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Ebstein E, Ottaviani S. Managing Gout in Patients with Metabolic Syndrome. Drugs Aging 2024:10.1007/s40266-024-01132-x. [PMID: 39060816 DOI: 10.1007/s40266-024-01132-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 07/28/2024]
Abstract
Gout is characterized by monosodium urate (MSU) crystal deposition secondary to hyperuricemia. Gout is associated with metabolic syndrome (MetS) and its related comorbid conditions such as cardiovascular disease (CVD). Major advances have been made in the comprehension of the link between MetS and gout. Despite observational studies suggesting an association between MetS-related conditions and hyperuricemia, there is no proof of causality. Most studies using Mendelian randomization did not find hyperuricemia as a causal factor for MetS-related conditions. In contrast, these conditions were found associated with hyperuricemia, which suggests a reverse causality. Among patients with gout, this high CVD risk profile implies the need for systematic screening for MetS-related conditions. Most international guidelines recommend systematic screening for and care of CVD and related risk factors in patients with gout. Some anti-hypertensive agents, such as losartan and calcium channel blockers, are able to decrease serum urate (SU) levels. However, there are potential interactions between gout management therapies and the treatment of metabolic diseases. Some data suggest that anti-inflammatory drugs used for gout flare treatment, such as colchicine or canakinumab, might have benefits for CVD. Regarding the impact of urate-lowering therapies on CVD risk, recent studies found a similar CVD safety profile for allopurinol and febuxostat. Finally, sodium-glucose cotransporter-2 inhibitors are promising for gout because of their ability to decrease SU levels and risk of recurrent flares. In this review, we focus on the clinical challenge of managing MetS in patients with gout, particularly older patients with co-medications.
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Affiliation(s)
- Esther Ebstein
- Rheumatology Department, Université Paris Cité, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France
| | - Sébastien Ottaviani
- Rheumatology Department, Université Paris Cité, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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Agca R, Popa CD, Heymans MW, Crusius B, Voskuyl AE, Nurmohamed MT. Does Adding Single-Nucleotide Polymorphisms to Risk Algorithms Improve Cardiovascular Disease Risk Prediction in Rheumatoid Arthritis? An Internal and External Validation of a Clinical Risk Score. Arthritis Care Res (Hoboken) 2024. [PMID: 38923367 DOI: 10.1002/acr.25382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 05/20/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Current risk algorithms do not accurately predict cardiovascular disease (CVD) risk in rheumatoid arthritis (RA). An area of interest is that of single-nucleotide polymorphisms (SNPs), of which several have been associated with CVD in the general population. We investigated whether these SNPs are associated with CVD in RA and whether SNPs could improve CVD risk prediction in RA. METHODS Sixty SNPs were genotyped in 353 patients with RA. Logistic and Cox regression analyses were performed to identify SNPs that were associated with CVD (n = 99). A prediction model with clinical variables was made. SNPs were added to investigate the additional predictive value. Both models were internally validated. External validation was done in a separate cohort (n = 297). RESULTS rs3184504, rs4773144, rs12190287, and rs445925 were significantly associated with new CVD. The clinical prediction model consisted of age, sex, body mass index, systolic blood pressure, high-density lipoprotein cholesterol (HDLc), and creatinine, with an area under the curve (AUC) of 0.74 (P = 0.03). Internal validation resulted in an AUC of 0.76 (P < 0.01). A new model was made including SNPs and resulted in a model with rs17011666 and rs801426, age, total cholesterol, and HDLc, which performed slightly better with an AUC of 0.77 (P < 0.01). External validation resulted in a good fit for the clinical model, but a poor fit for the SNP model. CONCLUSION Several SNPs were associated with CVD in RA. Risk prediction slightly improved after adding SNPs to the models, but the clinical relevance is debatable. However, larger studies are needed to determine more accurately the additional value of these SNPs to CVD risk prediction algorithms.
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Affiliation(s)
- Rabia Agca
- Amsterdam Rheumatology and Immunology Center, Amsterdam, the Netherlands
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Calin D Popa
- Radboud University Medical Center and Sint Maartenskliniek, Nijmegen, the Netherlands
| | | | - Bart Crusius
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Alexandre E Voskuyl
- Amsterdam Rheumatology and Immunology Center, Amsterdam, the Netherlands
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Amsterdam, the Netherlands
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Bedeković D, Bošnjak I, Bilić-Ćurčić I, Kirner D, Šarić S, Novak S. Risk for cardiovascular disease development in rheumatoid arthritis. BMC Cardiovasc Disord 2024; 24:291. [PMID: 38834973 DOI: 10.1186/s12872-024-03963-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 05/28/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis have significant cardiovascular mortality and morbidity. OBJECTIVE To investigate the effects of chronic inflammation in rheumatoid arthritis on cardiovascular morbidity association with cardiovascular risk factors risk factors. Mortality report is secondary just to show trends without sufficient statistical power as it is accidental endpoint. METHODS A total of 201 individuals without previous cardiovascular disease, 124 with rheumatoid arthritis (investigation group) and 77 with osteoarthritis (control group), were included in the study and followed up for an average of 8 years to assess the development of fatal or non-fatal cardiovascular diseases. The incidence and prevalence of cardiovascular risk factors were also investigated. RESULTS The total incidence of one or more fatal or nonfatal cardiovascular events was 43.9% in the investigation group and 37.5% in the control group. Of these patients, 31.7% and 30.9% survived cardiovascular events in the investigation and control groups, respectively. The most common cardiovascular disease among participants who completed the study and those who died during the study was chronic heart failure. The results of the subgroup analysis showed that strict inflammation control plays a central role in lowering cardiovascular risk. CONCLUSION A multidisciplinary approach to these patients is of paramount importance, especially with the cooperation of immunologists and cardiologists for early detection, prevention, and management of cardiovascular risks and diseases.
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Affiliation(s)
- Dražen Bedeković
- Department of Cardiovascular Diseases, Internal Medicine Clinic, University Hospital Osijek, J. Huttlera 4, Osijek, 31000, Croatia
- Faculty of Medicine Osijek, Department of Internal Medicine, University J.J. Strossmayer, J. Huttlera 4, Osijek, 31000, Croatia
| | - Ivica Bošnjak
- Department of Cardiovascular Diseases, Internal Medicine Clinic, University Hospital Osijek, J. Huttlera 4, Osijek, 31000, Croatia.
| | - Ines Bilić-Ćurčić
- Department for Pharmacology, Faculty of Medicine, J. J. Strossmayer University of Osijek, J. Huttlera 4, Osijek, 31000, Croatia
- Department of Endocrinology and Metabolism Disorders, Internal Medicine Clinic, University Hospital Centre Osijek, J. Huttlera 4, Osijek, 31000, Croatia
| | - Damir Kirner
- Department of Cardiovascular Diseases, Internal Medicine Clinic, University Hospital Osijek, J. Huttlera 4, Osijek, 31000, Croatia
- Faculty of Medicine Osijek, Department of Internal Medicine, University J.J. Strossmayer, J. Huttlera 4, Osijek, 31000, Croatia
| | - Sandra Šarić
- Department of Cardiovascular Diseases, Internal Medicine Clinic, University Hospital Osijek, J. Huttlera 4, Osijek, 31000, Croatia
- Faculty of Medicine Osijek, Department of Internal Medicine, University J.J. Strossmayer, J. Huttlera 4, Osijek, 31000, Croatia
| | - Srđan Novak
- Department of Rheumatology and Clinical Immunology, University Hospital Rijeka, Rijeka, Croatia
- Faculty of Medicine Rijeka, Department of Internal Medicine, University of Rijeka, Braće Branchetta 20/1, Rijeka, 51000, Croatia
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Mongin D, Pagano S, Lamacchia C, Juillard C, Antinori-Malaspina P, Dan D, Ciurea A, Möller B, Gabay C, Finckh A, Vuilleumier N. Anti-apolipoprotein A-1 IgG, incident cardiovascular events, and lipid paradox in rheumatoid arthritis. Front Cardiovasc Med 2024; 11:1386192. [PMID: 38832312 PMCID: PMC11144907 DOI: 10.3389/fcvm.2024.1386192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/24/2024] [Indexed: 06/05/2024] Open
Abstract
Objective To validate the prognostic accuracy of anti-apolipoprotein A-1 (AAA1) IgG for incident major adverse cardiovascular (CV) events (MACE) in rheumatoid arthritis (RA) and study their associations with the lipid paradox at a multicentric scale. Method Baseline AAA1 IgG, lipid profile, atherogenic indexes, and cardiac biomarkers were measured on the serum of 1,472 patients with RA included in the prospective Swiss Clinical Quality Management registry with a median follow-up duration of 4.4 years. MACE was the primary endpoint defined as CV death, incident fatal or non-fatal stroke, or myocardial infarction (MI), while elective coronary revascularization (ECR) was the secondary endpoint. Discriminant accuracy and incidence rate ratios (IRR) were respectively assessed using C-statistics and Poisson regression models. Results During follow-up, 2.4% (35/1,472) of patients had a MACE, consisting of 6 CV deaths, 11 MIs, and 18 strokes; ECR occurred in 2.1% (31/1,472) of patients. C-statistics indicated that AAA1 had a significant discriminant accuracy for incident MACE [C-statistics: 0.60, 95% confidence interval (95% CI): 0.57-0.98, p = 0.03], mostly driven by CV deaths (C-statistics: 0.77; 95% CI: 0.57-0.98, p = 0.01). IRR indicated that each unit of AAA1 IgG increase was associated with a fivefold incident CV death rate, independent of models' adjustments. At the predefined and validated cut-off, AAA1 displayed negative predictive values above 97% for MACE. AAA1 inversely correlated with total and HDL cholesterol. Conclusions AAA1 independently predicts CV deaths, and marginally MACE in RA. Further investigations are requested to ascertain whether AAA1 could enhance CV risk stratification by identifying patients with RA at low CV risk.
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Affiliation(s)
- Denis Mongin
- Division of Rheumatology, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sabrina Pagano
- Division of Laboratory Medicine, Department of Diagnostics and of Medical Specialties, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Celine Lamacchia
- Division of Rheumatology, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Catherine Juillard
- Division of Laboratory Medicine, Department of Diagnostics and of Medical Specialties, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Paola Antinori-Malaspina
- Division of Laboratory Medicine, Department of Diagnostics and of Medical Specialties, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Diana Dan
- Division of Rheumatology, Lausanne University Hospital and Faculty of Medicine, University of Lausanne, Lausanne, Switzerland
| | - Adrian Ciurea
- Division of Rheumatology, Zurich University Hospital and Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Burkhard Möller
- Division of Rheumatology and Immunology, Bern University Hospital and Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Cem Gabay
- Division of Rheumatology, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Axel Finckh
- Division of Rheumatology, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Vuilleumier
- Division of Laboratory Medicine, Department of Diagnostics and of Medical Specialties, Geneva University Hospitals and Geneva University, Geneva, Switzerland
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Cure O, Kizilkaya B, Ciftel S, Mercantepe F. The Effect of Anti-Tumor Necrosis Factor Therapy on The Plasma Atherogenic Index in Rheumatic Diseases. Metab Syndr Relat Disord 2024; 22:269-275. [PMID: 38252497 DOI: 10.1089/met.2023.0237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Background: The risk of atherosclerosis is increased in individuals with rheumatological disease. The objective of this study is to examine the heightened susceptibility to atherosclerosis in persons afflicted with rheumatological disorders. This study aimed to assess the impact of anti-tumor necrosis factor (anti-TNF) medication on the plasma atherogenic index (PAI) in persons diagnosed with rheumatological disease. Methods: This study used a retrospective cross-sectional design to investigate a cohort of 136 patients with rheumatological disease who were undergoing anti-TNF therapy (Group 1), as well as a comparison group of 117 patients getting conventional therapy (Group 2). Measurements of PAI were conducted at the initial baseline and again at the sixth month of treatment. Results: Initially, there was no statistically significant disparity observed in PAI values between the two cohorts. After a period of 6 months, a notable reduction in PAI was identified in the group receiving anti-TNF medication (P = 0.01), while no significant alteration was detected in the group receiving conventional treatment. Conclusion: It provides findings showing that anti-TNF therapy can reduce the PAI in individuals with rheumatological disease. This may indicate a potential cardiovascular protective effect of anti-TNF therapy.
