Lower limb arterial incompressibility and obstruction in rheumatoid arthritis

Genetic association between immune-mediated inflammatory diseases and peripheral artery disease: a Mendelian randomization study

Several observational studies have revealed that immune-mediated inflammatory diseases (IMIDs) are associated with an increased risk of peripheral artery disease (PAD). However, the causal association remains to be determined. To corroborate previous research, we conducted Mendelian randomization (MR) analysis with the aim of clarifying the associations of various IMIDs with PAD. two-sample MR analysis was conducted to investigate the potential causal association between eight common IMIDs (including rheumatoid arthritis (RA), Crohn's disease (CD), ulcerative colitis (UC), systemic lupus erythematosus (SLE), ankylosing spondylitis(AS), psoriasis(PSO), multiple sclerosis(MS), and hashimoto thyroiditis(HT)) and PAD. Genome-wide association study (GWAS) was used to identify genetic variants associated with IMIDs and PAD. We employed the inverse variance weighted (IVW) method as the primary method to verify the causal relationship between exposures (IMIDs) and outcomes (PAD). In addition, heterogeneity test, horizontal pleiotropy test, and leave-one-out analysis were performed to evaluate the robustness of the MR results. The IVW model yielded evidence of a positive association between RA and PAD (OR = 1.059, 95% CI: 1.026-1.094, p<0.001), which was consistent with the results obtained from MR-Egger regression and weighted median analyses, indicating that the results of MR analysis were reliable. However, no statistically significant associations were observed between other IMIDs, including UC, CD, SLE, AS, PSO, MS, and HT, and PAD. Our analysis supported the causal association of RA with increased risks of PAD. Strengthening screening and prevention of PAD is of great significance in reducing the risk of PAD in populations with RA.

Increased Risk of New-Onset Rheumatoid Arthritis Among Osteoarthritis Patients Received Total Knee Arthroplasty: a global federated health network analysis

Background: Complications of total knee arthroplasty (TKA) had been widely discussed. However, whether TKA influence risk of rheumatoid arthritis (RA) in osteoarthritis patients remained uncertain. We intend to evaluate the risk of RA in osteoarthritis patients underwent TKA. Methods: In this retrospective cohort study, data was retrieved from the US collaborative networks in TriNetX research network. Within the study period between 2005 and 2017, osteoarthritis patients underwent TKA were enrolled as case cohort whereas osteoarthritis patients never underwent TKA were enrolled as control cohort. Covariates were matched via propensity score matching. Risk of RA in TKA patients were valuated under various follow-up time and sensitivity models. Results: Under 1-year, 3-year and 5-year of follow-up, TKA patients were associated with significantly elevated risk of RA, especially under 1-year follow-up (HR=1.74; 95% CI, 1.39-2.18). Subgroup analysis demonstrated a significant increase in the risk of RA following TKA in the female subgroup (HR=1.42; 95% CI, 1.24-1.63), the subgroup aged 18-64 years (HR=1.48; 95% CI, 1.11-1.97), and the subgroup aged greater than 65 years old (HR=1.38; 95% CI, 1.21-1.58) based on 5-year follow-up. Conclusion: Clinicians should be concerned about uncharted association between TKA and RA reported our current study. Additional prospective studies and in-depth mechanistic inquiries were warranted to determine the causation.

Systematic review of associations between concomitant rheumatoid arthritis and peripheral arterial disease, health-related quality of life and functional capacity

Patients with rheumatoid arthritis (RA) are at an increased risk of cardiovascular disease and vascular morbidity. The association between peripheral arterial disease (PAD) and RA has not been previously investigated within the scope of a review. Conjoined disease manifestations may impact patient well-being, perpetuating increased mortality and quality of life deficits. To investigate the association between RA and PAD, along with RA and the ankle-brachial pressure index (ABPI), the impact of disease concomitance on health-related quality of life (HRQOL) and functional capacity (FC) was also investigated. Individual study appraisal was completed using the Crowe Critical Appraisal Tool (CCAT). A level of evidence analysis was conducted using the American Society of Plastic Surgeons (ASPS) Evidence Rating Scale for Prognostic/Risk Studies. AMED^®, CINAHL^®, Health Source: Nursing/Academic Edition, MEDLINE^®, AHFS^®, Scopus, Web of Science, Cochrane Library and Google scholar. Ten studies produced a CCAT rating of ≥ 30 (75%) and were deemed high quality, while a single study demonstrated a score of 26 (65%) suggesting moderate quality. A grade "II" levels of evidence was awarded to positive association between RA and PAD. A gradation of "I" was awarded to the association between ABPI and RA. The impact of concomitant manifestations on HRQOL and FC did not qualify for a level of evidence analysis. The systematic inflammatory nature of RA likely contributes to the increased incidence of PAD within the population. Further investigations are required to ascertain the impact of conjoined disease manifestations on HRQOL and FC.

