Mechanisms of hypertension in autoimmune rheumatic diseases

Hypertension in connective tissue disease

It is well documented that connective tissue disease (CTD) is a type of autoimmune disease characterized by chronic inflammation, which can occur across various organ systems throughout the whole body. Although the clinical manifestations of CTD are different, studies have shown that different CTD diseases have similar pathogenesis, implying that different CTD diseases may have similar clinical outcomes. Recent population-based studies have demonstrated an increased risk of cardiovascular disease (CVD) in patients with CTD compared with the control group, which is partially attributed to traditional cardiovascular risk factors, such as hypertension (HT), and that controlling the patients' blood pressure (BP) still constitutes one of the most effective means to prevent CVD. Although many studies have shown that the prevalence of HT in patients with CTD is higher than that in the general population, there is a lack of adequate data on the possible pathogenesis of HT. Also, the factors that promote the rise of BP, especially the relationship between connective tissue disease- hypertension (CTD-HT) and traditional cardiovascular risk factors (aging, sex, race, dyslipidemia, diabetes mellitus, smoking, obesity, etc.), have not been fully confirmed. In this review, we explore the mechanisms that might lead to elevated BP in patients with CTD and the factors that contribute to elevated BP and the management of CTD-HT, and we focus on whether traditional cardiovascular risk factors, the disease, and the presence of related therapeutic drugs are associated with an increased risk of HT in patients with CTD.

Mortality and cardiovascular risk in vasculitis ANCA. Importance of hypertension and renal function. Experience from southern Spain

BACKGROUND

Cardiovascular disease (CVD) is one of the principal causes of death in antineutrophil cytoplasmic antibody-(ANCA)-associated vasculitis (AAV).

OBJECTIVES

To evaluate the mortality and it's causes and CVD and its vascular risk factors (VRFs) in AAV patients in Andalusia.

METHODS

A multicenter cohort of 220 AAV patients followed-up from 1979 until June 2020 was studied in Andalussia, south of Spain. The information, including socio-demographic and clinical data was recorded retrospectively through chart review. Data was analysed using Chi2, ANOVA and Cox proportional hazards regresion as uni and multivariate test with a 95% confidence interval (CI).

RESULTS

During a mean ± standard deviation follow-up of 96.79 ± 75.83 months, 51 patients died and 30 presented at least one CVE. Independent prognostic factors of mortality were age (HR 1.083, p=0.001) and baseline creatinine (HR 4.41, p=0.01). Independent prognostic factors of CVE were age [hazard ratio (HR) 1.042, p=0.005] and the presence of hypertension (HTN) six months after diagnosis (HR 4.641, p=0.01). HTN, diabetes and renal failure, all of these important VRFs, are more prevalent in AAV patients than it is described in matched general population.

CONCLUSIONS

Age and baseline renal function, but not CVEs, are predictors of mortality and age and early HTN are independent predictors for having a CVE. CVD screening in AAV patients is demanded.

Leptin antagonism attenuates hypertension and renal injury in an experimental model of autoimmune disease

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that is characterized by B- and T-lymphocyte dysfunction and altered cytokine production, including elevated levels of the adipocytokine leptin. Leptin has various immunomodulatory properties, including promoting the expansion of proinflammatory T lymphocytes and the proliferation and survival of B cells. In the present study, we hypothesized that leptin antagonism would improve B- and T-cell dysfunction and attenuate hypertension in an experimental model of SLE, the NZBWF1 mouse. To test this hypothesis, 28-week-old female control and SLE mice were administered 5 mg/kg of murine leptin superantagonist (LA) or vehicle via ip injection every other day for four weeks. Analysis of peripheral blood immune cell populations showed no changes in total CD45R+ B and CD3+ T cell percentages after treatment with LA. However, SLE mice treated with LA had an improved CD4/CD8 ratio and decreased CD3+CD4-CD8- double negative (DN) T cells. Blood pressure was higher in SLE than in control, and treatment with LA decreased blood pressure in SLE mice. Treatment with LA also delayed the onset of albuminuria and decreased glomerulosclerosis in SLE mice. Renal immune cell infiltration was significantly higher in SLE mice as compared with control, but LA treatment was associated with decreased levels of renal CD4+ T cells. In conclusion, these data suggest that leptin plays a pathogenic role in the development of hypertension in SLE, in part, by promoting the expansion of inflammatory DN T cells and the infiltration of T cells into the kidneys.

Clinical characteristics of pediatric hypertension: a multicenter study in China

OBJECTIVES

Hypertension in children has attracted increasing attention. However, clinical-based studies investigating characteristics and secular trends of pediatric hypertension remain limited. This study aimed to investigate the clinical characteristics and secular trends of different types of hypertension among hospitalized children in China.