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Affiliation(s)
- Osman Cure
- Department of Rheumatology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Bayram Kizilkaya
- Department of Internal Medicine, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Serpil Ciftel
- Department of Endocrinology and Metabolism, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Filiz Mercantepe
- Department of Endocrinology and Metabolism, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
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Raadsen R, Hansildaar R, van Kuijk AWR, Nurmohamed MT. Male rheumatoid arthritis patients at substantially higher risk for cardiovascular mortality in comparison to women. Semin Arthritis Rheum 2023; 62:152233. [PMID: 37356211 DOI: 10.1016/j.semarthrit.2023.152233] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/11/2023] [Accepted: 06/11/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) are at an increased risk for developing cardiovascular diseases. While advice regarding cardiovascular risk screening and management in RA patients has been incorporated in several guidelines in recent years, its implementation and adherence is still poor. OBJECTIVES To assess the cardiovascular disease risk in new diagnosed RA patients and evaluate whether advice to initiate preventive medical treatment of high risk patients was followed. METHODS All patients with a recent diagnosis of RA, aged 40-70 years, were screened between May 2019 and December 2022 for cardiovascular diseases and risk factors within the first year after diagnosis at the outpatient rheumatology clinic, as part of standard care. Screening included a physical examination with blood pressure measurement, and laboratory tests with lipid profile tests. All patients and their general practitioner (GP) received an overview with their cardiovascular risk profile and a calculated 10-year cardiovascular mortality risk. Cardiovascular risk was defined as low (<1%), intermediate (1-5%), high (5-10%) and very high (>10%). The national pharmacy network was consulted to check whether or not patients started preventive medication after screening. RESULTS A total of 125 RA patients was included in this study. The mean age was 56 years and 78% was female. Median RA disease duration at screening was 6 months. Six patients (5%) indicated to have been screened before, and used antihypertensive medication. During screening, hypertension was found in 57% of male patients and 43% of female patients and dyslipidemia was found in 36% in male and 32% in female patients. 46% of male patients and 21% of female patients currently smoked. A high or very high 10-year cardiovascular mortality risk was found in 50% of male patients, but in only 4% of female patients. Only 26% of (very) high risk patients started antihypertensive or statin medication after screening. CONCLUSIONS An increased cardiovascular disease risk is often present in newly diagnosed RA patients, especially male patients, with a large proportion having undiagnosed and untreated hypertension and hypercholesterolemia. Even with structural screening and informing of the patients and GPs, treatment of cardiovascular risk factors in high risk patients remains insufficient. CV risk screening needs to be part of standard care for RA patients, with clear agreement on the responsibilities between primary and secondary care. Awareness of the importance of CVD risk screening needs to improve among both RA patients themselves and the GPs to ultimately reduce the cardiovascular burden of our patients. Obviously, a better collaboration between GPs and rheumatologists is urgently needed to lower the cardiovascular burden of our patients.
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Affiliation(s)
- R Raadsen
- Amsterdam Rheumatology and Immunology Center, Location VUmc and Reade, Amsterdam, Noord-Holland, the Netherlands.
| | - R Hansildaar
- Amsterdam Rheumatology and Immunology Center, Location VUmc and Reade, Amsterdam, Noord-Holland, the Netherlands
| | - A W R van Kuijk
- Amsterdam Rheumatology and Immunology Center, Location VUmc and Reade, Amsterdam, Noord-Holland, the Netherlands
| | - M T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Location VUmc and Reade, Amsterdam, Noord-Holland, the Netherlands; Department of Rheumatology, Amsterdam UMC Location VUmc, Amsterdam, Noord-Holland, the Netherlands
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7
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Qin L, Luo Q, Hu Y, Yan S, Yang X, Zhang Y, Xiong F, Wang H. The poor performance of cardiovascular risk scores in identifying patients with idiopathic inflammatory myopathies at high cardiovascular risk. Open Med (Wars) 2023; 18:20230703. [PMID: 37215054 PMCID: PMC10193404 DOI: 10.1515/med-2023-0703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 05/24/2023] Open
Abstract
Framingham risk score (FRS), systematic coronary risk evaluation (SCORE), the 10-year atherosclerotic cardiovascular disease risk algorithm (ASCVD), and their modified risk scores are the most common cardiovascular risk scores. The aim of this case-control study was to evaluate the performance of cardiovascular risk scores in detecting carotid subclinical atherosclerosis (SCA) in patients with idiopathic inflammatory myopathies (IIMs). A total of 123 IIMs patients (71.5% female, mean age 50 ± 14 years) and 123 age- and gender-matched healthy controls were included in this study. Carotid SCA was more prevalent in IIMs patients compared with controls (77.2 vs 50.4%, P < 0.001). Moreover, patients with carotid SCA+ had older age, and all risk scores were significantly higher in IIMs patients with SCA+ compared to subjects with SCA- (all P < 0.001). According to FRS, SCORE, and ASCVD risk scores, 77.9, 96.8, and 66.7% patients with SCA+ were classified as low risk category, respectively. The modified scores also demonstrated a modest improvement in sensitivity. Notably, by adopting the optimal cutoff values, these risk scores had good discrimination on patients with SCA+, with area under curves of 0.802-0.893. In conclusion, all cardiovascular risk scores had a poor performance in identifying IIMs patients at high cardiovascular risk.
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Affiliation(s)
- Li Qin
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, 410013, China
| | - Qiang Luo
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
| | - Yinlan Hu
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
| | - Shuangshuang Yan
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
| | - Xiaoqian Yang
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
| | - Yiwen Zhang
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, 610031, Sichuan, China
| | - Feng Xiong
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, No. 82, Qinglong Street,, Chengdu, 610031, Sichuan, China
| | - Han Wang
- Department of Cardiology, The Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, No. 82, Qinglong Street,, Chengdu, 610031, Sichuan, China
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Andonian B, Ross LM, Zidek AM, Fos LB, Piner LW, Johnson JL, Belski KB, Counts JD, Pieper CF, Siegler IC, Bales CW, Porter Starr KN, Kraus WE, Huffman KM. Remotely Supervised Weight Loss and Exercise Training to Improve Rheumatoid Arthritis Cardiovascular Risk: Rationale and Design of the Supervised Weight Loss Plus Exercise Training-Rheumatoid Arthritis Trial. ACR Open Rheumatol 2023; 5:252-263. [PMID: 36992545 PMCID: PMC10184018 DOI: 10.1002/acr2.11536] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 03/31/2023] Open
Abstract
Patients with rheumatoid arthritis (RA) remain at an increased risk for cardiovascular disease (CVD) and mortality. RA CVD results from a combination of traditional risk factors and RA-related systemic inflammation. One hypothetical means of improving overall RA CVD risk is through reduction of excess body weight and increased physical activity. Together, weight loss and physical activity can improve traditional cardiometabolic health through fat mass loss, while also improving skeletal muscle health. Additionally, disease-related CVD risk may improve as both fat mass loss and exercise reduce systemic inflammation. To explore this hypothesis, 26 older persons with RA and overweight/obesity will be randomized to 16 weeks of a usual care control arm or to a remotely Supervised Weight Loss Plus Exercise Training (SWET) program. A caloric restriction diet (targeting 7% weight loss) will occur via a dietitian-led intervention, with weekly weigh-ins and group support sessions. Exercise training will consist of both aerobic training (150 minutes/week moderate-to-vigorous exercise) and resistance training (twice weekly). The SWET remote program will be delivered via a combination of video conference, the study YouTube channel, and study mobile applications. The primary cardiometabolic outcome is the metabolic syndrome Z score, calculated from blood pressure, waist circumference, high-density lipoprotein cholesterol, triglycerides, and glucose. RA-specific CVD risk will be assessed with measures of systemic inflammation, disease activity, patient-reported outcomes, and immune cell function. The SWET-RA trial will be the first to assess whether a remotely supervised, combined lifestyle intervention improves cardiometabolic health in an at-risk population of older individuals with RA and overweight/obesity.
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Affiliation(s)
| | | | | | - Liezl B. Fos
- Duke University School of MedicineDurhamNorth Carolina
| | - Lucy W. Piner
- Duke University School of MedicineDurhamNorth Carolina
| | | | | | | | | | | | - Connie W. Bales
- Duke University School of Medicine and Geriatric Research, Education, and Clinical Center, Durham VA Medical CenterDurhamNorth Carolina
| | - Kathryn N. Porter Starr
- Duke University School of Medicine and Geriatric Research, Education, and Clinical Center, Durham VA Medical CenterDurhamNorth Carolina
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Atzeni F, Maiani S, Corda M, Rodríguez-Carrio J. Diagnosis and management of cardiovascular risk in rheumatoid arthritis: main challenges and research agenda. Expert Rev Clin Immunol 2023; 19:279-292. [PMID: 36651086 DOI: 10.1080/1744666x.2023.2170351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) exhibit a cardiovascular (CV) risk that is 1.5-2.0 times higher compared to the general population. This CV risk excess is likely caused by the involvement of chronic inflammation and immune dysregulation. Therefore, conventional algorithms and imaging techniques fail to fully account for this risk excess and provide a suboptimal risk stratification, hence limiting clinical management in this setting. AREAS COVERED Compelling evidence has suggested a role for adaptations of conventional algorithms (Framingham, SCORE, AHA, etc) or the development of RA-specific algorithms, as well as the use of a number of several, noninvasive imaging techniques to improve CV risk assessment in RA populations. Similarly, in-depth analyses of atherosclerosis pathogenesis in RA patients have shed new light into a plethora of soluble biomarkers (such as inflammatory cytokines, vascular remodeling mediators or autoantibodies) that may provide incremental value for CV risk stratification. EXPERT OPINION Extensive research has demonstrated a lack of performance of chart adaptations in capturing real CV risk in RA population, as well as for RA-specific algorithms. Similarly, limitations have been detected in the use of soluble mediators. The development of a novel, RA-specific algorithm including classical and non-traditional risk factors may be advisable.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Silvia Maiani
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Marco Corda
- S.C. Cardiologia UTIC, ARNAS, G.Brotzu, Cagliari, Italy
| | - Javier Rodríguez-Carrio
- Area of Immunology, Department of Functional Biology, Faculty of Medicine, University of Oviedo, Oviedo, Spain.,Area of Metabolism, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
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Solomon DH, Giles JT, Liao KP, Ridker PM, Rist PM, Glynn RJ, Broderick R, Lu F, Murray MT, Vanni K, Santacroce LM, Abohashem S, Robson PM, Fayad Z, Mani V, Tawakol A, Bathon J. Reducing cardiovascular risk with immunomodulators: a randomised active comparator trial among patients with rheumatoid arthritis. Ann Rheum Dis 2023; 82:324-330. [PMID: 36450449 PMCID: PMC9933165 DOI: 10.1136/ard-2022-223302] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Recent large-scale randomised trials demonstrate that immunomodulators reduce cardiovascular (CV) events among the general population. However, it is uncertain whether these effects apply to rheumatoid arthritis (RA) and if certain treatment strategies in RA reduce CV risk to a greater extent. METHODS Patients with active RA despite use of methotrexate were randomly assigned to addition of a tumour necrosis factor (TNF) inhibitor (TNFi) or addition of sulfasalazine and hydroxychloroquine (triple therapy) for 24 weeks. Baseline and follow-up 18F-fluorodeoxyglucose-positron emission tomography/CT scans were assessed for change in arterial inflammation, an index of CV risk, measured as an arterial target-to-background ratio (TBR) in the carotid arteries and aorta. RESULTS 115 patients completed the protocol. The two treatment groups were well balanced with a median age of 58 years, 71% women, 57% seropositive and a baseline disease activity score in 28 joints of 4.8 (IQR 4.0, 5.6). Baseline TBR was similar across the two groups. Significant TBR reductions were observed in both groups-ΔTNFi: -0.24 (SD=0.51), Δtriple therapy: -0.19 (SD=0.51)-without difference between groups (difference in Δs: -0.02, 95% CI -0.19 to 0.15, p=0.79). While disease activity was significantly reduced across both treatment groups, there was no association with change in TBR (β=0.04, 95% CI -0.03 to 0.10). CONCLUSION We found that addition of either a TNFi or triple therapy resulted in clinically important improvements in vascular inflammation. However, the addition of a TNFi did not reduce arterial inflammation more than triple therapy. TRIAL REGISTRATION NUMBER NCT02374021.
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Affiliation(s)
| | - Jon T Giles
- Columbia University Medical Center, New York, New York, USA
| | | | - Paul M Ridker
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pamela M Rist
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert J Glynn
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Fengxin Lu
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Kathleen Vanni
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Zahi Fayad
- Mount Sinai Medical Center, New York, New York, USA
| | | | - Ahmed Tawakol
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joan Bathon
- Columbia University Medical Center, New York, New York, USA
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Tekaya R, Rouached L, Ben Ahmed H, Ben Tekaya A, Bouden S, Saidane O, Bouzid K, Mahmoud I, Abdelmoula L. Variation of homocysteine levels in rheumatoid arthritis patients: relationship to inflammation, cardiovascular risk factors, and methotrexate. Z Rheumatol 2023; 82:38-43. [PMID: 34570274 DOI: 10.1007/s00393-021-01092-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the variation of homocysteine (Hcy) levels in patients with rheumatoid arthritis (RA) and to analyze the relationship to inflammatory parameters, cardiovascular risk, and methotrexate (MTX). METHODS This cross-sectional study assessed disease activity and treatment in RA patients. The European League Against Rheumatism (EULAR) 2015 HeartSCORE was performed for cardiovascular (CV) risk estimation and levels of plasma Hcy, serum folate concentrations, vitamin B12, and erythrocyte sedimentation rate (ESR) were measured. RESULTS A total of 103 participants with mean age 53 ± 10 years and mean disease duration 10.55 ± 7.34 years were included. Patients were treated with MTX in 69.9% of cases and corticosteroid in 80.5% of cases. Of all patients, 13% had a cardiovascular inheritance, 25% were hypertensive, and 18% had diabetes. The EULAR 2015 HeartSCORE was high and very high (≥5%) in 35% of cases. Mean Hcy level was 12.54 ± 4.2 µmol/L [6.89-32.92] and hyperhomocysteinemia was noted in 20.4% of patients. Analytic study demonstrated that hyperhomocysteinemia was associated with male gender (p = 0.01), MTX use (p = 0.01), smoking (p = 0.008), renal failure (p = 0.04), and high disease activity (p = 0.05), but there was no association with the HeartSCORE (p = 0.23). Hcy level was negatively correlated with folate (p = 0.009) and vitamin B12 level (p = 0.02) and positively with age (p = 0.01), C‑reactive protein (CRP; p = 0.05), and Simplified Disease Activity Index (SDAI; p = 0.03). In multivariate logistic regression analysis, current MTX use, levels of vitamin B12 and creatine, and Clinical Disease Activity Index (CDAI) appeared to be independent factors associated with hyperhomocysteinemia. CONCLUSION MTX use, CDAI, and the levels of vitamin B12 and creatine are independent factors associated with hyperhomocysteinemia.