Medial artery calcification in peripheral artery disease

Medial artery calcification (MAC) is a distinct, highly regulated process that is often identified in small and mid-sized arteries of the lower extremities. It is associated with advanced age, diabetes, and chronic kidney disease. MAC often occurs in conjunction with atherosclerotic occlusive disease in lower extremity arteries, and when seen together or in isolation, long-term limb outcomes are negatively affected. In patients with peripheral artery disease (PAD), the extent of MAC independently correlates with major amputation and mortality rates, and it predicts poor outcomes after endovascular interventions. It is associated with increased arterial stiffness and decreased pedal perfusion. New endovascular methods aimed at treating calcified lower-extremity lesions may improve our ability to treat patients with limb-threatening ischemia. Although recent developments have increased our understanding of the mechanisms contributing to MAC, further investigations are needed to understand the role of medial calcification in PAD, and to develop strategies aimed at improving patient outcomes.

Assessment of subclinical atherosclerosis with ankle-brachial index in psoriatic arthritis: A case-control study

Objectives

This study aims to evaluate subclinical atherosclerosis using the Ankle-Brachial Index (ABI) in patients with psoriatic arthritis (PsA).

Patients and methods

This case-control study included 51 PsA patients (24 males, 27 females; median age 47; range, 41 to 52 years) recruited at our hospital's outpatient clinics between October 2016 and January 2017 and 50 healthy controls (24 males, 26 females; median age: 48.5; range, 40.7 to 56 years). Anthropomorphic measurements and laboratory results were recorded. In patients, the 66 swollen/68 tender joints count, dactylitis score, Leeds Enthesitis Index, Health-related Quality of Life, the Psoriasis Area and Severity Index, and Dermatology Life Quality Index were evaluated. Ankylosing Spondylitis Quality of Life and Bath Ankylosing Spondylitis Disease Activity Index were applied to patients with axial disease. Then, Composite Psoriatic Disease Activity Index was determined. A Doppler probe and a standard blood pressure cuff were used to calculate the ABI values for each participant.

Results

Patients had lower right ABI (median, 1.05 vs. 1.1, p<0.01), lower left ABI (1.04 vs. 1.09, p<0.01) and lower overall ABI (1.03 vs. 1.09, p<0.01) compared with healthy subjects. Twelve (23.5%) patients had borderline ABI, but none of the controls (p<0.01). Patients with borderline ABI had a longer duration of psoriasis (25 vs. 15 years, p=0.03). The distribution of borderline ABI value was statistically significant between patients with axial disease and peripheral disease only (42.1% vs. 12.5%, p=0.02). Disease activity was found as an independent risk factor for borderline ABI in a binary logistic regression (odds ratio 6.306, 95% confidence interval 1.185 to 33.561, p=0.031).

Conclusion

Lower ABI was found in PsA patients than healthy controls even in those matched with traditional cardiovascular risk factors. All participants with borderline ABI were in the patient group. Borderline ABI was associated with disease activity and disease duration.

Biomechanical characterization of the passive response of the thoracic aorta in chronic hypoxic newborn lambs using an evolutionary strategy

The present study involves experiments and modelling aimed at characterizing the passive structural mechanical behavior of the chronic hypoxic lamb thoracic aorta, whose gestation, birth and postnatal period were carried at high altitude (3600 masl). To this end, the mechanical response was studied via tensile and pressurization tests. The tensile and pressurization tests measurements were used simultaneously to calibrate the material parameters of the Gasser-Holzapfel-Ogden (GHO) hyperelasctic anisotropic constitutive model through an analytical-numerical optimization procedure solved with an evolutionary strategy that guarantees a stable response of the model. The model and procedure of calibration adequately adjust to the material behavior in a wide deformation range with an appropriate physical description. The results of this study predict the mechanical response of the lamb thoracic aorta under generalized loading states like those that can occur in physiological conditions and/or in systemic arterial hypertension. Finally, the novel use of the evolutionary strategy, together with the set of experiments and tools used in this study, provide a robust alternative to validate biomechanical characterizations.

Association between ischemic stroke and seropositive rheumatoid arthritis in Korea: A nationwide longitudinal cohort study

The purpose of this longitudinal follow-up study was to investigate the risk of ischemic stroke nationwide in patients with seropositive rheumatoid arthritis (RA) and controls who were matched in age and sex. Patient data were collected from the National Health Insurance Service (NHIS) Health Screening (HEALS) cohort. Using the International Classification of Diseases code M05 (seropositive RA), with a prescription of any disease-modifying anti-rheumatic drug (DMARD), RA was identified. A total of 2,765 patients and 13,825 control subjects were included in our study. The 12-year incidence of ischemic stroke in each group was calculated using the Kaplan–Meier method. The risk ratio of ischemic stroke was estimated using Cox proportional hazards regression. Sixty-four patients (2.31%) in the seropositive RA group and 512 (3.70%) in the control group experienced ischemic stroke (P < 0.001) during the follow-up period. The hazard ratio of ischemic stroke in the seropositive RA group was 1.32 (95% confidence interval (CI), 1.02–1.73) after adjusting for age and sex. The adjusted hazard ratio of ischemic stroke in the seropositive RA group was 1.40 (95% CI, 1.07–1.82) after adjusting for demographics and comorbid medical disorders. According to the subgroup analysis, the hazard ratios of ischemic stroke risks in the female and hypertensive subgroups were 1.44 (95% CI, 1.05–1.97) and 1.66 (95% CI, 1.16–2.38), respectively. In the non-diabetes and non-dyslipidemia subgroups, the corresponding hazard ratios of ischemic stroke were 1.47 (95% CI, 1.11–1.95) and 1.43 (95% CI, 1.07–1.91). Seropositive RA patients have an increased risk of ischemic stroke. In female, hypertension, non-diabetes, and non-dyslipidemia RA subgroups, even without the traditional risk factors for stroke (except for hypertension), increased the risk, which could be potentially attributed to RA.

