the 2018 ESC/ESH treatment goals. Applying the 2017 ACC/AHA criteria would result in a substantial increase of hypertension prevalence (72.4%) for both genders and especially among younger individuals, accompanied by a dramatic drop in control rates among treated patients (16.7%). In conclusion, comorbid hypertension was highly prevalent in a large cohort of patients with rheumatic diseases according to ESH/ESC and especially, ACC/AHA guidelines. However, it remains underdiagnosed and undertreated in a significant portion, while control rates are far from optimal. Our findings highlight the importance of systematic screening and more aggressive treatment of hypertension among patients with rheumatic diseases.

Early Prediction of Cardiovascular Risk after Hematopoietic Cell Transplantation: Are We There Yet?

Cardiovascular (CV) events have emerged as a major cause of morbidity and mortality among hematopoietic cell transplantation (HCT) survivors. Accumulating evidence supports the presence of increased CV risk in HCT recipients. Most studies have focused mainly on traditional CV risk factors, such as the metabolic syndrome and hypertension. However, detection of these factors suggests the development of irreversible overt clinical atherosclerosis. Therefore, earlier prediction of CV risk is needed to prevent CV morbidity and mortality in these patients. In the field of CV research, endothelial dysfunction is considered an early event in the pathophysiology of CV risk factors, and a number of markers have been proposed for its assessment. In addition, markers of subclinical target organ damage have been introduced to implement CV risk prediction and early preventive or intensive therapeutic interventions. Furthermore, a number of CV models have been suggested aiming for optimal stratification of patients. Preliminary studies have indicated excess CV risk using these early markers in HCT recipients. However, their role in the pathophysiology and clinical practice in HCT survivors remains largely understudied. Taking into account the need for increased awareness from treating physicians in this evolving setting, we conducted a state-of-the-art review aiming to summarize current knowledge on endothelial dysfunction, subclinical target organ damage, and CV risk prediction in HCT survivors.

Assessment of arterial stiffness variables in patients with rheumatoid arthritis: A mediation analysis

We aimed to study arterial stiffness variables in patients with rheumatoid arthritis (RA), specifically considering their associations with path model mediation analysis. We examined arterial stiffness expressed by the pulse wave velocity (PVW), augmentation index (AIx), distensibility, and clinical and biochemical characteristics in a cohort of 214 RA patients. Variable associations were analysed using multivariate linear regression analysis. We also used path model mediation analysis for PWV variable. Our results indicate that age, systolic blood pressure (SBP), and body mass index (BMI) were significantly associated with PWV, and collectively accounted for 32% of PWV variability. The parallel mediation analysis showed that SBP and BMI accounted for 21% and 7% (a total of 28%) of the total effect of age on PWV, respectively, indicating a partial mediation effect. The associated variables with AIx were age and tender joint count, while those with distensibility were BMI and sex, overall accounting for 16.5% and 4.7% of the variation in AIx and distensibility, respectively. We observed no associations of arterial stiffness with inflammatory variables, disease activity and duration, or cholesterol levels. In conclusion, in our population of RA patients, age is the most important variable that determines the increase in PWV. We have also shown that a significant proportion of the negative effects of age on PWV occurs through increases in SBP and BMI. In our study, lipid and inflammation variables were not associated with an increase in arterial stiffness.