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Affiliation(s)
- Rawdha Tekaya
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Leila Rouached
- Medicine University Tunis EL Manar, Tunis, Tunisia. .,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia.
| | - Habib Ben Ahmed
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of cardiology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Aicha Ben Tekaya
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Selma Bouden
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Olfa Saidane
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Kahena Bouzid
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of biochemistry, Charles Nicolle Hospital, Tunis, Tunisia
| | - Ines Mahmoud
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Leila Abdelmoula
- Medicine University Tunis EL Manar, Tunis, Tunisia.,Department of rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
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12
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Yang C, Williams RD, Swerdel JN, Almeida JR, Brouwer ES, Burn E, Carmona L, Chatzidionysiou K, Duarte-Salles T, Fakhouri W, Hottgenroth A, Jani M, Kolde R, Kors JA, Kullamaa L, Lane J, Marinier K, Michel A, Stewart HM, Prats-Uribe A, Reisberg S, Sena AG, Torre CO, Verhamme K, Vizcaya D, Weaver J, Ryan P, Prieto-Alhambra D, Rijnbeek PR. Development and external validation of prediction models for adverse health outcomes in rheumatoid arthritis: A multinational real-world cohort analysis. Semin Arthritis Rheum 2022; 56:152050. [PMID: 35728447 DOI: 10.1016/j.semarthrit.2022.152050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/11/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Identification of rheumatoid arthritis (RA) patients at high risk of adverse health outcomes remains a major challenge. We aimed to develop and validate prediction models for a variety of adverse health outcomes in RA patients initiating first-line methotrexate (MTX) monotherapy. METHODS Data from 15 claims and electronic health record databases across 9 countries were used. Models were developed and internally validated on Optum® De-identified Clinformatics® Data Mart Database using L1-regularized logistic regression to estimate the risk of adverse health outcomes within 3 months (leukopenia, pancytopenia, infection), 2 years (myocardial infarction (MI) and stroke), and 5 years (cancers [colorectal, breast, uterine] after treatment initiation. Candidate predictors included demographic variables and past medical history. Models were externally validated on all other databases. Performance was assessed using the area under the receiver operator characteristic curve (AUC) and calibration plots. FINDINGS Models were developed and internally validated on 21,547 RA patients and externally validated on 131,928 RA patients. Models for serious infection (AUC: internal 0.74, external ranging from 0.62 to 0.83), MI (AUC: internal 0.76, external ranging from 0.56 to 0.82), and stroke (AUC: internal 0.77, external ranging from 0.63 to 0.95), showed good discrimination and adequate calibration. Models for the other outcomes showed modest internal discrimination (AUC < 0.65) and were not externally validated. INTERPRETATION We developed and validated prediction models for a variety of adverse health outcomes in RA patients initiating first-line MTX monotherapy. Final models for serious infection, MI, and stroke demonstrated good performance across multiple databases and can be studied for clinical use. FUNDING This activity under the European Health Data & Evidence Network (EHDEN) has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 806968. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation programme and EFPIA.
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Affiliation(s)
- Cynthia Yang
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Ross D Williams
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joel N Swerdel
- Janssen Research and Development, Titusville, NJ, United States
| | | | - Emily S Brouwer
- Janssen Research and Development, Titusville, NJ, United States
| | - Edward Burn
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | | | | | - Talita Duarte-Salles
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Walid Fakhouri
- Eli Lilly and Company, Windlesham, Surrey, United Kingdom
| | | | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, United Kingdom
| | - Raivo Kolde
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Jan A Kors
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lembe Kullamaa
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia; Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia; European Patients' Forum, Brussels, Belgium
| | - Jennifer Lane
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Albert Prats-Uribe
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sulev Reisberg
- Institute of Computer Science, University of Tartu, Tartu, Estonia; STACC, Tartu, Estonia; Quretec, Tartu, Estonia
| | - Anthony G Sena
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands; Janssen Research and Development, Titusville, NJ, United States
| | | | - Katia Verhamme
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - James Weaver
- Janssen Research and Development, Titusville, NJ, United States; Observational Health Data Sciences and Informatics, New York, NY, United States
| | - Patrick Ryan
- Janssen Research and Development, Titusville, NJ, United States; Observational Health Data Sciences and Informatics, New York, NY, United States
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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Shi LH, Lam SH, So H, Li EK, Li TK, Szeto CC, Tam LS. High inflammatory burden predicts cardiovascular events in patients with axial spondyloarthritis: a long-term follow-up study. Ther Adv Musculoskelet Dis 2022; 14:1759720X221122401. [PMID: 36105413 PMCID: PMC9465578 DOI: 10.1177/1759720x221122401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background Axial spondyloarthritis (axSpA) patients are at higher risk of cardiovascular (CV) disease (CVD) than the general population, partly due to consequences of inflammation or its treatment. But relationship between inflammation in axSpA and cardiovascular events (CVE) is unknown. Objectives To examine whether inflammatory burden over time can predict CVE independent of baseline CV risk factors in axSpA patients. Design A cohort analysis was performed in patients who had been recruited since January 2001. The primary outcome was a first CVE occurring between January 2001 and December 2020. Methods Three CVD risk scores were computed at baseline. The performance of the original and modified (*1.5 multiplication factor) CV risk algorithms were assessed. Time-varying Cox proportional hazard models and Kaplan-Meier survival analysis were used to assess whether inflammatory burden (Bath ankylosing spondylitis disease activity index [BASDAI] and inflammatory markers), nonsteroidal anti-inflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) can predict the development of first CVE. Results 463 patients (35 [26-45] years, male: 360 [77.8%]) were recruited. After a median follow-up of 12 (7-19) years, 61 patients (13.2%) experienced a first CVE. Traditional/modified CV risk scores underestimated CV risk. Erythrocyte sedimentation rate (ESR) ⩾ 20 mm/h was associated with a significantly higher risk of CVE during follow-up (HR: 2.07, 95%CI [1.10, 3.98], p = 0.008). Active disease as indicated by a rising BASDAI also showed positive trend towards a higher risk of developing CVE over time. After adjusting for CV risk scores in the multivariable models, high ESR level (ESR ⩾ 20 mm/h) over time remained significantly associated with a higher risk of developing CV events. Conclusion Increased inflammatory burden as reflected by elevated ESR levels (ESR ⩾ 20) was associated with increased risk of CVE, while the use of NSAIDs and DMARDs were not.
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Affiliation(s)
- Lin-Hong Shi
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Steven H Lam
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ho So
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Edmund K Li
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tena K Li
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cheuk-Chun Szeto
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, New Territories 999077, Hong Kong
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14
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Chu JH, Michos ED, Ouyang P, Vaidya D, Blumenthal RS, Budoff MJ, Blaha MJ, Whelton SP. Coronary artery calcium and atherosclerotic cardiovascular disease risk in women with early menopause: The Multi-Ethnic Study of Atherosclerosis (MESA). Am J Prev Cardiol 2022; 11:100362. [PMID: 35769201 PMCID: PMC9234594 DOI: 10.1016/j.ajpc.2022.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/13/2022] [Accepted: 06/05/2022] [Indexed: 11/26/2022] Open
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15
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Persistence of C-reactive protein increased levels and high disease activity are predictors of cardiovascular disease in patients with axial spondyloarthritis. Sci Rep 2022; 12:7498. [PMID: 35525861 PMCID: PMC9079083 DOI: 10.1038/s41598-022-11640-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 04/13/2022] [Indexed: 01/03/2023] Open
Abstract
An accurate prediction of cardiovascular (CV) risk in patients with Axial Spondyloarthritis (axSpA) is a strong unmet need, as CV risk algorithms poorly perform in these subjects. The aim of this study was to establish whether the persistence of high C-reactive protein (CRP) and high disease activity may be considered predictive factors of CVD in axSpA. 295 patients without personal history of CVD, were consecutively enrolled in this study. To evaluate the relationship between CV events occurrence (fatal and non-fatal) and the persistence of increased CRP levels, ASDAS (Ankylosing Spondylitis Disease Activity Score) > 2.1, and BASDAI (Bath Ankylosing Spondylitis Disease Activity) > 4 during the follow-up, univariable and multivariable Cox Proportional Hazard Models have been performed. During follow-up (we analyzed 10-years retrospective data), 23 patients had a CV event. Multivariable Cox Proportional Hazard Models showed a strong association between CV event and the persistency of increased CRP levels (namely, percentage of visits in which CRP levels were increased) (HR = 1.03; 95%CI 1.015-1.045; p < 0.001), of ASDAS > 2.1 (HR = 1.014, 95%CI 1.000-1.028, p = 0.047), and of BASDAI > 4 (HR 1.019, 95%CI 1.006-1.033, p = 0.006) during follow-up, after adjustment for age, sex, and diabetes. This study suggests that persistence of increased CRP levels and high disease activity may be considered biomarkers to identify those axSpA patients at higher risk of CVD. Innovative axSpA-specific CV risk score, including these variables, have to be developed.
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16
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Yagensky V, Schirmer M. Cardiovascular Risks and Risk Stratification in Inflammatory Joint Diseases: A Cross-Sectional Study. Front Med (Lausanne) 2022; 9:786776. [PMID: 35280915 PMCID: PMC8904360 DOI: 10.3389/fmed.2022.786776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background It is well established that patients with inflammatory joint diseases (IJD) have an increased cardiovascular (CV) mortality and morbidity. According to the 2016 EULAR recommendations on CV risk management, rheumatologists should ensure appropriate management of CV risk in rheumatoid arthritis (RA) and other IJDs. The aim was to assess the CV risk and CV disease in Middle-European patients with IJD. Methods A retrospective chart review was performed for CV risk factors and CV disease in outpatients of a rheumatology outpatient clinic. CV risk was assessed according to the 2016 European Guidelines on CV disease prevention and also using 2 other approaches to compare the results with data from Norwegian and Spanish cohorts. Results Out of 432 patients, the prevalence of CV disease reached from 8.7% in spondyloarthritis (SpA) and 12.8% in psoriatic arthritis (PsA) to 18.7% in patients with RA. The number of CV risk factors did not differ between patients with RA, SpA, PsA, and non-inflammatory rheumatic disease (NIRD) (with 1.68 ± 0.13, 1.70 ± 0.13, 2.04 ± 0.16, and 1.78 ± 0.34, respectively). CV risk assessment could be performed in 82 patients after exclusion because of missing data and age. Stratification according to ESC guidelines showed low in 50%, moderate in 12.2%, high in 20.7%, and very high CV risk in 17.1% of patients aged between 40 and 65 years. CV risk in the Middle-European patients with IJD was higher than in the German general population (p = 0.004), and similar to the Norwegian patients with IJD, although patients with Middle-European PsA were at higher risk than the Norwegian patients (p = 0.045). Compared to the Spanish patients, Middle-European patients with IJD were more likely assigned to the high- to a very high-risk group (34.2 vs. 16.2%, p < 0.001), especially in RA disease (49.1 vs. 21%, respectively, p < 0.001). Discussion High prevalence of established CV disease together with high CV risk in patients with IJD urges for increased vigilance for CV risk factors followed by appropriate interaction by the treating physicians. The prospective use of an international CV risk assessment tool will allow not only estimation of the individual CV risk but also provide data for direct comparisons with the general population and other international cohorts.
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Affiliation(s)
| | - Michael Schirmer
- Department of Internal Medicine, Clinic II, Medical University of Innsbruck, Innsbruck, Austria
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17
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Cardiovascular Risk Prediction Parameters for Better Management in Rheumatic Diseases. Healthcare (Basel) 2022; 10:healthcare10020312. [PMID: 35206926 PMCID: PMC8872463 DOI: 10.3390/healthcare10020312] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 12/30/2022] Open
Abstract
The early detection of cardiovascular disease (CVD) serves as a key element in preventive cardiology. The risk of developing CVD in patients with rheumatic disease is higher than that of the general population. Thus, the objective of this narrative review was to assess and describe updated risk-prediction parameters for CVD in patients suffering from rheumatic diseases, and, additionally, to evaluate therapeutic and risk management possibilities. The processes of recognizing CVD risk factors in rheumatic diseases, establishing diagnoses, and discovering CV risk assessments are currently displeasing in clinical practice; they have a limited clinical impact. A large number of references were found while screening PUBMED, Scopus, and Google scholar databases; the 47 most relevant references were utilized to build up this study. The selection was limited to English language full text articles, RCTs, and reviews published between 2011 and 2021. Multiple imaging techniques, such as ECG, ultrasound, and cIMT, as well as biomarkers like osteoprotegerin cytokine receptor and angiopoietin-2, can be beneficial in both CV risk prediction and in early subclinical diagnosis. Physical exercise is an essential non-pharmacological intervention that can maintain the health of the cardiovascular system and, additionally, influence the underlying disease. Lipid-lowering drugs (methotrexate from the non-biologic DMARDs family as well as biologic DMARDs such as anti-TNF) were all associated with a lower CV risk; however, anti-TNF medication can decrease cardiac compliance and promote heart failure in patients with previously diagnosed chronic HF. Although they achieved success rates in reducing inflammation, glucocorticoids, NSAIDs, and COX-2 inhibitors were correlated with an increased risk of CVD. When taking all of the aforementioned points into consideration, there appears to be a dire need to establish and implement CVD risk stratification models in rheumatic patients.