Evaluation of the Risk of Getting Peripheral Artery Disease in Rheumatoid Arthritis and the Selection of Appropriate Diagnostic Methods

This study aims to review the evidence regarding the association between peripheral artery disease (PAD) and rheumatoid arthritis (RA), as well as influential underlying factors and diagnostic options. Eligible literature was searched in PubMed published up to June 1, 2020, in English. Case studies, case series, reviews, and meta-analyses were excluded. We also excluded non-human studies and those 20 years and older. A total of 44 studies were finally incorporated in the narrative review. The results indicated that compared to controls, RA patients are more prone to PAD. Traditional risk factors, disease-characteristics, vitamin D deficiency, therapy used, and other relevant conditions have a variable effect on overall PAD progression. Studies comparing diagnostic options revealed that vascular function and morphology are connected but are still distinctive processes. In early-stage disease, there are functional alterations in the endothelium that can be controlled by anti-inflammatory medications. Ankle-Brachial Index (ABI) <0.9 might not be quite susceptible to PAD evaluation. Supplemental diagnostic tools could detect vascular disease in the preclinical stage. Most risk factors are adjustable, and the management will have a good impact on vascular health. PAD is mostly subclinical when the therapeutic options have a better impact. Diagnostic modalities should be chosen depending on the features of RA. In addition, multiple diagnostic options increase the accuracy of PAD diagnosis. Future prospective studies with larger populations at different age groups and different disease activity duration are essential to make firm conclusions and better understand the phenomenon of RA and PAD.

Cardiac and vascular complications in rheumatoid arthritis

Rheumatoid arthritis (RA) is an independent risk factor for the development of a variety of cardiovascular diseases, with a 1.5-factor increase in risk. This literature review aims to provide a global overview of the pathogenesis, effects of anti-rheumatoid treatment on cardiovascular risk, a description of the cardiovascular complications associated with RA, and current opinion on cardiovascular risk assessment and management in patients with RA. Author conducted a literature search in PubMed, Scopus, Web of Science and Embase regarding RA and associated cardiovascular complications. The mechanism of increased risk of cardiovascular disease in patients with RA is complex. There are specific genetic factors associated with both diseases, and traditional cardiovascular risk factors may be more prevalent in patients with RA. Most anti-rheumatic drugs decrease cardiovascular risk, and general recommendations focus on reduction of disease activity and strict management of cardiovascular risk as per the general population.

Subclinical atherosclerosis and history of cardiovascular events in Italian patients with rheumatoid arthritis: Results from a cross-sectional, multicenter GIRRCS (Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale) study

Several studies have pointed out a significant association between rheumatoid arthritis (RA) and accelerated atherosclerosis. At the best of our knowledge, no such study has been carried out in a large Italian series and, in this study, we aimed to investigate the prevalence of both subclinical atherosclerosis and history of cardiovascular events (CVEs), in patients consecutively admitted from January 1, 2015 to December 31, 2015 to Rheumatology Units throughout the whole Italy.Centers members of GIRRCS (Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale) were invited to enrol patients consecutively admitted from January 1, 2015 to December 31, 2015 and satisfying American College of Rheumatology/ European League Against Rheumatism criteria for RA and to investigate each of them for: traditional cardiovascular risk factors: sex, age, smoking habit, total cholesterol, triglycerides, glycaemia, high blood pressure, metabolic syndrome (MS), type 2 diabetes (T2D); RA features: disease duration as assessed from the first symptom, disease activity as evaluated by DAS28, radiographic damage as assessed by hands and feet x-ray, and previous joint surgery; prevalence of both subclinical atherosclerosis and history of CVEs.Eight centers participated to the study. From January 1, 2015 to December 31, 2015, the 1176 patients, who had been investigated for all the items, were enrolled in the study. They were mostly women (80.52%), with a median age of 60 years (range, 18-91 years), a median disease duration of 12 years (range, 0.8-25 years), seropositive in 69.21%. Nineteen percent were in remission; 17.51% presented low disease activity; 39.45% moderate disease activity; 22.61% high disease activity.Eighty-two patients (6.9%) had a history for CVEs (58 myocardial infarction, 38 heart failure, 10 ischemic transitory attack, and 7 stroke). This figure appears to be lower than that reported worldwide (8.5%). After excluding the 82 patients with a history of CV events, subclinical atherosclerosis was detected in 16% of our patients, (176 patients), a figure lower than that reported worldwide (32.7%) and in previous Italian studies.This is the first Italian multicenter study on subclinical and clinical atherosclerosis in patients with RA. We pointed out a low prevalence of both subclinical atherosclerosis and history of CV events.