METHODS

This retrospective analysis was based on medical records from nine tertiary children's hospitals in China during 2010∼2020. A total of 5847 pediatric inpatients (aged <18 years) with the diagnosis of hypertension were enrolled. Information on the clinical characteristics of each patient was obtained from their first admission records.

RESULTS

During the past decade, secondary hypertension sustained to be the dominant type of hypertension in children, with the proportion increased from 51.2% during 2010∼2015 to 59.8% during 2016∼2020. The main causes of secondary hypertension were neurologic disorders in children aged 0∼2 years, which changed to renal diseases after 3 years of age. Compared with primary hypertension, secondary hypertension was common in girls (43.1 vs. 23.3%) and children under 5 years of age (32.2 vs. 2.1%). Moreover, over four-fifths of primary hypertensive individuals had obesity and obesity-related comorbidities, and the proportion of clusters of one or more comorbidities increased in the past decade (79.7 → 85.2%).

CONCLUSION

Secondary hypertension sustained to be the dominant type of hypertension among children, especially in girls. Renal diseases were the most common causes of secondary hypertension in children, followed by rheumatic immune diseases. For primary hypertension, over four-fifths of inpatients had obesity and obesity-related diseases, and the proportion kept rising.

Antihypertensive effects of immunosuppressive therapy in autoimmune disease

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder that primarily affects women of childbearing age. While immune system dysfunction has been implicated in the development of hypertension (HTN) in SLE, the effect of immunomodulatory drugs on blood pressure (BP) control in SLE patients is unknown. In the present study, we hypothesized that first-line immunomodulatory therapies prescribed to SLE patients would have a beneficial impact on BP. We retrospectively analyzed the Research Data Warehouse containing de-identified patient data (n = 1,075,406) from the University of Mississippi Medical Center for all patients with a clinical diagnosis of SLE. BP responses were analyzed in SLE patients that were initially prescribed a single therapy (methotrexate, hydroxychloroquine, azathioprine, mycophenolate mofetil (MMF), or prednisone). Of the 811 SLE patients who met criteria, most were hypertensive (56%), female (94%), and black (65%). Individuals prescribed MMF or hydroxychloroquine had significantly decreased BP and improved BP control at follow-up (>7 days and <3 months after initial visit). Our results suggest that MMF and hydroxychloroquine have beneficial effects on BP, independent of adjunctive antihypertensive therapies and existing renal disease.

Prevalence of Hypertension and Its Associated Risk Factors Among Patients with Rheumatoid Arthritis in the Kingdom of Saudi Arabia

Purpose

Data regarding hypertension prevalence among patients with rheumatoid arthritis in Saudi Arabia are scarce. This study was aimed at estimating the prevalence of hypertension and its associated risk factors among patients with rheumatoid arthritis in Saudi Arabia.

Patients and Methods

This was a cross-sectional study of adult patients with rheumatoid arthritis who presented at the OPD of two major hospitals in Riyadh city. Patient information such as demographic characteristics, comorbidities, drug use, and other clinical data were captured through medical record review and supplemented by patient interviews. Multivariate logistic regression was used to identify the significant factors for hypertension.

Results

The prevalence of hypertension was found in 32.35% of the 1490 rheumatoid arthritis patients who participated in our study. Logistic regression analyses revealed that advanced age, female sex, low education level, unemployment, smoking, and consulting with physicians less than two times within the past 12 months were risk factors for increased hypertension prevalence among patients with rheumatoid arthritis. A significantly higher risk of hypertension was observed among RA patients with obesity, diabetes, hyperlipidemia, cancer, kidney disease, osteoporosis, and Parkinson’s disease than among patients without these comorbidities.

Conclusion

Hypertension is highly prevalent among patients with rheumatoid arthritis, and advanced age, sex, low educational level, unemployment, smoking, and comorbidities are risk factors for increased hypertension prevalence.

Fluid shear stress enhances T cell activation through Piezo1

Background

T cell activation is a mechanical process as much as it is a biochemical process. In this study, we used a cone-and-plate viscometer system to treat Jurkat and primary human T cells with fluid shear stress (FSS) to enhance the activation of the T cells through mechanical means.

