The relevance of performing exercise test before starting supervised physical exercise in asymptomatic cardiovascular patients with rheumatic diseases

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.

Increased sympathetic and haemodynamic responses to exercise and muscle metaboreflex activation in post-menopausal women with rheumatoid arthritis

KEY POINTS

Rheumatoid arthritis (RA) patients present exacerbated blood pressure responses to exercise, but little is known regarding the underlying mechanisms involved.  This study assessed autonomic and haemodynamic responses to exercise and to the isolated activation of muscle metaboreflex in post-menopausal women with RA.  Participants with RA showed augmented pressor and sympathetic responses to exercise and to the activation of muscle metaboreflex. These responses were associated with multiple pro- and anti-inflammatory cytokines and with pain.  The results of the present study support the suggestion that an abnormal reflex control of circulation is an important mechanism underlying the exacerbated cardiovascular response to exercise and increased cardiovascular risk in RA.

ABSTRACT

Studies have reported abnormal cardiovascular responses to exercise in rheumatoid arthritis (RA) patients, but little is known regarding the underlying mechanisms involved. This study assessed haemodynamic and sympathetic responses to exercise and to the isolated activation of muscle metaboreflex in women diagnosed with RA. Thirty-three post-menopausal women diagnosed with RA and 10 matched controls (CON) participated in this study. Mean arterial pressure (MAP), heart rate (HR) and muscle sympathetic nerve activity (MSNA frequency and incidence) were measured during a protocol of isometric knee extension exercise (3 min, 30% of maximal voluntary contraction), followed by post-exercise ischaemia (PEI). Participants with RA showed greater increases in MAP and MSNA during exercise and PEI than CON (ΔMAP_exercise  = 16 ± 11 vs. 9 ± 6 mmHg, P = 0.03; ΔMAP_PEI  = 15 ± 10 vs. 5 ± 5 mmHg, P = 0.001; ΔMSNA_exercise  = 17 ± 14 vs. 7 ± 9 bursts min^-1 , P = 0.04; ΔMSNA_PEI  = 14 ± 10 vs. 6 ± 4 bursts min^-1 , P = 0.04). Autonomic responses to exercise showed significant (P < 0.05) association with pro- (i.e. IFN-γ, IL-8, MCP-1 and TNFα) and anti-inflammatory (i.e. IL-1ra and IL-10) cytokines and with pain. In conclusion, post-menopausal women with RA showed augmented pressor and sympathetic responses to exercise and to the activation of muscle metaboreflex. These findings provide mechanistic insights that may explain the abnormal cardiovascular responses to exercise in RA.

The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis - 2019

Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.

Chronotropic Incompetence and Reduced Heart Rate Recovery in Rheumatoid Arthritis

BACKGROUND/OBJECTIVE

Recent studies have indicated that cardiac autonomic dysfunction is an early sign of cardiovascular impairment in rheumatoid arthritis (RA). Previous studies have mainly focused on resting assessments; however, analysis of heart rate (HR) responses to exercise might provide additional information on cardiac autonomic dysfunction in this disease. Thus, we aimed to assess the HR responses during and after a maximal graded exercise test in patients with RA and healthy controls (CONs).

METHODS

This was a cross-sectional study in which 27 female RA patients and 14 female CONs frequency matched by physical activity, age, and body mass index were compared for HR responses during and after a maximal graded exercise test.

RESULTS

Rheumatoid arthritis patients showed reduced chronotropic response (94.3% ± 16.3% vs. 106.1% ± 10.3%, p = 0.02) and lower HR recovery (HRR) at 30 seconds (8.6 ± 6.7 vs. 13.4 ± 5.2 beats/min [bpm], p = 0.02), 60 seconds (16.5 ± 7.8 vs. 24.0 ± 9.9 bpm, p = 0.01), 120 seconds (32.6 ± 9.9 vs. 40.7 ± 12.3 bpm, p = 0.03), and 180 seconds (46.5 ± 12.6 vs. 55.5 ± 13.4 bpm, p = 0.05) post-maximal exercise test when compared with CONs. Moreover, the prevalence of chronotropic incompetence (i.e., failure to reach 80% of the HR-predicted response) and abnormal HRR (i.e., HRR ≤12 bpm) were, respectively, 22.2% and 37.1% in RA patients.

CONCLUSIONS

Patients with RA showed reduced chronotropic response to exercise and slower postexercise HRR. These abnormal autonomic responses to exercise indicate the presence of cardiac autonomic dysfunction and increased cardiovascular risk in this population.