Prevalence of type 2 diabetes and impaired fasting glucose in patients affected by rheumatoid arthritis: Results from a cross-sectional study

Although the better management of rheumatoid arthritis (RA) has significantly improved the long-term outcome of affected patients, a significant proportion of these may develop associated comorbidities including cardiometabolic complications. However, it must be pointed out that a comprehensive cardiometabolic evaluation is still poorly integrated into the management of RA patients, due to a limited awareness of the problem, a lack of appropriate clinical studies, and optimal strategies for cardiovascular (CV) risk reduction in RA. In addition, although several studies investigated the possible association between traditional CV risk factors and RA, conflicting results are still available.On this basis, we planned this cross-sectional study, aimed at investigating the prevalence of type 2 diabetes (T2D) and impaired fasting glucose (IFG) in RA patients compared with age- and gender- matched control individuals. Furthermore, we analyzed the role of both traditional and RA-related CV risk factors in predicting T2D and IFG.We observed an increased prevalence of T2D in RA patients when compared with age- and gender-matched controls. Regression analyses demonstrated that the presence of high blood pressure (HBP), a longer disease duration, and exposure to corticosteroids (CCS) were significantly associated with an increased likelihood of being classified as T2D. In addition, we observed an increased prevalence of IFG in RA patients when compared with age- and gender-matched controls. Regression analyses demonstrated that a higher body mass index (BMI), the presence of metabolic syndrome (MetS), higher levels of total cholesterol, the presence of radiographic damage, and higher serum levels of C-reactive protein (CRP) were significantly associated with an increased likelihood of presenting IFG.In this cross-sectional study, we observed an increased prevalence of T2D and IFG in an Italian cohort of RA patients when compared with age- and gender-matched control individuals. Interestingly, both RA-specific features, such as disease duration, CCS exposure, and radiographic damage, and traditional CV risk factors, such as HBP and MetS, were significantly associated with glucose metabolism abnormalities.

Association between antibodies to carbamylated proteins and subclinical atherosclerosis in rheumatoid arthritis patients

BACKGROUND

Rheumatoid arthritis (RA) patients carry a high risk of cardiovascular morbidity and mortality. The excess of cardiovascular disease cannot be entirely explained by traditional risk factors and the immune system contributes to the development of atherosclerosis. Moreover, post-translational modifications such as citrullination and carbamylation have been linked to inflammation and atherosclerosis. Anti-carbamylated proteins antibodies (anti-CarP) are a new subset of autoantibodies identified in RA patients. This study aimed to investigate a possible association between anti-CarP and subclinical atherosclerosis in RA patients.

METHODS

We enrolled RA patients and normal healthy controls (NHS) without known cardiovascular risk factors or heart disease. Cardiovascular risk was assessed using the Modified Systemic Coronary Risk Evaluation (mSCORE). Anti-CarP were investigated by a solid phase "home-made" ELISA. Anti-citrullinated protein antibodies (ACPA) and Rheumatoid Factor (RF) were investigated by ELISA assays. Subclinical atherosclerosis was evaluated by brachial artery Flow-Mediated Dilatation (FMD) and Carotid Intima-Media Thickness (c-IMT) while arterial stiffness by Ankle-Brachial Index (ABI) and Cardio-Ankle Vascular Index (CAVI).

RESULTS

We enrolled 50 RA patients (34 F and 16 M, mean age 58.4 ± 13.1 years, mean disease duration 127 ± 96.7 months) and 30 age and sex matched NHS. According to the mSCORE, 58% of patients had a low risk, 32% a moderate and 8% a high risk for cardiovascular disease. FMD was significantly lower in RA patients than in NHS (5.6 ± 3.2 vs 10.7 ± 8.1%; p < 0.004) and CAVIs significantly higher in a RA patients compared to NHS (left CAVI 8.9 ± 1.7 vs 8.1 ± 1.5; p < 0.04 for and right CAVI 8.8 ± 1.6 vs 8.0 ± 1.4; p < 0.04 for the). ABI and c-IMT did not differ between the two populations. The multivariate regression analysis showed a significant association of anti-CarP antibodies with FMD, left and right CAVI and both c-IMT (r = 1.6 and p = 0.05; r = 1.7 and p = 0.04; r = 2.9 and p = 0.05; r = 1.5 and p = 0.03; r = 1.1 and p = 0.03 respectively).

CONCLUSIONS

This study confirms that RA patients, without evidence of cardiovascular disease or traditional risk factors, have an impaired endothelial function. Moreover, we found an association with anti-CarP antibodies suggesting a possible contribution of these autoantibodies to endothelial dysfunction, the earliest stage of atherosclerosis. Besides ultrasound assessment, anti-CarP should be assessed in RA patients and considered an additional cardiovascular risk factor.

Endogenous bone morphogenetic protein 2 plays a role in vascular smooth muscle cell calcification induced by interleukin 6 in vitro

Systemic inflammation is involved in vascular calcification and cardiovascular disease which is the leading cause of mortality in rheumatoid arthritis (RA). A high level of serum interleukin (IL)-6 plays a key role in local and systemic inflammation in RA. However, the underlying mechanisms remain unclear. We established a human umbilical artery smooth muscle cell (HUASMC) culturing method to investigate the possible role of IL-6 on vascular calcification. HUASMCs were obtained from umbilical arteries of healthy neonates. To detect calcification effects, HUASMCs were treated with (experimental group) or without (control group) recombinant human (rh) IL-6. The calcium deposition stain and calcium concentrations were measured, as well as the mRNA and protein levels of the regulating factor of osteogenic differentiation-bone morphogenetic protein (BMP) 2 and those calcifying related molecules including bone-specific alkaline phosphatase (BAP), osteoprotegerin (OPG), and osteopontin (OPN). Our study showed that rhIL-6 induced calcification of HUASMCs in a time- and dose-dependent manner, and upregulated expressions of BMP2, BAP, OPG, and OPN of HUASMCs. We then used the anti-BMP2 siRNA to knockdown the expression of endogenous BMP2 to confirm its role. HUASMCs were transfected with negative siRNA (control group) or the valid anti-BMP2 siRNA (experimental group) before they were treated with rhIL-6. Cells transfected with negative siRNA without IL-6 stimulating served as the blank group. The results showed that anti-BMP2 siRNA markedly decreased expressions of BMP2, BAP, OPG, and OPN, and also partly reduced the calcification of HUASMCs induced by rhIL-6. Collectively, according to our study, rhIL-6 could induce the extracellular calcification and osteogenic differentiation of human artery smooth muscle cells through upregulating endogenous BMP2 in vitro. This may be one of the underlying mechanisms of the overwhelming vascular calcification in RA.