Results

The FSS treatment of T cells in combination with soluble and bead-bound CD3/CD28 antibodies increased the activation of signaling proteins essential for T cell activation, such as zeta-chain-associated protein kinase-70 (ZAP70), nuclear factor of activated T cells (NFAT), nuclear factor kappa B (NF-κB), and AP-1 (activator protein 1). The FSS treatment also enhanced the expression of the cytokines tumor necrosis factor alpha (TNF-α), interleukin 2 (IL-2), and interferon gamma (IFN-γ), which are necessary for sustained T cell activation and function. The enhanced activation of T cells by FSS was calcium dependent. The calcium signaling was controlled by the mechanosensitive ion channel Piezo1, as GsMTx-4 and Piezo1 knockout reduced ZAP70 phosphorylation by FSS.

Conclusions

These results demonstrate an intriguing new dynamic to T cell activation, as the circulatory system consists of different magnitudes of FSS and could have a proinflammatory role in T cell function. The results also identify a potential pathophysiological relationship between T cell activation and FSS, as hypertension is a disease characterized by abnormal blood flow and is correlated with multiple autoimmune diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12915-022-01266-7.

Autoimmune Rheumatic Diseases and Vascular Function: The Concept of Autoimmune Atherosclerosis

Autoimmune rheumatic diseases (AIRDs) with unknown etiology are increasing in incidence and prevalence. Up to 5% of the population is affected. AIRDs include rheumatoid arthritis, system lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. In patients with autoimmune diseases, the immune system attacks structures of its own body, leading to widespread tissue and organ damage, which, in turn, is associated with increased morbidity and mortality. One third of the mortality associated with autoimmune diseases is due to cardiovascular diseases. Atherosclerosis is considered the main underlying cause of cardiovascular diseases. Currently, because of finding macrophages and lymphocytes at the atheroma, atherosclerosis is considered a chronic immune-inflammatory disease. In active inflammation, the liberation of inflammatory mediators such as tumor necrotic factor alpha (TNFa), interleukine-6 (IL-6), IL-1 and other factors like T and B cells, play a major role in the atheroma formation. In addition, antioxidized, low-density lipoprotein (LDL) antibodies, antinuclear antibodies (ANA), and rheumatoid factor (RF) are higher in the atherosclerotic patients. Traditional risk factors like gender, age, hypercholesterolemia, smoking, diabetes mellitus, and hypertension, however, do not alone explain the risk of atherosclerosis present in autoimmune diseases. This review examines the role of chronic inflammation in the etiology-and progression-of atherosclerosis in autoimmune rheumatic diseases. In addition, discussed here in detail are the possible effects of autoimmune rheumatic diseases that can affect vascular function. We present here the current findings from studies that assessed vascular function changes using state-of-the-art techniques and innovative endothelial function biomarkers.

Outcomes of cardiogenic shock with autoimmune rheumatological disorders

AIMS

Data on cardiogenic shock (CS) in autoimmune diseases (AID) is limited. Our study aims to evaluate in-hospital outcomes of CS in hospitalized patients with underlying AID compared with patients without AID.

METHODS

The National Inpatient Sample (NIS) database years 2011-17 was used to identify hospitalizations for CS. We retrospectively compared in-hospital outcomes of CS in patients with underlying AID versus non-AID.

RESULTS

Of 863,239 patients diagnosed with CS, 23,127 (2.7%) had underlying AID. The AID population was older with more women and African American patients (P < 0.001 for all). There was a significant increase in in-hospital mortality in patients with AID vs non-AID that persisted after adjustment for demographics, comorbidities, insurance, socioeconomic status and hospital characteristics (38.3% vs 36.3%, aOR 1.06; 95% CI: 1.02-1.09, P = 0.001). Patients with AID had a lower rate of respiratory complications (11.5% vs 13.1%), acute stroke (6.0% vs 6.8%), use of mechanical circulatory support (12.0% vs 14.5%) and discharge to an outside facility (29.1% vs 28.8%) (P ≤ 0.001 for all). Using multivariable logistic regression, we identified female gender, Native American ethnicity, heart failure, coagulopathy, pulmonary circulation disorders, metastatic cancer, and fluid and electrolytes disorders as independent predictors of mortality in patients with AID who were diagnosed with CS.

CONCLUSION

Patients with AID hospitalized with CS have increased mortality which may be related to their underlying disease process and lack of effective disease-directed therapy for CS related to AID.