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18
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Cacciapaglia F, Spinelli FR, Piga M, Erre GL, Sakellariou G, Manfredi A, Viapiana O, Fornaro M, Colella S, Floris A, Mangoni AA, Castagna F, Vacchi C, Orsolini G, Bugatti S, Cafaro G, Cauli A, Gremese E, Atzeni F, Bartoloni E. Estimated 10-year cardiovascular risk in a large Italian cohort of rheumatoid arthritis patients: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group. Eur J Intern Med 2022; 96:60-65. [PMID: 34657778 DOI: 10.1016/j.ejim.2021.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several cardiovascular (CV) risk algorithms are available to predict CV events in the general population. However, their performance in patients with rheumatoid arthritis (RA) might differ from the general population. This cross-sectional multicentre study aimed to estimate the 10-year CV risk using two different algorithms in a large RA cohort and in patients with osteoarthritis (OA). METHODS In a consecutive series of RA patients and matched OA controls without prior CV events, clinical and serologic data and traditional CV risk factors were recorded. The 10-year CV risk was assessed with the Systematic COronary Risk Evaluation (SCORE) and the "Progetto Cuore" algorithms. RESULTS 1,467 RA patients and 342 OA subjects were included. RA patients were more frequently diabetic (9.9% vs 6.4%; p=0.04) and smokers (20.4% vs 12.5%; p=0.002) but had lower prevalence of obesity (15% vs 21%; p=0.003). Dyslipidaemia was more prevalent in OA (32.5% vs 21.7%; p<0.0001). The 10-year estimated CV risk was 1.6% (95%CI 1.3-1.9) in RA and 1.4% (95%CI 1.3-1.6) in OA (p=0.002) according to SCORE and 6.5% (95%CI 6.1-6.9) in RA and 4.4% (95%CI 3.9-5.1) in OA (p<0.001) according to "Progetto Cuore". Regardless of the score used, RA patients had a 3- to-4-fold increased 10-year risk of CV events compared to OA subjects. CONCLUSION RA patients have a significantly higher 10-year risk of CV events than OA subjects. In addition to effective disease control and joint damage prevention, specific protective measures targeting modifiable traditional CV risk factors should be implemented in RA.
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Affiliation(s)
- Fabio Cacciapaglia
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy.
| | - Francesca Romana Spinelli
- Dipartimento di Medicina Interna e Specialità Mediche - Reumatologia, Università degli Studi di Roma La Sapienza, Roma, Italy
| | - Matteo Piga
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Gian Luca Erre
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Garifallia Sakellariou
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Andreina Manfredi
- Rheumatology Unit, Azienda Ospedaliera Universitaria Policlinico of Modena, Modena, Italy
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Marco Fornaro
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy
| | - Sergio Colella
- Rheumatology Unit - Department of Emergency Medicine and Transplantation (DETO), Università degli Studi di Bari Facoltà di Medicina e Chirurgia, Bari, Puglia, Italy
| | - Alberto Floris
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Arduino Aleksander Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Floriana Castagna
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Caterina Vacchi
- Rheumatology Unit, Azienda Ospedaliera Universitaria Policlinico of Modena, Modena, Italy
| | - Giovanni Orsolini
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Serena Bugatti
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giacomo Cafaro
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alberto Cauli
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari, University Clinic AOU, Cagliari, Italy
| | - Elisa Gremese
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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19
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Choi HK, McCormick N, Yokose C. Excess comorbidities in gout: the causal paradigm and pleiotropic approaches to care. Nat Rev Rheumatol 2022; 18:97-111. [PMID: 34921301 DOI: 10.1038/s41584-021-00725-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 02/07/2023]
Abstract
Gout is a common hyperuricaemic metabolic condition that leads to painful inflammatory arthritis and a high comorbidity burden, especially cardiometabolic-renal (CMR) conditions, including hypertension, myocardial infarction, stroke, obesity, hyperlipidaemia, type 2 diabetes mellitus and chronic kidney disease. Substantial advances have been made in our understanding of the excess CMR burden in gout, ranging from pathogenesis underlying excess CMR comorbidities, inferring causal relationships from Mendelian randomization studies, and potentially discovering urate crystals in coronary arteries using advanced imaging, to clinical trials and observational studies. Despite many studies finding an independent association between blood urate levels and risk of incident CMR events, Mendelian randomization studies have largely found that serum urate is not causal for CMR end points or intermediate risk factors or outcomes (such as kidney function, adiposity, metabolic syndrome, glycaemic traits or blood lipid concentrations). Although limited, randomized controlled trials to date in adults without gout support this conclusion. If imaging studies suggesting that monosodium urate crystals are deposited in coronary plaques in patients with gout are confirmed, it is possible that these crystals might have a role in the inflammatory pathogenesis of increased cardiovascular risk in patients with gout; removing monosodium urate crystals or blocking the inflammatory pathway could reduce this excess risk. Accordingly, data for CMR outcomes with these urate-lowering or anti-inflammatory therapies in patients with gout are needed. In the meantime, highly pleiotropic CMR and urate-lowering benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors and key lifestyle measures could play an important role in comorbidity care, in conjunction with effective gout care based on target serum urate concentrations according to the latest guidelines.
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Affiliation(s)
- Hyon K Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA.
- Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Arthritis Research Canada, Vancouver, British Columbia, Canada.
| | - Natalie McCormick
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Chio Yokose
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Liao KP, Huang J, He Z, Cremone G, Lam E, Hainer JM, Morgan V, Bibbo C, Di Carli M. Coronary Microvascular Dysfunction in Rheumatoid Arthritis Compared to Diabetes Mellitus and Association With All-Cause Mortality. Arthritis Care Res (Hoboken) 2021; 73:159-165. [PMID: 31705724 DOI: 10.1002/acr.24108] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) is a predictor of cardiac death in diabetes mellitus (DM) independent of traditional cardiovascular (CV) risk factors. Rheumatoid arthritis (RA) is a chronic inflammatory condition, with excess CV risk compared to the general population, in which CMD is hypothesized to play a role; however, there are limited data on CMD in RA and any association with clinical outcomes. The objective of this study was to compare the prevalence of CMD in RA to that in DM and to test the association with all-cause mortality. METHODS We performed a retrospective cohort study using data from a registry of all patients undergoing stress myocardial perfusion positron emission tomography as part of routine clinical care from 2006 to 2017. The inclusion criterion was a normal perfusion scan. Patients with RA or DM were classified using previously published approaches. Coronary flow reserve (CFR) was calculated for all patients in the registry and linked with mortality data. CMD was defined as CFR <2.0. RESULTS We studied 73 patients with RA and 441 patients with DM. Among patients with a normal perfusion scan, the prevalence of CMD in RA was similar to that in DM (P = 0.2). CMD was associated with increased risk for all-cause mortality in RA (hazard ratio 2.4 [95% confidence interval 1.4-4.2]) as well as increased risk for cardiac-related death at rates similar to those in DM. CONCLUSION These findings suggest an important role for CMD as a potential contributor to excess CV risk and mortality in RA, as previously observed in DM, as well as evidence for a mechanistic link between inflammation and cardiovascular disease.
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Affiliation(s)
| | - Jie Huang
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Zeling He
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Ethan Lam
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Jon M Hainer
- Brigham and Women's Hospital, Boston, Massachusetts
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21
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Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis. Biomolecules 2021; 11:biom11010081. [PMID: 33435178 PMCID: PMC7827097 DOI: 10.3390/biom11010081] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/06/2020] [Accepted: 01/08/2021] [Indexed: 12/15/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease that affects about 1% of the global population, with a female–male ratio of 3:1. RA preferably affects the joints, with consequent joint swelling and deformities followed by ankylosis. However, evidence has accumulated showing that patients suffering from RA can also develop extra-articular manifestations, including cardiovascular disease states, neuropathies, and multiorgan dysfunction. In particular, peripheral nerve disorders showed a consistent impact in the course of the disease (prevalence about 20%) mostly associated to vasculitis of the nerve vessels leading to vascular ischemia, axonal degeneration, and neuronal demyelination. The pathophysiological basis of this RA-associated microvascular disease, which leads to impairment of assonal functionality, is still to be better clarified. However, endothelial dysfunction and alterations of the so-called brain-nerve barrier (BNB) seem to play a fundamental role. This review aims to assess the potential mechanisms underlying the impairment of endothelial cell functionality in the development of RA and to identify the role of dysfunctional endothelium as a causative mechanism of extra-articular manifestation of RA. On the other hand, the potential impact of lifestyle and nutritional interventions targeting the maintenance of endothelial cell integrity in patients with RA will be discussed as a potential option when approaching therapeutic solutions in the course of the disease.
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22
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Rohrich DC, van de Wetering EHM, Rennings AJ, Arts EE, Meek IL, den Broeder AA, Fransen J, Popa CD. Younger age and female gender are determinants of underestimated cardiovascular risk in rheumatoid arthritis patients: a prospective cohort study. Arthritis Res Ther 2021; 23:2. [PMID: 33397472 PMCID: PMC7784252 DOI: 10.1186/s13075-020-02384-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background Rheumatoid arthritis (RA) patients have an increased cardiovascular (CV) risk. Here, we aimed to investigate whether gender and age are contributing to the misclassification of CV risk in RA patients. Methods Prospectively collected data on cardiovascular risk factors and incident events from the Nijmegen inception cohort were analyzed, with up to 10 years follow-up. Original as well as the EULAR-modified (M)_SCORE algorithms were used to calculate CV risk. Patients were stratified in deciles according to predicted risk; the Hosmer-Lemeshow test was used to check concordance between observed and predicted risk, in subgroups of gender and age. Results There were 863 RA patients included with 128 incident CV events. When using SCORE in the whole group, there was evidence of a discrepancy between the predicted and observed CV risk (H-L test p < 0.003), mainly present in the female subgroup (H-L test p < 0.001). Interestingly, 36% of females who developed an event belonged to the low CV risk group, whereas this was just 10% in RA males. When analyzing the subgroups based on age, a discrepancy was present only in the youngest patients (H-L test p < 0.001 in patients < 55 years) consisting of an underestimation of CV risk (5.3% predicted vs. 8.0% observed). Similar results were obtained when the M_SCORE was applied. Conclusion CV risk is especially underestimated in female and younger RA patients. This suggests that modifying the weight for the female gender and/or younger age in currently used CV risk algorithms might improve their predictive value in RA, contributing to better CV risk management.
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Affiliation(s)
- Daphne C Rohrich
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands
| | - Eline H M van de Wetering
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Alexander J Rennings
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Elke E Arts
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Inger L Meek
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands
| | - Jaap Fransen
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Calin D Popa
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands. .,Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands.
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23
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Increased short-term risk of cardiovascular events in inflammatory rheumatic diseases: results from a population-based cohort. Rheumatol Int 2021; 41:311-318. [PMID: 33388968 DOI: 10.1007/s00296-020-04754-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
Cardiovascular diseases represent the first cause of death globally. Inflammatory rheumatic disease (IRMD) patients, due to their lifelong inflammatory status, are at increased risk of developing premature cardiovascular disease. We aimed to assess the risk for cardiovascular events (CVE) in a population-based study. We followed 10,153 adults from the EpiDoC Cohort, a large Portuguese population-based prospective study (2011-2016). IRMD patients were identified at baseline and followed during 5 years. CVE were defined as a composite of self-reported myocardial infarction or angina pectoris, arrhythmias, valvular disease, stroke or transient ischemic attack and peripheral artery disease. Statistical analysis was performed by utilizing multivariate logistic regression and goodness-of-fit and area under ROC curve. At baseline, IRMD patients had similar age as the non-IRMD participants (mean age 55 vs 53 years-old; 72.1% female); dyslipidaemia and sedentary lifestyle were more common (40.7% vs 31.4%, p = 0.033; 87.3% vs 67%, p = 0.016, respectively). During an average follow-up of 2.6 years, 26 CVE were reported among IRMD patients. IRMD patients had higher odd of CVE (OR 1.64, 95% CI 1.04-2.58; p = 0.03), despite comparable mortality rates (1.7% vs 0.7%, p = 0.806). A stepwise approach attained that gender, age, history of hypertension, body mass index, IRMD and follow-up time are the most important predictive variables of CVE (AUC 0.80). IRMD patients, at community level, have an increased short-term risk of major CVE when compared to non-IRMD, and that highlights the potential benefit of a systematic screening and more aggressive cardiovascular risk assessment and management of these patients.
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24
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Navarini L, Caso F, Costa L, Currado D, Stola L, Perrotta F, Delfino L, Sperti M, Deriu MA, Ruscitti P, Pavlych V, Corrado A, Di Benedetto G, Tasso M, Ciccozzi M, Laudisio A, Lunardi C, Cantatore FP, Lubrano E, Giacomelli R, Scarpa R, Afeltra A. Cardiovascular Risk Prediction in Ankylosing Spondylitis: From Traditional Scores to Machine Learning Assessment. Rheumatol Ther 2020; 7:867-882. [PMID: 32939675 PMCID: PMC7695785 DOI: 10.1007/s40744-020-00233-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The performance of seven cardiovascular (CV) risk algorithms is evaluated in a multicentric cohort of ankylosing spondylitis (AS) patients. Performance and calibration of traditional CV predictors have been compared with the novel paradigm of machine learning (ML). METHODS A retrospective analysis of prospectively collected data from an AS cohort has been performed. The primary outcome was the first CV event. The discriminatory ability of the algorithms was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), which is like the concordance-statistic (c-statistic). Three ML techniques were considered to calculate the CV risk: support vector machine (SVM), random forest (RF), and k-nearest neighbor (KNN). RESULTS Of 133 AS patients enrolled, 18 had a CV event. c-statistic scores of 0.71, 0.61, 0.66, 0.68, 0.66, 0.72, and 0.67 were found, respectively, for SCORE, CUORE, FRS, QRISK2, QRISK3, RRS, and ASSIGN. AUC values for the ML algorithms were: 0.70 for SVM, 0.73 for RF, and 0.64 for KNN. Feature analysis showed that C-reactive protein (CRP) has the highest importance, while SBP and hypertension treatment have lower importance. CONCLUSIONS All of the evaluated CV risk algorithms exhibit a poor discriminative ability, except for RRS and SCORE, which showed a fair performance. For the first time, we demonstrated that AS patients do not show the traditional ones used by CV scores and that the most important variable is CRP. The present study contributes to a deeper understanding of CV risk in AS, allowing the development of innovative CV risk patient-specific models.
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Affiliation(s)
- Luca Navarini
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Francesco Caso
- Rheumatology Unit, Department of Clinical Medicine and Surgery, School of Medicine, University Federico II of Naples, Naples, Italy.
| | - Luisa Costa
- Rheumatology Unit, Department of Clinical Medicine and Surgery, School of Medicine, University Federico II of Naples, Naples, Italy
| | - Damiano Currado
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Liliana Stola
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Fabio Perrotta
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | | | - Michela Sperti
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Marco A Deriu
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Aquila, Italy
| | - Viktoriya Pavlych
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Aquila, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giacomo Di Benedetto
- 7HC, srl. Via Giovanni Paisiello 55 CAP 00198, Rome, Italy
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cadiz, Spain
| | - Marco Tasso
- Rheumatology Unit, Department of Clinical Medicine and Surgery, School of Medicine, University Federico II of Naples, Naples, Italy
| | - Massimo Ciccozzi
- Unit of Clinical Laboratory Science, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Alice Laudisio
- Unit of Geriatrics, Department of Medicine, Università Campus Bio-Medico di Roma, Roma, Italy
| | | | - Francesco Paolo Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ennio Lubrano
- Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Italy
| | - Roberto Giacomelli
- Rheumatology Unit, Department of Clinical Medicine and Surgery, School of Medicine, University Federico II of Naples, Naples, Italy
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Aquila, Italy
| | | | - Antonella Afeltra
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
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Jamthikar AD, Gupta D, Saba L, Khanna NN, Viskovic K, Mavrogeni S, Laird JR, Sattar N, Johri AM, Pareek G, Miner M, Sfikakis PP, Protogerou A, Viswanathan V, Sharma A, Kitas GD, Nicolaides A, Kolluri R, Suri JS. Artificial intelligence framework for predictive cardiovascular and stroke risk assessment models: A narrative review of integrated approaches using carotid ultrasound. Comput Biol Med 2020; 126:104043. [PMID: 33065389 DOI: 10.1016/j.compbiomed.2020.104043] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/10/2020] [Accepted: 10/04/2020] [Indexed: 12/12/2022]
Abstract
RECENT FINDINGS Cardiovascular disease (CVD) is the leading cause of mortality and poses challenges for healthcare providers globally. Risk-based approaches for the management of CVD are becoming popular for recommending treatment plans for asymptomatic individuals. Several conventional predictive CVD risk models based do not provide an accurate CVD risk assessment for patients with different baseline risk profiles. Artificial intelligence (AI) algorithms have changed the landscape of CVD risk assessment and demonstrated a better performance when compared against conventional models, mainly due to its ability to handle the input nonlinear variations. Further, it has the flexibility to add risk factors derived from medical imaging modalities that image the morphology of the plaque. The integration of noninvasive carotid ultrasound image-based phenotypes with conventional risk factors in the AI framework has further provided stronger power for CVD risk prediction, so-called "integrated predictive CVD risk models." PURPOSE of the review: The objective of this review is (i) to understand several aspects in the development of predictive CVD risk models, (ii) to explore current conventional predictive risk models and their successes and challenges, and (iii) to refine the search for predictive CVD risk models using noninvasive carotid ultrasound as an exemplar in the artificial intelligence-based framework. CONCLUSION Conventional predictive CVD risk models are suboptimal and could be improved. This review examines the potential to include more noninvasive image-based phenotypes in the CVD risk assessment using powerful AI-based strategies.
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Affiliation(s)
- Ankush D Jamthikar
- Department of Electronics and Communication Engineering, Visvesvaraya National Institute of Technology, Nagpur, Maharashtra, India
| | - Deep Gupta
- Department of Electronics and Communication Engineering, Visvesvaraya National Institute of Technology, Nagpur, Maharashtra, India
| | - Luca Saba
- Department of Radiology, University of Cagliari, Italy
| | - Narendra N Khanna
- Department of Cardiology, Indraprastha APOLLO Hospitals, New Delhi, India
| | - Klaudija Viskovic
- Department of Radiology and Ultrasound, University Hospital for Infectious Diseases, Croatia
| | - Sophie Mavrogeni
- Cardiology Clinic, Onassis Cardiac Surgery Center, Athens, Greece
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St Helena, CA, USA
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Scotland, UK
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Gyan Pareek
- Minimally Invasive Urology Institute, Brown University, Providence, RI, USA
| | - Martin Miner
- Men's Health Center, Miriam Hospital Providence, Rhode Island, USA
| | - Petros P Sfikakis
- Rheumatology Unit, National Kapodistrian University of Athens, Greece
| | - Athanasios Protogerou
- Department of Cardiovascular Prevention & Research Unit Clinic & Laboratory of Pathophysiology, National and Kapodistrian Univ. of Athens, Greece
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Professor M Viswanathan Diabetes Research Centre, Chennai, India
| | - Aditya Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - George D Kitas
- R & D Academic Affairs, Dudley Group NHS Foundation Trust, Dudley, United Kingdom
| | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre and University of Nicosia Medical School, Nicosia, Cyprus
| | | | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA.
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26
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Fernández-Ortiz AM, Ortiz AM, Pérez S, Toledano E, Abásolo L, González-Gay MA, Castañeda S, González-Álvaro I. Effects of disease activity on lipoprotein levels in patients with early arthritis: can oxidized LDL cholesterol explain the lipid paradox theory? Arthritis Res Ther 2020; 22:213. [PMID: 32917272 PMCID: PMC7488761 DOI: 10.1186/s13075-020-02307-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
Background An increased risk of cardiovascular (CV) complications has been described in patients with rheumatoid arthritis (RA). It is the result of the combined effect of classic CV risk factors and others that are specific to the disease. Methods We assessed data from 448 early arthritis (EA) patients: 79% women, age (median [p25-p75]) at onset: 55 [44–67] years and disease duration at study entry 5 [3–8] months; and 72% fulfilled the 1987 RA criteria at 2 years of follow-up. Rheumatoid factor was positive in 54% of patients and anti-citrullinated peptide antibodies in 50%. The follow-up of patients ranged from 2 to 5 years with more than 1400 visits with lipoprotein measurements available (mean 2.5 visits/patient). Demographic- and disease-related variables were systematically recorded. Total cholesterol (TC), high-density lipoprotein (HDL-C), and low-density lipoprotein (LDL-C) levels were obtained from routine laboratory tests. Oxidized-LDL (oxLDL-C) levels were assessed using a commercial ELISA kit. We fitted population-averaged models nested by patient and visit to determine the effect of independent variables on serum levels of TC, its fractions, and oxLDL-C. Results After adjustment for several confounders, high-disease activity was significantly associated with decreased TC, HDL-C, and LDL-C levels and increased oxLDL-C levels. Standardized coefficients showed that the effect of disease activity was greater on oxLDL-C and HDL-C. Interestingly, we observed that those patients with lower levels of LDL-C showed higher oxLDL-C/LDL-C ratios. Conclusions High-disease activity in EA patients results in changes in the HDL-C and oxLDL-C levels, which in turn may contribute to the increased risk of CV disease observed in these patients.
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Affiliation(s)
| | - Ana M Ortiz
- Rheumatology Division, Hospital Universitario La Princesa, IIS-IP, Diego de León 62, 28006, Madrid, Spain
| | - Silvia Pérez
- Rheumatology Division, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Esther Toledano
- Rheumatology Division, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Lydia Abásolo
- Rheumatology Division, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Miguel A González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander, Spain
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario La Princesa, IIS-IP, Diego de León 62, 28006, Madrid, Spain.,Cátedra UAM-Roche, EPID-Future, Universidad Autónoma Madrid, Madrid, Spain
| | - Isidoro González-Álvaro
- Rheumatology Division, Hospital Universitario La Princesa, IIS-IP, Diego de León 62, 28006, Madrid, Spain.
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27
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Jamthikar AD, Gupta D, Puvvula A, Johri AM, Khanna NN, Saba L, Mavrogeni S, Laird JR, Pareek G, Miner M, Sfikakis PP, Protogerou A, Kitas GD, Kolluri R, Sharma AM, Viswanathan V, Rathore VS, Suri JS. Cardiovascular risk assessment in patients with rheumatoid arthritis using carotid ultrasound B-mode imaging. Rheumatol Int 2020; 40:1921-1939. [PMID: 32857281 PMCID: PMC7453675 DOI: 10.1007/s00296-020-04691-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/18/2020] [Indexed: 12/18/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease that affects synovial joints and has various extra-articular manifestations, including atherosclerotic cardiovascular disease (CVD). Patients with RA experience a higher risk of CVD, leading to increased morbidity and mortality. Inflammation is a common phenomenon in RA and CVD. The pathophysiological association between these diseases is still not clear, and, thus, the risk assessment and detection of CVD in such patients is of clinical importance. Recently, artificial intelligence (AI) has gained prominence in advancing healthcare and, therefore, may further help to investigate the RA-CVD association. There are three aims of this review: (1) to summarize the three pathophysiological pathways that link RA to CVD; (2) to identify several traditional and carotid ultrasound image-based CVD risk calculators useful for RA patients, and (3) to understand the role of artificial intelligence in CVD risk assessment in RA patients. Our search strategy involves extensively searches in PubMed and Web of Science databases using search terms associated with CVD risk assessment in RA patients. A total of 120 peer-reviewed articles were screened for this review. We conclude that (a) two of the three pathways directly affect the atherosclerotic process, leading to heart injury, (b) carotid ultrasound image-based calculators have shown superior performance compared with conventional calculators, and (c) AI-based technologies in CVD risk assessment in RA patients are aggressively being adapted for routine practice of RA patients.
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Affiliation(s)
- Ankush D Jamthikar
- Department of Electronics and Communications Engineering, Visvesvaraya National Institute of Technology, Nagpur, MH, India
| | - Deep Gupta
- Department of Electronics and Communications Engineering, Visvesvaraya National Institute of Technology, Nagpur, MH, India
| | | | - Amer M Johri
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, ON, Canada
| | - Narendra N Khanna
- Department of Cardiology, Indraprastha APOLLO Hospitals, New Delhi, India
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
| | - Sophie Mavrogeni
- Cardiology Clinic, Onassis Cardiac Surgery Center, Athens, Greece
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St Helena, CA, USA
| | - Gyan Pareek
- Minimally Invasive Urology Institute, Brown University, Providence, RI, USA
| | - Martin Miner
- Men's Health Center, Miriam Hospital, Providence, RI, USA
| | - Petros P Sfikakis
- Rheumatology Unit, National Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Protogerou
- Department of Cardiovascular Prevention, National and Kapodistrian University of Athens, Athens, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Dudley, UK
| | | | - Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Professor M Viswanathan Diabetes Research Centre, Chennai, India
| | - Vijay S Rathore
- Nephrology Department, Kaiser Permanente, Sacramento, CA, USA
| | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, 95661, USA.
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28
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Lam SHM, Cheng IT, Li EK, Wong P, Lee J, Yip RML, Yim CW, Ying SK, Li M, Li TK, Lee APW, Tam LS. DAPSA, carotid plaque and cardiovascular events in psoriatic arthritis: a longitudinal study. Ann Rheum Dis 2020; 79:1320-1326. [PMID: 32737113 DOI: 10.1136/annrheumdis-2020-217595] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine whether Disease Activity in Psoriatic Arthritis (DAPSA) reflecting the inflammatory component of psoriatic arthritis (PsA) can predict cardiovascular (CV) events independent of traditional CV risk factors and subclinical carotid atherosclerosis. METHODS A cohort analysis was performed in patients with PsA who had been followed since 2006. The outcome of interest was first CV event. Four different CV disease (CVD) risk scores and DAPSA were computed at baseline. The presence of carotid plaque (CP) and carotid intima-media thickness (CIMT) was also determined in a subgroup of patients using high-resolution ultrasound. The association between DAPSA, CVD risk scores, CP, CIMT and the occurrence of CV events was assessed using Cox proportional hazard models. RESULTS 189 patients with PsA (mean age: 48.9 years; male: 104 (55.0%)) were recruited. After a median follow-up of 9.9 years, 27 (14.3%) patients developed a CV event. Higher DAPSA was significantly associated with an increased risk of developing CV events (HR: 1.04, 95% CI (1.01 to 1.08), p=0.009). The association remained significant after adjusting for all CV risk scores in the multivariable models. In the subgroup analysis, 154 patients underwent carotid ultrasound assessment and 23 (14.9%) of them experienced a CV event. CP was associated with increased risk of developing CV events after adjusting for three CV risk scores and DAPSA, with HR ranging from 2.35 to 3.42. CONCLUSION Higher DAPSA and the presence of CP could independently predict CVD events in addition to traditional CV risk scores in patients with PsA.
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Affiliation(s)
- Steven Ho Man Lam
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Isaac T Cheng
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Edmund K Li
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Priscilla Wong
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jolie Lee
- Department of Medicine and Geriatrics, Tai Po Hospital, Hong Kong, Hong Kong
| | - Ronald Man-Lung Yip
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong, Hong Kong
| | - Cheuk-Wan Yim
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong, Hong Kong
| | - Shirley K Ying
- Department of Medicine, Princess Margaret Hospital, Hong Kong, China
| | - Martin Li
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Tena K Li
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Alex Pui-Wai Lee
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lai-Shan Tam
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, New Territories, Hong Kong
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Cardiovascular Events Risk Factors in Patients with Rheumatoid Arthritis. Fam Med 2020. [DOI: 10.30841/2307-5112.3.2020.211397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Björsenius I, Rantapää-Dahlqvist S, Berglin E, Södergren A. Extent of atherosclerosis after 11-year prospective follow-up in patients with early rheumatoid arthritis was affected by disease severity at diagnosis. Scand J Rheumatol 2020; 49:443-451. [PMID: 32691642 DOI: 10.1080/03009742.2020.1767200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Cardiovascular disease (CVD) is increased among patients with rheumatoid arthritis (RA). The underlying cause is not clear. In this prospective study, patients with early RA were investigated for associations between subclinical atherosclerosis and CVD risk factors as well as inflammation. Method: At diagnosis, RA patients were recruited into a prospective study. A subgroup was included (n = 55) for ultrasound measurements of intima-media thickness (IMT) at inclusion (T0), and after 5 years (T5) and 11 years (T11). Thirty-one age and gender-matched controls were also included for comparison. Results: IMT increased significantly between T0 and T11 among patients and controls (p < 0.0001). No statistically significant differences in IMT between patients and controls were detected at T11, T5, or T0 (p > 0.05 for all). In simple regression models, IMT at T11 was significantly associated with age (p < 0.0001), as well as systolic blood pressure at T0 (p < 0.01) and T11 (p < 0.01) among RA patients. Furthermore, the composite Systematic COronary Risk Evaluation (SCORE) measurements (p < 0.0001) and Reynolds risk score (p < 0.01) and the radiographic Larsen score (p < 0.05) at T0 were all significantly associated with IMT at T11. Results from conditional logistic regression analysis showed an increased progression rate between T0 and T11 in the RA group compared with controls (p < 0.05). Conclusion: We found increased atherosclerotic development among patients with RA compared with controls 11 years after diagnosis. The atherosclerotic burden was associated with disease severity at baseline.
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Affiliation(s)
- I Björsenius
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University , Umeå, Sweden
| | - S Rantapää-Dahlqvist
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University , Umeå, Sweden
| | - E Berglin
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University , Umeå, Sweden
| | - A Södergren
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University , Umeå, Sweden.,Wallenberg Centre for Molecular Medicine (WCMM), Umeå University , Umeå, Sweden
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31
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Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol 2020; 16:361-379. [PMID: 32494054 DOI: 10.1038/s41584-020-0428-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Patients with rheumatoid arthritis (RA) are at high risk of developing cardiovascular disease (CVD). Inflammation has a pivotal role in the pathogenesis of CVD. RA is an inflammatory joint disease and, compared with the general population, patients with RA have approximately double the risk of atherosclerotic CVD, stroke, heart failure and atrial fibrillation. Although this high risk of CVD has been known for decades, patients with RA receive poorer primary and secondary CVD preventive care than other high-risk patients, and an unmet need exists for improved CVD preventive measures for patients with RA. This Review summarizes the evidence for atherosclerotic CVD in patients with RA and provides a contemporary analysis of what is known and what needs to be further clarified about recommendations for CVD prevention in patients with RA compared with the general population. The management of traditional CVD risk factors, including blood pressure, lipids, diabetes mellitus and lifestyle-related risk factors, as well as the effects of inflammation and the use of antirheumatic medication on CVD risk and risk management in patients with RA are discussed. The main aim is to provide a roadmap of atherosclerotic CVD risk management and prevention for patients with RA.
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Abstract
Adaptive as well as innate immune responses contribute to the development of atherosclerosis. Studies performed in experimental animals have revealed that some of these immune responses are protective while others contribute to the progression of disease. These observations suggest that it may be possible to develop novel therapies for cardiovascular disease by selectively modulating such atheroprotective and proatherogenic immunity. Recent advances in cancer treatment using immune check inhibitors and CAR (chimeric antigen receptor) T-cell therapy serve as excellent examples of the possibilities of targeting the immune system to combat disease. LDL (low-density lipoprotein) that has accumulated in the artery wall is a key autoantigen in atherosclerosis, and activation of antigen-specific T helper 1–type T cells is thought to fuel plaque inflammation. Studies aiming to prove this concept by immunizing experimental animals with oxidized LDL particles unexpectedly resulted in activation of atheroprotective immunity involving regulatory T cells. This prompted several research groups to try to develop vaccines against atherosclerosis. In this review, we will discuss the experimental and clinical data supporting the possibility of developing immune-based therapies for lowering cardiovascular risk. We will also summarize ongoing clinical studies and discuss the challenges associated with developing an effective and safe atherosclerosis vaccine.
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Affiliation(s)
- Jan Nilsson
- From the Department of Clinical Sciences Malmö, Lund University, Sweden (J.N.)
| | - Göran K. Hansson
- Department of Medicine, Karolinska University Hospital Solna, Karolinska Institute, Sweden (G.K.H.)
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Wibetoe G, Sexton J, Ikdahl E, Rollefstad S, Kitas GD, van Riel P, Gabriel S, Kvien TK, Douglas K, Sandoo A, Arts EE, Wållberg-Jonsson S, Dahlqvist SR, Karpouzas G, Dessein PH, Tsang L, El-Gabalawy H, Hitchon CA, Pascual-Ramos V, Contreas-Yañes I, Sfikakis PP, González-Gay MA, Colunga-Pedraz IJ, Galarza-Delgado DA, Azpiri-Lopez JR, Crowson CS, Semb AG. Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models. Arthritis Res Ther 2020; 22:90. [PMID: 32326974 PMCID: PMC7178602 DOI: 10.1186/s13075-020-02178-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/31/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. METHODS RA patients aged 30-70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusion criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. RESULTS A total of 1974 patients were included in the main analyses, and 144 events were observed during follow-up, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15-32% of patients. C-statistics ranged 0.68-0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. CONCLUSIONS The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive.
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Affiliation(s)
- Grunde Wibetoe
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway.
| | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Eirik Ikdahl
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
| | - Silvia Rollefstad
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
| | - George D Kitas
- School of Sport, Exercise and Rehabilitation, University of Birmingham, Birmingham, UK
- Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Piet van Riel
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sherine Gabriel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karen Douglas
- Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Aamer Sandoo
- Dudley Group NHS Foundation Trust, West Midlands, UK
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Elke E Arts
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | | | - George Karpouzas
- Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Patrick H Dessein
- Vrije Universiteit Brussel, Brussels, Belgium
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Linda Tsang
- Rheumatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | | | - Virginia Pascual-Ramos
- Instituto Nactional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Irazu Contreas-Yañes
- Instituto Nactional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Petros P Sfikakis
- First Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miguel A González-Gay
- Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, Santander, Spain
| | | | | | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anne Grete Semb
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
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DeMizio DJ, Geraldino-Pardilla LB. Autoimmunity and Inflammation Link to Cardiovascular Disease Risk in Rheumatoid Arthritis. Rheumatol Ther 2020; 7:19-33. [PMID: 31853784 PMCID: PMC7021876 DOI: 10.1007/s40744-019-00189-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) patients have a 50% increased risk of cardiovascular (CV)-related morbidity and mortality. This excess CV risk is closely linked to RA disease severity and chronic inflammation, hence is largely underestimated by traditional risk calculators such as the Framingham Risk Score. Epidemiological studies have shown that patients with RA are more likely to have silent ischemic heart disease, develop heart failure, and experience sudden death compared with controls. Elevations in pro-inflammatory cytokines, circulating autoantibodies, and specific T cell subsets, are believed to drive these findings by promoting atherosclerotic plaque formation and cardiac remodeling. Current European League Against Rheumatism (EULAR) guidelines state that rheumatologists are responsible for the assessment and coordination of CV disease (CVD) risk management in patients with RA, yet the optimal means to do so remain unclear. While these guidelines focus on disease activity control to mitigate excess CV risk, rather than providing a precise algorithm for choice of therapy, studies suggest a differential impact on CV risk of non-biologic disease-modifying anti-rheumatic drugs (DMARDs), biologic DMARDs, and small molecule-based therapy. In this review, we explore the mechanisms linking the pathophysiologic intrinsic features of RA with the increased CVD risk in this population, and the impact of different RA therapies on CV outcomes.
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Affiliation(s)
- Daniel J DeMizio
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Laura B Geraldino-Pardilla
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.
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35
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Wei T, Yang B, Liu H, Xin F, Fu L. Development and validation of a nomogram to predict coronary heart disease in patients with rheumatoid arthritis in northern China. Aging (Albany NY) 2020; 12:3190-3204. [PMID: 32112552 PMCID: PMC7066926 DOI: 10.18632/aging.102823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/27/2020] [Indexed: 01/31/2023]
Abstract
We developed and validated a nomogram to predict coronary heart disease (CHD) in patients with rheumatoid arthritis (RA) in northern China. We analyzed a cohort of RA patients admitted to the Department of Rheumatology and Immunology of the First Affiliated Hospital of China Medical University from 2011 to 2017. To select a high-performance model for clinical data prediction, we evaluated the F1-scores of six machine learning models. Based on the results, we selected multivariable logistic regression analysis for the development of a prediction model. We then generated an individualized prediction nomogram that included age, sex, hypertension, anti-cyclic citrullinated peptide antibody positivity, the erythrocyte sedimentation rate, and serum LDL-cholesterol, triglyceride and HDL-cholesterol levels. The prediction model exhibited better discrimination than the Framingham Risk Score in predicting CHD in RA patients. The area under the curve of the prediction model was 0.77, with a sensitivity of 63.9% and a specificity of 77.2%. The nomogram exhibited good calibration and clinical usefulness. In conclusion, our prediction model was more accurate than the Framingham Risk Score in predicting CHD in RA patients. Our nomogram combining various risk factors can be used for the individualized preoperative prediction of CHD in patients with RA.
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Affiliation(s)
- Tingting Wei
- Department of Clinical Epidemiology and Evidence-based Medicine, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Bowen Yang
- Department of Medical Record Management Center, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Haina Liu
- Department of Rheumatology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Fangran Xin
- Department of Clinical Epidemiology and Evidence-based Medicine, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Lingyu Fu
- Department of Clinical Epidemiology and Evidence-based Medicine, The First Affiliated Hospital, China Medical University, Shenyang, China.,Department of Medical Record Management Center, The First Affiliated Hospital, China Medical University, Shenyang, China
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36
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Ångström L, Hörnberg K, Sundström B, Jonsson SW, Södergren A. Aerobic capacity is associated with disease activity and cardiovascular risk factors in early rheumatoid arthritis. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 25:e1833. [PMID: 31913553 PMCID: PMC7378948 DOI: 10.1002/pri.1833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/12/2019] [Accepted: 12/13/2019] [Indexed: 12/21/2022]
Abstract
Objectives The aim of this study was to investigate aerobic capacity and its associations with disease activity and risk factors for cardiovascular disease (CVD) in early rheumatoid arthritis (RA). Methods This cross‐sectional study included 67 patients with early RA. Aerobic capacity was estimated with the Åstrand submaximal test adjusted according to the Nord‐Tröndelag Health Study formula. The following were also assessed: subclinical atherosclerosis by carotid intima‐media thickness and pulse wave analysis; body composition by dual X‐ray absorptiometry; estimated CVD mortality risk by the Systematic Coronary Risk Evaluation; disease activity by the Disease Activity Score 28, C‐reactive protein and erythrocyte sedimentation rate; blood lipids by total cholesterol, low‐density lipoproteins, high‐density lipoproteins, and triglycerides; and functional ability by the Stanford health assessment questionnaire. Univariate and multiple linear regression analyses were performed to explore the associations between variables. Results The mean (SD) aerobic capacity was 31.6 (8.7) ml O2−1 kg min−1. Disease activity and risk factors for CVD were more favourable for patients with aerobic capacity above the median value. Aerobic capacity was associated with ESR and several CVD risk factors, independent of age and sex. In a multiple regression model that was adjusted for age and sex, aerobic capacity was significantly associated with per cent body fat (β = −0.502, 95% CI [−0.671, −0.333]) and triglycerides (β = −2.365, 95% CI [−4.252, −0.479]). Conclusions Disease activity and risk factors for CVD were in favour for patients with a higher aerobic capacity. Aerobic capacity was associated with disease activity and several risk factors for CVD, independent of age and sex. In RA, these findings may provide insights into the benefits of using aerobic capacity as a marker to prevent CVD.
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Affiliation(s)
- Lars Ångström
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Kristina Hörnberg
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Björn Sundström
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | | | - Anna Södergren
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden
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de Thurah A, Andersen IT, Tinggaard AB, Riis AH, Therkildsen J, Bøtker HE, Bøttcher M, Hauge EM. Risk of major adverse cardiovascular events among patients with rheumatoid arthritis after initial CT-based diagnosis and treatment. RMD Open 2020; 6:e001113. [PMID: 31958282 PMCID: PMC6999677 DOI: 10.1136/rmdopen-2019-001113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is a known risk factor for developing coronary artery disease (CAD). The influence of RA on the prognosis after initial CAD diagnosis and treatment is however largely unknown. We examined the risk of major cardiovascular events among RA and non-RA patients with chest pain referred to cardiac CT. METHODS This was a follow-up study, using data from the Western Denmark Heart Registry, containing data on CT angiography examinations (Cardiac CT). Information on RA diagnosis and covariates were identified through nationwide administrative registers. The primary outcome was a combined outcome including, myocardial infarction, ischaemic or unspecified stroke, coronary artery bypass grafting, percutaneous coronary intervention, and all-cause mortality. Median time until events or censoring was 3.5 years (min/max: 0.0: 9.2). Cox proportional hazard models were used to examine the association between RA/non-RA patients and outcomes. RESULTS Among 42 257 patients, referred between 2008 and 2016, we identified 358 (0.8%) with RA. An increased risk was seen in RA compared with non-RA (adjusted HR 1.35, 95% CI 0.93 to 1.96). Among patients who had received flare treatment more than once prior to cardiac CT the adjusted HR 1.80 (95% CI 1.08 to 3.00), and among patients with seropositive RA the adjusted HR 1.42 (95% CI 0.93 to 2.16). CONCLUSION In patients referred to cardiac CT due to chest pain, we found a trend of an association between RA and the combined primary outcome, supporting that RA per se, but in particular seropositive and active RA, may increase the risk of CAD even after initial CAD diagnosis and treatment.
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Affiliation(s)
- Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital Skejby, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Anders Hammerich Riis
- Department of Clinical Epidemiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Hans Erik Bøtker
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital Skejby, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Castañeda S, Vicente-Rabaneda EF, García-Castañeda N, Prieto-Peña D, Dessein PH, González-Gay MA. Unmet needs in the management of cardiovascular risk in inflammatory joint diseases. Expert Rev Clin Immunol 2019; 16:23-36. [DOI: 10.1080/1744666x.2019.1699058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Santos Castañeda
- Rheumatology Division, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
- Department of Medicine, Cátedra UAM-ROCHE, EPID Future, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | | | | | - Diana Prieto-Peña
- Division and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Patrick H. Dessein
- Honorary Research Professor, School of Physiology and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Miguel A. González-Gay
- Division and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
- School of Medicine, University of Cantabria, Santander, Spain
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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High CRP Levels After Critical Illness are Associated With an Increased Risk of Rehospitalization. Shock 2019; 50:525-529. [PMID: 29438222 DOI: 10.1097/shk.0000000000001118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Chronic inflammation, even at subclinical levels, is associated with adverse long-term outcome. PATIENTS AND METHODS In this prospective, observational study, 66 critically ill patients surviving to hospital discharge were included. C-reactive protein (CRP) levels were determined at hospital discharge, 1, 2, and 6 weeks after hospital discharge. All the patients were repeatedly screened for adverse events resulting in rehospitalization or death for 1.5 years. RESULTS After hospital discharge, over two-thirds of the patients exhibited elevated CRP levels (>2.0 mg/L). During the first week, CRP decreased compared with hospital discharge (P < 0.001) but did not change after week 1 (P = 0.67). Age (P = 0.24), surgical status (P = 0.95), or sepsis (P = 0.77) did not influence the CRP course. The latter differed between patients with (n = 15) and without (n = 51) adverse events (P = 0.003). CRP levels of patients without adverse events persistently decreased after hospital discharge (P = 0.03), whereas those of patients with adverse events did not (P = 0.86) but rebounded early. CONCLUSIONS Plasma CRP levels in critically ill patients decreased during the first week after hospital discharge but remained unchanged during the subsequent 5 weeks. Over two-thirds of the patients exhibited elevated CRP levels compatible with chronic sub-clinical inflammation. Persistently elevated CRP levels after hospital discharge are associated with higher risk of rehospitalization.
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40
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Sobchak C, Akhtari S, Harvey P, Gladman D, Chandran V, Cook R, Eder L. Value of Carotid Ultrasound in Cardiovascular Risk Stratification in Patients With Psoriatic Disease. Arthritis Rheumatol 2019; 71:1651-1659. [PMID: 31165591 DOI: 10.1002/art.40925] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 05/07/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to assess whether subclinical atherosclerosis, as evaluated by carotid ultrasound, could predict incident cardiovascular events (CVEs) in patients with psoriatic disease (PsD) and determine whether incorporation of imaging data could improve CV risk prediction by the Framingham Risk Score (FRS). METHODS In this cohort analysis, patients with PsD underwent ultrasound assessment of the carotid arteries at baseline. The extent of atherosclerosis was assessed using carotid intima-media thickness (CIMT) and total plaque area (TPA). Incident CVEs (new or recurrent) that occurred following the ultrasound assessment were identified. The association between measures of carotid atherosclerosis and the risk of developing an incident CVE was evaluated using Cox proportional hazards models, with adjustment for the FRS. RESULTS In total, 559 patients with PsD were assessed, of whom 23 had incident CVEs ascertained. The calculated rate of developing a first CVE during the study period was 1.11 events per 100 patient-years (95% confidence interval [95% CI] 0.74-1.67). When analyzed separately in Cox proportional hazards models that were controlled for the FRS, the TPA (hazard ratio [HR] 3.74, 95% CI 1.55-8.85; P = 0.003), mean CIMT (HR 1.21, 95% CI 1.03-1.42; P = 0.02), maximal CIMT (HR 1.11, 95% CI 1.01-1.22; P = 0.03), and high TPA category (HR 3.25, 95% CI 1.18-8.95; P = 0.02) were each predictive of incident CVEs in patients with PsD. CONCLUSION The burden of carotid atherosclerosis is associated with an increased risk of developing future CVEs. Combining vascular imaging data with information on traditional CV risk factors could improve the accuracy of CV risk stratification in patients with PsD.
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Affiliation(s)
| | | | - Paula Harvey
- Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Dafna Gladman
- University of Toronto, Krembil Research Institute and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Vinod Chandran
- University of Toronto, Krembil Research Institute and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Richard Cook
- University of Waterloo, Waterloo, Ontario, Canada
| | - Lihi Eder
- Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
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Kitas GD, Nightingale P, Armitage J, Sattar N, Belch JJF, Symmons DPM. A Multicenter, Randomized, Placebo-Controlled Trial of Atorvastatin for the Primary Prevention of Cardiovascular Events in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2019; 71:1437-1449. [PMID: 30983166 PMCID: PMC6771601 DOI: 10.1002/art.40892] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/12/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with increased cardiovascular event (CVE) risk. The impact of statins in RA is not established. We assessed whether atorvastatin is superior to placebo for the primary prevention of CVEs in RA patients. METHODS A randomized, double-blind, placebo-controlled trial was designed to detect a 32% CVE risk reduction based on an estimated 1.6% per annum event rate with 80% power at P < 0.05. RA patients age >50 years or with a disease duration of >10 years who did not have clinical atherosclerosis, diabetes, or myopathy received atorvastatin 40 mg daily or matching placebo. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, transient ischemic attack, or any arterial revascularization. Secondary and tertiary end points included plasma lipids and safety. RESULTS A total of 3,002 patients (mean age 61 years; 74% female) were followed up for a median of 2.51 years (interquartile range [IQR] 1.90, 3.49 years) (7,827 patient-years). The study was terminated early due to a lower than expected event rate (0.70% per annum). Of the 1,504 patients receiving atorvastatin, 24 (1.6%) experienced a primary end point, compared with 36 (2.4%) of the 1,498 receiving placebo (hazard ratio [HR] 0.66 [95% confidence interval (95% CI) 0.39, 1.11]; P = 0.115 and adjusted HR 0.60 [95% CI 0.32, 1.15]; P = 0.127). At trial end, patients receiving atorvastatin had a mean ± SD low-density lipoprotein (LDL) cholesterol level 0.77 ± 0.04 mmoles/liter lower than those receiving placebo (P < 0.0001). C-reactive protein level was also significantly lower in the atorvastatin group than the placebo group (median 2.59 mg/liter [IQR 0.94, 6.08] versus 3.60 mg/liter [IQR 1.47, 7.49]; P < 0.0001). CVE risk reduction per mmole/liter reduction in LDL cholesterol was 42% (95% CI -14%, 70%). The rates of adverse events in the atorvastatin group (n = 298 [19.8%]) and placebo group (n = 292 [19.5%]) were similar. CONCLUSION Atorvastatin 40 mg daily is safe and results in a significantly greater reduction of LDL cholesterol level than placebo in patients with RA. The 34% CVE risk reduction is consistent with the Cholesterol Treatment Trialists' Collaboration meta-analysis of statin effects in other populations.
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Affiliation(s)
- George D. Kitas
- Dudley Group NHS Foundation Trust, Russells Hall Hospital, Stourbridge, UKand Research UK Centre for EpidemiologyManchesterUK
| | | | | | - Naveed Sattar
- University of Glasgow, Glasgow, UKand Oxford Centre for Diabetes, Endocrinology and MetabolismOxfordUK
| | - Jill J. F. Belch
- University of Dundee and Ninewells Hospital and Medical SchoolDundeeUK
| | - Deborah P. M. Symmons
- Arthritis Research UK Centre for Epidemiology, University of Manchesterand NIHR Manchester Biomedical Research CenterManchester NHS Foundation TrustManchesterUK
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Bordy R, Totoson P, Prati C, Marie C, Wendling D, Demougeot C. Microvascular endothelial dysfunction in rheumatoid arthritis. Nat Rev Rheumatol 2019; 14:404-420. [PMID: 29855620 DOI: 10.1038/s41584-018-0022-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The systemic autoimmune disease rheumatoid arthritis (RA) is characterized by increased cardiovascular mortality and morbidity and is an independent cardiovascular risk factor. Cardiovascular diseases (CVDs) result from accelerated atherogenesis, which is a consequence of endothelial dysfunction in the early stages of the disease. Endothelial dysfunction is a functional and reversible alteration of endothelial cells and leads to a shift in the properties of the endothelium towards reduced vasodilation, a pro-inflammatory state, and proliferative and prothrombotic properties. In RA, endothelial dysfunction can occur in the large vessels (such as the conduit arteries) and in the small vessels of the microvasculature, which supply oxygen and nutrients to the tissue and control inflammation, repair and fluid exchange with the surrounding tissues. Growing evidence suggests that microvascular endothelial dysfunction contributes to CVD development, as it precedes and predicts the development of conduit artery atherosclerosis and associated risk factors. As such, numerous studies have investigated microvascular endothelial dysfunction in RA, including its link with disease activity, disease duration and inflammation, the effect of treatments on endothelial function, and possible circulating biomarkers of microvascular endothelial dysfunction. Such findings could have important implications in the cardiovascular risk management of patients with RA.
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Affiliation(s)
- Romain Bordy
- PEPITE EA4267, FHU INCREASE, Universitaire Bourgogne Franche-Comté, UFR Santé, F-25000, Besançon, France
| | - Perle Totoson
- PEPITE EA4267, FHU INCREASE, Universitaire Bourgogne Franche-Comté, UFR Santé, F-25000, Besançon, France
| | - Clément Prati
- PEPITE EA4267, FHU INCREASE, Universitaire Bourgogne Franche-Comté, UFR Santé, F-25000, Besançon, France.,Service de Rhumatologie, Centre Hospitalier Régional et Universitaire de Besançon, F-25000, Besançon, France
| | - Christine Marie
- INSERM UMR1093 CAPS, Universitaire Bourgogne Franche-Comté, UFR des Sciences de Santé, F-21000, Dijon, France
| | - Daniel Wendling
- Service de Rhumatologie, Centre Hospitalier Régional et Universitaire de Besançon, F-25000, Besançon, France.,EA 4266, Universitaire Bourgogne Franche-Comté, UFR Santé, F-25000, Besançon, France
| | - Céline Demougeot
- PEPITE EA4267, FHU INCREASE, Universitaire Bourgogne Franche-Comté, UFR Santé, F-25000, Besançon, France.
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Colaco K, Ocampo V, Ayala AP, Harvey P, Gladman DD, Piguet V, Eder L. Predictive Utility of Cardiovascular Risk Prediction Algorithms in Inflammatory Rheumatic Diseases: A Systematic Review. J Rheumatol 2019; 47:928-938. [DOI: 10.3899/jrheum.190261] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 01/04/2023]
Abstract
Objective.We performed a systematic review of the literature to describe current knowledge of cardiovascular (CV) risk prediction algorithms in rheumatic diseases.Methods.A systematic search of MEDLINE, EMBASE, and Cochrane Central databases was performed. The search was restricted to original publications in English, had to include clinical CV events as study outcomes, assess the predictive properties of at least 1 CV risk prediction algorithm, and include patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), or psoriasis. By design, only cohort studies that followed participants for CV events were selected.Results.Eleven of 146 identified manuscripts were included. Studies evaluated the predictive performance of the Framingham Risk Score, QRISK2, Systematic Coronary Risk Evaluation (SCORE), Reynolds Risk Score, American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE), Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA), and the Italian Progetto CUORE score. Approaches to improve predictive performance of general risk algorithms in patients with RA included the use of multipliers, biomarkers, disease-specific variables, or a combination of these to modify or develop an algorithm. In both SLE and PsA patients, multipliers were applied to general risk algorithms. In studies of RA and SLE patients, efforts to include nontraditional risk factors, disease-related variables, multipliers, and biomarkers largely failed to substantially improve risk estimates.Conclusion.Our study confirmed that general risk algorithms mostly underestimate and at times overestimate CV risk in rheumatic patients. We did not find studies that evaluated models for psoriasis or AS, which further demonstrates a need for research in these populations.
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Hollan I, Ronda N, Dessein P, Agewall S, Karpouzas G, Tamargo J, Niessner A, Savarese G, Rosano G, Kaski JC, Wassmann S, Meroni PL. Lipid management in rheumatoid arthritis: a position paper of the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:104-114. [DOI: 10.1093/ehjcvp/pvz033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity, partly due to alterations in lipoprotein quantity, quality and cell cholesterol trafficking. Although cardiovascular disease significantly contributes to mortality excess in RA, cardiovascular prevention has been largely insufficient. Because of limited evidence, optimal strategies for lipid management (LM) in RA have not been determined yet, and recommendations are largely based on expert opinions. In this position paper, we describe abnormalities in lipid metabolism and introduce a new algorithm for estimation of cardiovascular risk (CVR) and LM in RA. The algorithm stratifies patients according to RA-related factors impacting CVR (such as RA activity and severity and medication). We propose strategies for monitoring of lipid parameters and treatment of dyslipidaemia in RA (including lifestyle, statins and other lipid-modifying therapies, and disease modifying antirheumatic drugs). These opinion-based recommendations are meant to facilitate LM in RA until more evidence is available.
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Affiliation(s)
- Ivana Hollan
- Lillehammer Hospital for Rheumatic Diseases, M. Grundtvigs veg 6, 2609 Lillehammer, Norway
- Department of Medicine, Division of Cardiovascular Medicine, 75 Francis Street, Boston, MA, 02115, USA
| | | | - Patrick Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
- Department of Rheumatology, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Jubilee Road, Parktown, Johannesburg 2196, South Africa
- Rheumatology Unit, Free University Hospital, Faculty of Medicine and Pharmacy, Free University, Laarbeeklaan 103, Jette, Brussels 1090, Belgium
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - George Karpouzas
- Department of Medicine, Division of Rheumatology, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, 1124 W Carson Street, Building E4-R17A,Torrance, CA 90502, USA
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Plaza de Ramón y Cajal s/n, 28040, Madrid, Spain
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gianluigi Savarese
- Norrbacka, S1:02, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Roma, Via della Pisana 249, 00163 Roma, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 ORE, UK
| | - Sven Wassmann
- Cardiology Pasing, Institutstr. 14, 81241 Munich, Germany
- Department of Cardiology, University of the Saarland, Kirrbergerstr. 100, 66421 Homburg/Saar, Germany
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Via Ariosto, 14, 20145 Milan, Italy
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Giles JT, Wasko MCM, Chung CP, Szklo M, Blumenthal RS, Kao A, Bokhari S, Zartoshti A, Stein CM, Bathon JM. Exploring the Lipid Paradox Theory in Rheumatoid Arthritis: Associations of Low Circulating Low-Density Lipoprotein Concentration With Subclinical Coronary Atherosclerosis. Arthritis Rheumatol 2019; 71:1426-1436. [PMID: 30883031 DOI: 10.1002/art.40889] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/12/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) patients with the lowest circulating low-density lipoprotein (LDL) concentrations are at heightened risk of cardiovascular events. However, the atherosclerosis burden within this subgroup is unknown. METHODS RA patients pooled from 4 cohort studies of cardiovascular disease (CVD; n = 546) were compared with non-RA controls from the Multi-Ethnic Study of Atherosclerosis (n = 5,279). Those taking lipid-lowering medications were excluded. Differences in cardiac computed tomography-derived Agatston coronary artery calcium (CAC) scores between the RA and control groups were compared across strata of LDL concentration. RESULTS Among those with low LDL concentrations (<70 mg/dl), mean adjusted CAC scores were >4-fold higher for RA patients than for controls (18.6 versus 4.6 Agatston units, respectively; P < 0.001), a difference significantly greater than that in any other LDL concentration stratum except LDL concentration ≥160 mg/dl. Similarly, 32% of the RA patients with low LDL concentration had a CAC score of ≥100 Agatston units compared with only 7% of controls in the same LDL concentration stratum (odds ratio 5.97; P < 0.001), a difference significantly greater than that in all of the other LDL concentration strata. Low LDL concentration was most strongly associated with higher CAC score among RA patients who were white, had ever smoked, or were not obese. Other than a higher frequency of current smokers, RA patients with low LDL concentrations did not have more CVD risk factors or higher measures of RA disease activity or severity than RA patients with higher LDL concentrations. CONCLUSION RA patients with low LDL concentration may represent a group for whom heightened screening and prevention of atherosclerotic CVD is appropriate.
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Affiliation(s)
| | - Mary Chester M Wasko
- Allegheny Health Network, Temple University School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | - Amy Kao
- EMD Serono Research & Development Institute, Inc., Billerica, Maryland
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Rheumatoid Arthritis: Atherosclerosis Imaging and Cardiovascular Risk Assessment Using Machine and Deep Learning-Based Tissue Characterization. Curr Atheroscler Rep 2019; 21:7. [PMID: 30684090 DOI: 10.1007/s11883-019-0766-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF THE REVIEW Rheumatoid arthritis (RA) is a chronic, autoimmune disease which may result in a higher risk of cardiovascular (CV) events and stroke. Tissue characterization and risk stratification of patients with rheumatoid arthritis are a challenging problem. Risk stratification of RA patients using traditional risk factor-based calculators either underestimates or overestimates the CV risk. Advancements in medical imaging have facilitated early and accurate CV risk stratification compared to conventional cardiovascular risk calculators. RECENT FINDING In recent years, a link between carotid atherosclerosis and rheumatoid arthritis has been widely discussed by multiple studies. Imaging the carotid artery using 2-D ultrasound is a noninvasive, economic, and efficient imaging approach that provides an atherosclerotic plaque tissue-specific image. Such images can help to morphologically characterize the plaque type and accurately measure vital phenotypes such as media wall thickness and wall variability. Intelligence-based paradigms such as machine learning- and deep learning-based techniques not only automate the risk characterization process but also provide an accurate CV risk stratification for better management of RA patients. This review provides a brief understanding of the pathogenesis of RA and its association with carotid atherosclerosis imaged using the B-mode ultrasound technique. Lacunas in traditional risk scores and the role of machine learning-based tissue characterization algorithms are discussed and could facilitate cardiovascular risk assessment in RA patients. The key takeaway points from this review are the following: (i) inflammation is a common link between RA and atherosclerotic plaque buildup, (ii) carotid ultrasound is a better choice to characterize the atherosclerotic plaque tissues in RA patients, and (iii) intelligence-based paradigms are useful for accurate tissue characterization and risk stratification of RA patients.
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47
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Ljung L, Ueda P, Liao KP, Greenberg JD, Etzel CJ, Solomon DH, Askling J. Performance of the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis in a geographically distant National Register-based cohort: an external validation. RMD Open 2018; 4:e000771. [PMID: 30622736 PMCID: PMC6307600 DOI: 10.1136/rmdopen-2018-000771] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/22/2018] [Accepted: 11/13/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cardiovascular (CV) risk stratification for patients with rheumatoid arthritis (RA) should facilitate evidence-based management. Prior work has derived an internally validated a CV risk score, the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA), using US data. The aim of this study was to perform an external validation among unselected patients with RA from Europe. METHODS Three large, partially overlapping, cohorts of patients with RA from the Swedish Rheumatology Quality register were identified for external validation, two with information on smoking and two with close to 10 years of median follow-up. The 10 -year rate of first CV events was assessed using the Kaplan-Meier method. The performance of ERS-RA was assessed using C-index and comparisons of observed versus predicted risks. RESULTS The C-index for ERS-RA varied across the three RA cohorts, from 0.75 to 0.78. Predicted risks corresponded well to observed risks among individuals with ≤10 % observed 10- year CV risk, but underestimated risk in individuals with a higher observed risk. In the absence of data on smoking, ERS-RA underestimated the CV risk by 3.3%, whereas in the cohorts including data on smoking, the calibration was within 1% (0.06% and 0.7%). In the clinically relevant risk intervals (<5%, 5.0%-<7.5%, 7.5%-<10%), ERS-RA performed well. CONCLUSIONS In an unselected Swedish population with RA, ERS-RA performed well, although the 10-year CV risk was underestimated in high-risk groups and in the absence of data on smoking. ERS-RA could be considered as a risk stratification tool for targeted preventive interventions in clinical rheumatology practice.
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Affiliation(s)
- Lotta Ljung
- Department of Medicine Solna, Clinical Epidemiology Section, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Peter Ueda
- Department of Medicine Solna, Clinical Epidemiology Section, Karolinska Institutet, Stockholm, Sweden
| | - Katherine P Liao
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey D Greenberg
- Division of Rheumatology, New York University School of Medicine (JDG), NYU Hospital for Joint Diseases, New York City, New York, USA
| | | | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Johan Askling
- Department of Medicine Solna, Clinical Epidemiology Section, Karolinska Institutet, Stockholm, Sweden
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Ramírez Huaranga MA, Mínguez Sánchez MD, Zarca Díaz de la Espina MÁ, Espinosa Prados PJ, Romero Aguilera G. What role does rheumatoid arthritis disease activity have in cardiovascular risk? REUMATOLOGIA CLINICA 2018; 14:339-345. [PMID: 28438483 DOI: 10.1016/j.reuma.2017.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/05/2017] [Accepted: 03/19/2017] [Indexed: 11/17/2022]
Abstract
Rheumatoid arthritis (RA) is associated with a 1.3 to 3-fold increase in mortality, being the major cause of death from cardiovascular complications (40%-50%). Therefore, the initial approach should include cardiovascular risk (CVR) assessment using algorithms adapted for this population. Although, SCOREM is an important advance, there are data indicating that subclinical atherosclerosis may be underdiagnosed. OBJECTIVE To estimate the strength of association between carotid ultrasound and SCOREM in this population, as well as the implication of disease activity. METHODOLOGY Cross-sectional, observational, analytical study performed at the General Hospital of Ciudad Real, Spain, between June 2013 and May 2014. The evaluation of CVR was performed and, according to SCOREM, the population was divided into low and high (medium, high and very high) risk. We studied the presence of subclinical atherosclerosis in low-risk patients. RESULTS Of the total of 119 RA patients, 73.1% had traditional risk factors. Thirty-eight patients were excluded because of a previous cardiovascular event, diabetes mellitus and/or nephropathy. Atheromatous plaque was observed in 14.63% of the low-risk population. The factor with the strongest association to the presence of subclinical atherosclerosis was a moderate or high activity of RA measured by the simplified disease activity index with an odds ratio of 4.95 (95% CI: 1.53-16.01). CONCLUSIONS Although there was an acceptable correlation between the presence of subclinical atherosclerosis and SCOREM, there was a considerable proportion of atheromatous plaques in low-risk patients. Disease activity was the risk factor most closely associated with increased CVR.
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Affiliation(s)
| | | | | | | | - Guillermo Romero Aguilera
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real; Universidad de Castilla La-Mancha, Ciudad Real, España
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Wahlin B, Innala L, Magnusson S, Möller B, Smedby T, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Performance of the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis Is Not Superior to the ACC/AHA Risk Calculator. J Rheumatol 2018; 46:130-137. [PMID: 30275258 DOI: 10.3899/jrheum.171008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cardiovascular (CV) risk estimation calculators for the general population do not perform well in patients with rheumatoid arthritis (RA). An RA-specific risk calculator has been developed, but did not perform better than a risk calculator for the general population when validated in a heterogeneous multinational cohort. METHODS In a cohort of patients with new-onset RA from northern Sweden (n = 665), the risk of CV disease was estimated by the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA) and the American College of Cardiology/American Heart Association algorithm (ACC/AHA). The ACC/AHA estimation was analyzed, both as crude data and when adjusted according to the recommendations by the European League Against Rheumatism (ACC/AHA × 1.5). ERS-RA was calculated using 2 variants: 1 from patient and physician reports of hypertension (HTN) and hyperlipidemia [ERS-RA (reported)] and 1 from assessments of blood pressure (BP) and blood lipids [ERS-RA (measured)]. The estimations were compared with observed CV events. RESULTS All variants of risk calculators underestimated the CV risk. Discrimination was good for all risk calculators studied. Performance of all risk calculators was poorer in patients with a high grade of inflammation, whereas ACC/AHA × 1.5 performed best in the high-inflammatory patients. In those patients with an estimated risk of 5-15%, no risk calculator performed well. CONCLUSION ERS-RA underestimated the risk of a CV event in our cohort of patients, especially when risk estimations were based on patient or physician reports of HTN and hyperlipidemia instead of assessment of BP and blood lipids. The performance of ERS-RA was no better than that of ACC/AHA × 1.5, and neither performed well in high-inflammatory patients.
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Affiliation(s)
- Bengt Wahlin
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden. .,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University.
| | - Lena Innala
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Staffan Magnusson
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Bozena Möller
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Torgny Smedby
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Solbritt Rantapää-Dahlqvist
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Solveig Wållberg-Jonsson
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
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Popkova TV, Novikova DS. ACCORDING TO THE MATERIALS OF THE 2015/2016 NEW EUROPEAN LEAGUE AGAINST RHEUMATISM (EULAR) GUIDELINES FOR REDUCING CARDIOVASCULAR RISK IN PATIENTS WITH INFLAMMATORY ARTHRITIS: GENERAL CHARACTERIZATION AND DISCUSSION PROBLEMS. RHEUMATOLOGY SCIENCE AND PRACTICE 2018. [DOI: 10.14412/1995-4484-2018-272-279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
According to the materials of the 2015/2016 new European League Against Rheumatism (EULAR) guidelines for reducing cardiovascular risk in patients with inflammatory arthritis. The authors identify three main principles of prevention of cardiovascular diseases in rheumatoid arthritis and other chronic inflammatory arthritis and provide a general characterization of the guidelines, by reviewing the discussion problems.
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