Toe blood pressure and toe-brachial index

TBP and TBI are considered more accurate in assessing lower extremity perfusion in those patients with a falsely elevated ABI suspected from medial arterial calcification. Like the ABI, a TBI may be obtained by the nurse through a similar procedure using a sphygmomanometer and hand-held Doppler. Knowledge by the vascular nurse of this noninvasive technique will assist in a more timely recognition of PAD and may improve long-term patient outcomes.

Prevalence of lower extremity peripheral arterial disease in individuals with chronic immune mediated inflammatory disorders

OBJECTIVE

To compare the prevalence of lower extremity peripheral artery disease (PAD) and to assess whether age-associated progression in ankle-brachial index (ABI) differs between individuals with chronic immune-mediated inflammatory diseases (CIID) and the general population.

METHODS

Pooled analysis with data from individuals aged 50 years and older with ABI measurements, obtained from population-based cross-sectional studies conducted in Catalonia (Spain). Information on three CIID diagnoses (i.e., inflammatory bowel disease, systemic connective tissue disorders, and inflammatory polyarthropathies and spondylopathies, considered as one entity for purposes of analysis) was obtained from electronic medical records. To ascertain the statistical association between PAD and CIID, logistic regression models were fitted and adjusted for age, sex, and cardiovascular risk factors. We tested the interaction between age and CIID diagnosis for ABI values.

RESULTS

We included 8799 individuals, 312 (3.6%) with CIID. The age-standardized prevalence of PAD was higher in the CIID group (12% vs. 6% in general population, p = 0.001), and the model adjusted for age, sex, and cardiovascular risk factors also showed higher risk in individuals with CIID [Odds Ratio (95% confidence interval) = 1.65 (1.15-2.38); p = 0.007]. The inflammatory polyarthropathies/spondylopathies diagnosis was significantly associated with PAD in the fully adjusted model [1.80 (1.18-2.75); p = 0.006]. The atherosclerotic process was accelerated in individuals with CIID, compared to the general population (p for interaction<0.001).

CONCLUSION

In individuals with CIID, age-standardized prevalence of PAD was significantly higher than in the general population and the atherosclerotic process was accelerated. However, only inflammatory polyarthropathies/spondylopathies was associated with significant risk of PAD.

Can the ankle brachial pressure index (ABPI) and carotis intima media thickness (CIMT) be new early stage markers of subclinical atherosclerosis in patients with rheumatoid arthritis?

BACKGROUND

It takes years for atherosclerosis to manifest symptoms. However, it needs to be identified earlier because of the premature cardiovascular risk factors in patients with rheumatoid arthritis (RA). In this study, we aimed to investigate the effect of atherosclerosis on the ankle brachial pressure index (ABPI) and carotis intima media thickness (CIMT) in patients with RA.

METHODS

RA patients attending the rheumatology clinic were examined retrospectively; then we called them for the measurements of ABPI and CIMT prospectively. Subjects were divided into four groups, as follows (Table 1): group 1 comprised RA patients with an ABPI less than 0.9; group 2 included RA patients with an ABPI between 0.9 and 1.2; group 3 was made up of RA patients with an ABPI greater than 1.2; and group 4 included patients without RA with an ABPI between 0.9 and 1.2 as a control group. Patients' demographic data were recorded. Hypertension (HT), diabetes mellitus, ABPI and CIMT measurements were taken by specialists. Duration of RA and disease scores (disease activity score-28, health assessment questionnaire score and visual assessment score) were recorded.

RESULTS

The prevalence of peripheral vascular disease in patients with RA was twice as high as that in the normal population of equivalent age. Patients in group 2, with RA and normal ABPI, exhibited a significant higher mean in CIMT (mm) compared with the control group (p < 0.01), despite having normal ABPI. This confirms that these patients have a higher risk of stroke compared with the control group. Group 1's newly diagnosed HT (p < 0.01) and systolic blood pressure (SBP) values (p < 0.01) were higher and statistically significant when compared with the group 4 (control group); in addition, significant plaque levels were observed in the carotid arteries (p < 0.01). Group 3 patients had a similar history of HT and increased SBP compared with patients in group 4 (p < 0.01), and had similar characteristics to with group 1. No statistically significant differences were found between the groups in terms of inflammatory markers such as C-reactive protein and rheumatoid factor, anti-cyclic citrullinated peptide and white blood cell counts.

CONCLUSION

Based on the present findings, patients with RA need to be evaluated in the early stage of the disease for subclinical peripheral artery disease using the ABPI, as well as CIMT, which is also a non-invasive technique, in terms of cerebrovascular events. Inflammatory markers exhibited no statistically significant difference. We think that the atherosclerotic process stems not only from the inflammatory effects of RA, but also perhaps from its immunological nature.

Cardiovascular disease risk scores in the current practice: which to use in rheumatoid arthritis?

Cardiovascular disease (CVD) is the highest prevalence disease in the general population (GP) and it accounts for 20 million deaths worldwide each year. Its prevalence is even higher in rheumatoid arthritis. Early detection of subclinical disease is critical and the use of cardiovascular risk prediction models and calculators is widely spread. The impact of such techniques in the GP was previously studied. Despite their common background and similarities, some disagreement exists between most scores and their importance in special high-risk populations like rheumatoid arthritis (RA), having a low level of evidence. The current article aims to single out those predictive models (models) that could be most useful in the care of rheumatoid arthritis patients.

Beyond the joint: Subclinical atherosclerosis in rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune inflammatory disease associated with increased cardiovascular risk and higher mortality in respect to general population. Beyond joint disease, inflammation is the major determinant of accelerated atherosclerosis observed in rheumatoid arthritis. We review the relationship between inflammation, atherosclerosis and cardiovascular risk in rheumatoid arthritis, focusing on the assessment of subclinical atherosclerosis by functional and morphological methods. These tools include flow mediated dilatation, carotid intima-media thickness, ankle/brachial index, coronary calcium content, pulse wave analysis and serum biomarker of subclinical atherosclerosis.

Noncardiac vascular disease in rheumatoid arthritis: increase in venous thromboembolic events?

OBJECTIVE

To investigate the incidence of noncardiac vascular disease in a community-based incidence cohort of patients with rheumatoid arthritis (RA) and compare it to that in the general population and to investigate trends in the incidence of noncardiac vascular disease in patients with RA.

METHODS

A population-based inception cohort of patients with incident RA between January 1, 1980 and December 31, 2007 in Olmsted County, Minnesota and a cohort of non-RA subjects from the same population base was assembled and followed up until December 31, 2008. Venous thromboembolic, cerebrovascular, and peripheral arterial events were ascertained by medical record review.

RESULTS

The study population included 813 patients with RA with a mean±SD age of 55.9±15.7 years (68% women) and an average length of followup of 9.6±6.9 years. Compared to non-RA subjects of similar age and sex, patients diagnosed as having RA between 1995 and 2007 had a higher incidence (%) of venous thromboembolism (cumulative incidence±SE 6.7±1.7 versus 2.8±1.1, respectively; P=0.005) but similar rates of cerebrovascular and peripheral arterial events. Among patients with RA, the incidence of venous thromboembolic, cerebrovascular, and peripheral arterial events was similar in the 1995-2007 time period compared to the 1980-1994 time period.

CONCLUSION

Our findings indicate that the incidence of venous thromboembolism is increased in patients with RA compared to non-RA subjects. The incidence of cerebrovascular events and peripheral vascular disease events is similar in patients with RA compared to non-RA subjects. Among patients with RA, the incidence of noncardiac vascular disease has remained stable in recent decades.

Validated methods for assessment of subclinical atherosclerosis in rheumatology

Rheumatoid arthritis, as well as other types of arthritides and connective tissue diseases, is associated with accelerated atherosclerosis, and increased cardiovascular morbidity and mortality. The early signs of cardiovascular disease therefore need to be recognized in patients with these conditions so that effective cardiovascular protection can be introduced. This Review provides an overview of validated techniques that are currently available to determine subclinical atherosclerosis in patients with rheumatic conditions. Techniques for early assessment of endothelial dysfunction include brachial artery flow-mediated vasodilation and laser Doppler flowmetry. Coronary circulation can be assessed by measuring coronary flow reserve using CT, MRI or PET based techniques. The standard indicators of arterial stiffness are pulse-wave velocity and the augmentation index. Carotid atherosclerosis is determined by the common carotid intima-media thickness (ccIMT) measurement or by the assessment of plaques and plaque areas. The combination of ccIMT with plaque assessment is likely to increase the predictive value of this approach. The potential use of a multimarker approach to increase the diagnostic and prognostic value of these clinical assessments is also discussed.

Traditional cardiovascular risk factors in rheumatoid arthritis: a meta-analysis

OBJECTIVE

Rheumatoid arthritis is associated with increased cardiovascular morbidity and mortality. We performed a systematic review of the literature and a meta-analysis to look for differences in the prevalence of traditional cardiovascular risk factor between RA patients and controls.

METHODS

Medline database was searched to identify studies evaluating the prevalence of traditional cardiovascular risk factors in rheumatoid arthritis patients and controls. Studies were selected and reviewed by two investigators. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated and pooled using a random-effects model. Statistical heterogeneity was evaluated through the use of Chi2 and I2 statistics.

RESULTS

Fifteen case-control studies with a total of 2956 patients and 3713 controls met the inclusion criteria. The prevalence of smoking was increased in RA patients in comparison with controls: OR (95%CI) 1.56 (1.35-1.80) (P < 0.00001). The prevalence of hypertension did not differ: OR (95% CI) 1.09 (0.91-1.31) (P = 0.35). The prevalence of diabetes mellitus was increased in RA: OR (95%CI) 1.74 (1.22-2.50) (P = 0.003). The prevalence of hypercholesterolemia did not differ: OR (95%CI) 0.84 (0.67-1.04) (P = 0.11). HDL cholesterol levels were lower in RA patients: weighted mean difference -17.72 mg/dl (-18.35 - -17.08) (P < 0.00001). Significant heterogeneity among studies was found for diabetes mellitus and HDL cholesterol levels.

CONCLUSIONS

Some traditional cardiovascular risk factors, such as smoking, diabetes mellitus or lower HDL cholesterol levels, appear more prevalent in rheumatoid arthritis patients and could contribute to the increased cardiovascular morbidity and mortality observed in rheumatoid arthritis.

Looking through the 'window of opportunity': is there a new paradigm of podiatry care on the horizon in early rheumatoid arthritis?

Over the past decade there have been significant advances in the clinical understanding and care of rheumatoid arthritis (RA). Major paradigm changes include earlier disease detection and introduction of therapy, and 'tight control' of follow-up driven by regular measurement of disease activity parameters. The advent of tumour necrosis factor (TNF) inhibitors and other biologic therapies have further revolutionised care. Low disease state and remission with prevention of joint damage and irreversible disability are achievable therapeutic goals. Consequently new opportunities exist for all health professionals to contribute towards these advances. For podiatrists relevant issues range from greater awareness of current concepts including early referral guidelines through to the application of specialist skills to manage localised, residual disease activity and associated functional impairments. Here we describe a new paradigm of podiatry care in early RA. This is driven by current evidence that indicates that even in low disease activity states destruction of foot joints may be progressive and associated with accumulating disability. The paradigm parallels the medical model comprising early detection, targeted therapy, a new concept of tight control of foot arthritis, and disease monitoring.'Podiatrists are experts on foot disorders: both patients and rheumatologists can profit from the involvement of a podiatrist'- Korda and Balint, 2004 1.

Subclinical peripheral arterial disease in rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is associated with accelerated atherosclerosis in the carotid arteries, but little is known about the magnitude of this process in peripheral arteries. Assessing preclinical atherosclerosis in both arterial beds in RA might provide additional prognostic value during risk stratification for primary prevention. Therefore in the present structural study we examined femoral versus carotid subclinical atherosclerosis in RA and controls.

METHODS

Intima-media thickness (IMT) and atheromatous plaque presence and vulnerability in femoral versus carotid arteries were examined in 80 RA patients without overt cardiovascular disease or diabetes and 80 controls matched 1:1 for age, gender and traditional cardiovascular disease risk factors.

RESULTS

Femoral IMT and plaque prevalence were increased in RA than controls (p=0.001 and 0.008, respectively). These increases remained significant after adjustment for potentially confounding factors that differed between groups, such as C-reactive protein and HDL-cholesterol serum levels, and statin use. Femoral plaque vulnerability did not differ between RA and controls. The presence of RA was found to be an independent predictor of increased femoral IMT (p=0.004), after adjustment for traditional cardiovascular risk factors, C-reactive protein and treatment with angiotensin converting enzyme inhibitors and statins. Femoral plaques were less frequent than carotid plaques in RA patients (22.5% vs 45.0% respectively, p=0.003) and in contrast to carotid plaques were independent of age and glucose levels.

CONCLUSIONS

Subclinical peripheral atherosclerosis in RA is more advanced than in controls. Prospective studies are required to confirm that RA is an independent risk factor for peripheral arterial disease.

Estudo caso-controle com resposta multinomial: uma proposta de análise

Este estudo revisa alguns artigos com delineamento do tipo caso-controle em que se tem os casos classificados em dois ou mais tipos. A aplicação de modelos para respostas multinomiais e a adequabilidade destes aos estudos caso-controle é discutida. Dentre os ajustes possíveis, argumenta-se que o modelo logístico Politômico é o mais indicado para a obtenção de medidas epidemiológicas de risco e associação neste tipo de delineamento. Como ilustração, apresenta-se uma aplicação desse modelo em um estudo caso-controle de base populacional, comparando os resultados com aqueles obtidos em um ajuste logístico binomial. A abordagem multinomial possibilita investigar, em uma única análise, a ocorrência de associações entre co-variáveis e uma ou algumas das classes de casos estudados, abrindo a possibilidade, de grande interesse epidemiológico, de identificação de fatores de risco e de proteção individualizados para cada subgrupo de interesse.

Hypertension in rheumatoid arthritis

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.

Ankle arthrodesis in rheumatoid arthritis: techniques, results, and complications

This article defines specific risks associated with rheumatoid arthritis, including an increased incidence of medical comorbidities, the use of steroids and other immunosuppressive agents, osteoporosis, vascular disease, and the common occurrence of severe deformity. This article suggests approaches for management and techniques that may improve specific surgical issues in this challenging patient population.

Therapy Insight: managing cardiovascular risk in patients with rheumatoid arthritis

Chronic low-grade inflammation was recognized during the past decade as an important risk factor for the development of atherosclerosis and, more recently, for the development of heart failure. Patients with rheumatoid arthritis (RA) are at increased risk of morbidity and mortality from ischemic cardiovascular events and heart failure. Epidemiologic and clinical studies indicate that RA is an independent risk factor for cardiovascular disease, which suggests that chronic exposure to high levels of inflammatory mediators contributes to this enhanced risk. The relative contribution of conventional risk factors to the acceleration of cardiovascular disease does not seem to be increased in patients with RA compared with control populations. Nonetheless, some preclinical laboratory measures of risk factors (e.g. insulin sensitivity) are adversely modulated in the context of the highly inflammatory rheumatoid microenvironment. Discerning the net effect of RA therapies on cardiovascular disease is also challenging because, theoretically, their biologic effects could either promote or attenuate atherosclerosis and ventricular dysfunction; however, available data suggest a beneficial effect on cardiovascular morbidity and mortality in patients with RA. This review provides an overview of the potential influence of RA and its treatment on the development and progression of cardiovascular disease, and outlines some preliminary recommendations for prevention and management of this complication in patients with RA.

Excess recurrent cardiac events in rheumatoid arthritis patients with acute coronary syndrome

BACKGROUND

Cardiovascular mortality is increased in rheumatoid arthritis. Possible reasons include an increased incidence of ischaemic heart disease or worse outcome after acute coronary syndrome (ACS).

OBJECTIVES

To assess the outcome of ACS in rheumatoid arthritis compared with case matched controls in the context of underlying cardiac risk factors, clinical presentation, and subsequent management.

METHODS

40 patients with rheumatoid arthritis and ACS identified from coronary care admission registers between 1990 and 2000 were case matched as closely as possible for age, sex, classical cardiovascular risk factors, type and severity of ACS, and admission date (+/-3 months) with 40 controls. A standardised proforma was used for detailed case note review.

RESULTS

Age, sex, other cardiovascular risk factors, and type and severity of presenting ACS were not significantly different between cases and controls. Recurrent cardiac events were commoner in rheumatoid arthritis (23/40, 57.5%) than controls (12/40, 30%) (p = 0.013); there were 16/40 deaths in rheumatoid arthritis (40%) v 6/40 (15%) in controls (p = 0.012). Recurrent events occurred earlier in rheumatoid arthritis (log rank survival, p = 0.05). Presentation with chest pain occurred in all controls compared with 33/40 rheumatoid patients (82%) (p = 0.006); collapse occurred in one control (2.5%) v 7/40 rheumatoid patients (17.5%) (p = 0.025). Treatment during the ACS was not significantly different in the two groups.

CONCLUSIONS

Recurrent ischaemic events and death occur more often after ACS in rheumatoid arthritis. Atypical presentation is commoner in rheumatoid arthritis. There is an urgent need to develop identification and intervention strategies for ACS specific to this high risk group.

Disease modification and cardiovascular risk reduction: two sides of the same coin?

Inflammatory rheumatic diseases are associated with a substantial increase in accelerated atherosclerosis, with complex interactions between traditional and disease-related risk factors. Therefore, cardiovascular risk reduction should be considered as integral to the control of disease activity in the care plans of patients with RA, SLE and, arguably any chronic inflammatory disease. Shared care structures, already established for the monitoring of DMARDs, could be adapted to communicate and monitor cardiovascular risk reduction objectives. We review the evidence for the efficacy of a range of therapeutic strategies, the majority of which impact on both disease activity and cardiovascular risk. The algorithm proposed here attempts to distil the latest advice from specialist panels at the National Cholesterol Education Program and the British Hypertension Society, as well as incorporating the existing data on SLE and RA patients. The algorithm is structured to minimize clinic time and resources necessary to stratify patients into groups for ROUTINE, SUBSTANTIAL or INTENSIVE risk management; the associated table summarizes optimal therapeutic objectives in each of these groups. The implication of this algorithm is that management of cardiovascular risk should be much more aggressive than is currently the norm in patients with chronic inflammatory diseases, such as RA and SLE. Long-term studies of such interventions are needed to further clarify the benefits of intensive cardiovascular risk management in these patients.

[Atherosclerosis and rheumatoid arthritis]

AIMS

To identify studies which have shown that rheumatoid arthritis (RA) is associated with an increase in cardiovascular morbidity and mortality. To identify the different factors that may be involved. To consider what management would decrease the cardiovascular morbidity and mortality of RA.

RESULTS

Epidemiological studies have shown that the risk of a cardiovascular event is increased twofold in RA patients irrespective of the traditional cardiovascular risk factors. Non-invasive methods have shown that RA patients have endothelial dysfunction, decreased arterial compliance and increased intima-media thickers, predictive factors for cardiovascular events in comparison to controls after controlling for traditional cardiovascular risk factors. The increased cardiovascular risk is directly mediated by inflammatory syndrome, which also indirectly increases the risk by inducing dyslipidemia and insulin resistance. Treatments also have a hamful effect, whether it be corticosteroid therapy, non-steroidal anti-inflammatory drugs (NSAIDs), or methotrexate (MTX), which leads to hyperhromocysteinemia.

CONCLUSION

It should be possible to decrease cardiovascular morbidity and mortality by a strict control of the disease's activity. We should also take measures to combat other cardiovascular risk factors: as low a dose as possible for corticosteroid therapy, limited prescription of NSAIDs, systematic supplementation of MTX with folic acid encouragement of smoking cessation, regular lipid tests and prescription of statins treatment for hyperlipemia in accordance with current recommendations.