Hypertension and endothelial dysfunction in the pristane model of systemic lupus erythematosus

Autoimmune diseases such as psoriasis, rheumatoid arthritis, and systemic lupus erythematosus (SLE) have high rates of hypertension and cardiovascular disease. Systemic lupus erythematosus is a prototypic autoimmune disorder that primarily affects women of childbearing age and is associated with a loss of self-tolerance, autoreactive B and T lymphocytes, and the production of autoantibodies, especially to nuclear components. In this study, we hypothesized that the pristane-inducible model of SLE would develop hypertension and vascular dysfunction as the disease progressed. To test this hypothesis, female C57BL/6 mice were administered PBS or pristane. Seven months after pristane administration, mice developed various autoantibodies, including anti-dsDNA IgG, anti-ssDNA IgG, and anti-nRNP IgG, as well as hypergammaglobulinemia. Several other immunological changes, including increased circulating neutrophils and increased CD4- CD8- (double negative) thymocytes were also detected. Mean arterial pressure (MAP) was elevated in pristane-treated mice when compared to PBS-treated mice. In addition, second-order mesenteric arteries from pristine-treated mice had impaired relaxation to the endothelium-dependent vasodilator acetylcholine compared to PBS-treated mice. These data suggest that the immune system dysfunction present in the pristane model of lupus contributes to the development of hypertension and vascular dysfunction.

Cardio-Rheumatology: Cardiovascular Complications in Systemic Autoimmune Rheumatic Diseases / Is Inflammation the Common Link and Target?

In the current Thematic Issue of Current Vascular Pharmacology (CVP), entitled "Systemic Autoimmune Rheumatic Diseases and Cardiology", presented in two parts, Part 1 and Part 2, review articles are included from specialists in cardiology, rheumatology, immunology and related fields. These reviews discuss the cardiovascular complications of the main systemic Autoimmune Rheumatic Diseases (ARDs). For example, the underlying pathogenetic mechanisms, the role of cardiovascular imaging and recommendations for prevention and management. These articles place inflammation as the key process, linking cardiovascular complications with ARDs. From all these reviews, the conclusion is the need for collaboration between the disciplines of Rheumatology and Cardiology to establish the emerging field of Cardio- Rheumatology. This will aid to fine-tune risk stratification and optimize preventive strategies and pharmacological therapies for patients with ARDs.

Cardio-Rheumatology: Two Collaborating Disciplines to Deal with the Enhanced Cardiovascular Risk in Autoimmune Rheumatic Diseases

In Part 1 of this Thematic Issue entitled "Systemic Autoimmune Rheumatic Diseases and Cardiology", a panel of specialists and experts in cardiology, rheumatology, immunology and related fields discussed the cardiovascular complications of spondyloarthritides, rheumatoid arthritis, Sjogren's syndrome and vasculitides, as well as relevant cardiovascular issues related to non-biologic and biologic disease-modifying anti-rheumatic drugs (DMARDs), and provided their recommendations for prevention and management of these complications. In part 2 of this Thematic Issue, experts discuss the enhanced cardiovascular risk conferred by additional autoimmune rheumatic diseases (ARDs), including systemic lupus erythematosus, the antiphospholipid syndrome, psoriasis and psoriatic arthritis and juvenile idiopathic arthritis. These, and the previous articles, place inflammation as the key common link to explain the enhanced risk of cardiovascular complications in patients with ARDs. It follows that treatment should probably target inflammation. From all these contemporary reviews, the conclusion that is derived further supports the notion of the emerging field of Cardio- Rheumatology where physicians and experts from these two disciplines collaborate in risk stratification and optimization of preventive strategies and drug therapies in patients with ARDs.

Pharmacological management of cardiovascular risk in chronic inflammatory rheumatic diseases

INTRODUCTION

Cardiovascular comorbidity is a major burden in patients with chronic inflammatory rheumatic diseases and a significant determinant of their outcome. In addition to optimal management of the underlying inflammatory condition according to current guidelines, individual cardiovascular risk factors, particularly dyslipidaemia, hypertension, and impaired glucose tolerance should be assessed regularly and guide risk stratification and requirement for treatment.

AREAS DISCUSSED

We critically reviewed manuscripts and guidelines on the pharmacological management of dyslipidaemia, hypertension, and diabetes in patients with chronic inflammatory rheumatic diseases (PubMed, MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar, up to 1 March 2020). Lifestyle changes are of paramount importance for the management of these risk factors. In the current narrative review, we discuss pharmacological therapies available and emerging therapies aiming to help patients achieve recommended targets, depending on their individual risk.

EXPERT OPINION

CVD risk is increased in people with chronic inflammatory rheumatic diseases. Cardiovascular risk factor management is an essential part of their care. Although relevant guidance exists, there are still major gaps in knowledge and risk factor management implementation in these patient groups. Some practical guidance based on our interpretation of existing data and experience in the field is provided in this review.

Safety Profile of Biologics Used in Rheumatology: An Italian Prospective Pharmacovigilance Study

Post-marketing surveillance activities are essential to detect the risk/benefit profile of biologic disease-modifying antirheumatic drugs (bDMARDs) in inflammatory arthritis. The aim of this study was to evaluate adverse events (AEs) in patients treated with bDMARDs in rheumatology during a prospective pharmacovigilance study from 2016 to 2018. Descriptive statistical analyses were performed to evaluate bDMARDs-related variables of patients without AEs/failures vs patients with AEs and failures. The risk profile among biologics was assessed by comparing patients treated with each bDMARD to patients treated with etanercept. A total of 1155 patients were enrolled, mostly affected by rheumatoid arthritis (46.0%). AEs and failures were experienced by 8.7% and 23.3%, respectively. The number of comorbidities significantly influenced the onset of AEs, while anxiety-depressive, gastrointestinal disease, and fibromyalgia influenced onset of failures. The probability of developing an AE was significantly lower in patients treated with secukinumab, while the probability of developing treatment failure was significantly lower in patients treated with golimumab, secukinumab and tocilizumab. A total of 216 AEs were reported (25.5% serious), mostly regarding infections (21.8%), musculoskeletal (17.6%) and skin (16.2%) disorders. Serious AEs included neutropenia (12.7%), lymphocytosis (9.1%) and uveitis (7.3%). The obtained results revealed known AEs but real-world data should be endorsed for undetected safety concerns.

Effects of ticagrelor, empagliflozin and tamoxifen against experimentally-induced vascular reactivity defects in rats in vivo and in vitro

BACKGROUND

In the current investigation, the effects of the P2Y12 blocker ticagrelor, the sodium/glucose transporter-2-inhibitor empagliflozin, and the selective estrogen receptor modulator tamoxifen were examined against rheumatoid arthritis (RA)/diabetes mellitus (DM)-co-morbidity-induced defects in vascular reactivity.

METHODS

After model setting, rats were allocated into a normal control, an RA/DM-co-morbidity, and three treatment groups receiving ticagrelor, empagliflozin and tamoxifen. Aorta tissue was isolated for enzyme-linked immunosorbent assay (ELISA) and western blot estimation of the pro-inflammatory molecules angiotensin-II (Ang-II) and endothelin-1 (ET-1), the adhesion molecules P-selectin and vascular cell adhesion molecule-1 (VCAM-1), the energy preserving molecule adenosine-5'-monophosphate-activated protein kinase (AMPK), and the anti-inflammatory molecule vasoactive intestinal peptide (VIP). Estimations of endothelial nitric oxide synthase (eNOS) and matrix metalloproteinase (MMP)-2 were performed immunohistochemically, together with histopathological examination using hematoxylin and eosin and Masson trichrome staining. An in vitro study on rat aortic strips was conducted to assess aorta vasorelaxation.

RESULTS

Ticagrelor, empagliflozin and tamoxifen significantly increased aorta tissue AMPK and eNOS and decreased Ang-II, ET-1, P-selectin, VCAM-1 and VIP levels compared with RA/DM-co-morbidity, coupled with improved acetylcholine vasorelaxation in vitro.

CONCLUSION

Ticagrelor, empagliflozin and tamoxifen may correct vascular reactivity defects, where modulation of vascular AMPK, eNOS, Ang-II, ET-1, P-selectin, VCAM-1 and MMP-2 underline their protective effects.

Bilirubin Safeguards Cardiorenal and Metabolic Diseases: a Protective Role in Health

PURPOSE OF REVIEW

To discuss recent advances indicating that bilirubin safeguards against cardiorenal and metabolic diseases.

RECENT FINDINGS

Several investigations from human patient populations and experimental animal models have shown that bilirubin improves cardiorenal and metabolic dysfunction. The latest studies found an entirely new function of bilirubin suggesting that it acts as a hormone signaling molecule capable of activating nuclear receptors for burning fat, which may explain several of its protective actions. This review highlights the current findings (within the last 3 years) regarding cardiorenal and metabolic protective effects of bilirubin and the latest mechanism(s) that may be mediating these effects.

Immunity and hypertension: New targets to lighten the pressure

LINKED ARTICLES

This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.

Mechanisms of hypertension in autoimmune rheumatic diseases

Patients with autoimmune rheumatic diseases including rheumatoid arthritis and systemic lupus erythematosus have an increased prevalence of hypertension. There is now a large body of evidence showing that the immune system is a key mediator in both human primary hypertension and experimental models. Many of the proposed immunological mechanisms leading to primary hypertension are paralleled in autoimmune rheumatic disorders. Therefore, examining the link between autoimmunity and hypertension can be informative for understanding primary hypertension. This review examines the prevalent hypertension, the immune mediators that contribute to the prevalent hypertension and their impact on renal function and how the risk of hypertension is potentially influenced by common hormonal changes that are associated with autoimmune rheumatic diseases.

Linked Articles

This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc