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Corrao S, Calvo L, Giardina A, Cangemi I, Falcone F, Argano C. Rheumatoid arthritis, cardiometabolic comorbidities, and related conditions: need to take action. Front Med (Lausanne) 2024; 11:1421328. [PMID: 39114820 PMCID: PMC11303151 DOI: 10.3389/fmed.2024.1421328] [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: 04/22/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024] Open
Abstract
Rheumatoid Arthritis (RA) is associated with an increased risk of cardiovascular disease and mortality, however, traditional cardiovascular risk factors do not fully explain this relationship. This high risk of cardiovascular morbidity and mortality in RA has been increasingly acknowledged in past decades, with accumulating evidence that RA is an independent cardiovascular risk factor; RA is also associated with metabolic syndrome, which correlates with disease activity, contributing to the increased prevalence of coronary heart disease in RA patients. Moreover, multimorbidity, including the presence of long-term conditions, impacts adverse clinical outcomes in RA patients, emphasizing the need for holistic management that requires an understanding of shared pathophysiological mechanisms, such as systemic inflammation and immune dysregulation. For all these reasons, the management of RA patients with cardiometabolic comorbidities is a complex endeavor that requires a patient-centered, multidisciplinary approach. In this sense, there is a need to re-evaluate the approach toward a proactive model of care, moving away from a reactive medical paradigm to a multidimensional integrated management model, including aggressive screening, preventive strategies, and tailored therapeutic interventions. The aim of this review was to thoroughly review the literature on cardiometabolic comorbidities and related conditions linked to RA to enable us to identify the necessary actions required to effectively tackle the increasing burden of illness from a fully comprehensive perspective.
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Affiliation(s)
- Salvatore Corrao
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties [PROMISE], University of Palermo, Palermo, Italy
| | - Luigi Calvo
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
| | - Annarita Giardina
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
| | - Ignazio Cangemi
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
| | - Fabio Falcone
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties [PROMISE], University of Palermo, Palermo, Italy
| | - Christiano Argano
- Department of Clinical Medicine, Internal Medicine Unit, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
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Rong JC, Chen XD, Jin NK, Hong J. Exploring the causal association of rheumatoid arthritis with atrial fibrillation: a Mendelian randomization study. Clin Rheumatol 2024; 43:29-40. [PMID: 37930596 DOI: 10.1007/s10067-023-06804-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND It has been proved that rheumatoid arthritis (RA) patients have high incidence of atrial fibrillation (AF). Nevertheless, whether they have causal relevance is uncertain. This study aimed to explore and verify the authenticity of causal relationship between RA and AF using Mendelian randomization (MR). METHODS The genome-wide association study (GWAS) summary data from Biobank Japan Project (BBJ) (RA, 4199 cases and 208,254 controls) were regarded as exposure data and the GWAS data from European Bio-informatics Institute database (EBI) (AF, 15,979 cases and 102,776 controls) as outcome data. The causal effect was appraised by the inverse variance weighted (IVW) method, MR-Egger regression, and weighted median estimator. MR-robust adjusted profile score (MR-RAPS) method was delivered to examine the robustness of causal relationship and MR Pleiotropy Residual Sum and Outlier (MR-PRESSO) method to control horizontal (directional) pleiotropy. RESULTS The results indicated that RA increased the risk of AF (IVW, the odds ratio (OR) = 1.060; 95% confidence interval (CI), 1.028 to 1.092; p = 1.411 × 10-4; weighted median, OR = 1.046, 95% CI, 1.002 to 1.093, p = 0.047). The MR analysis also showed this causal effect through all four IVW methods with various statistical algorithms. Both MR-RAPS and MR-PRESSO supported the causality of RA and AF. Also, the MR-PRESSO result indicated the absence of apparent pleiotropy. CONCLUSION There is a causal association between RA and AF. RA patients are genetically more vulnerable to AF. This study may contribute to further exploring early clinical prevention and fundamental mechanism of AF in patients with RA. Key Points • We provided some genetic evidence for the causal link between rheumatoid arthritis (RA) and atrial fibrillation (AF) with multiple Mendelian randomization (MR) methods. • RA patients were genetically more vulnerable to AF. • This study partly shed light on latent fundamental mechanisms underlying RA-induced AF and inspired future studies on RA-AF relationship.
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Affiliation(s)
- Jia-Cheng Rong
- Cardiovascular Department, Ningbo Hangzhou Bay Hospital, Hangzhou Bay New Area, Ningbo, Zhejiang, China
| | - Xu-Dong Chen
- Cardiovascular Department, Ningbo Hangzhou Bay Hospital, Hangzhou Bay New Area, Ningbo, Zhejiang, China
| | - Na-Ke Jin
- Cardiovascular Department, Ningbo Hangzhou Bay Hospital, Hangzhou Bay New Area, Ningbo, Zhejiang, China
| | - Jun Hong
- Cardiovascular Department, Ningbo Hangzhou Bay Hospital, Hangzhou Bay New Area, Ningbo, Zhejiang, China.
- Cardiovascular Department, Ningbo Hospital of Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Zhang J, Hou Q, Han Q, Peng X, Cao H, Wu S, Li K. Prediction of Major Adverse Cardiovascular Events by Triglyceride Glucose Index in Predominantly Male Patients with Rheumatoid Arthritis. Rev Cardiovasc Med 2024; 25:28. [PMID: 39077648 PMCID: PMC11262396 DOI: 10.31083/j.rcm2501028] [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: 08/01/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 07/31/2024] Open
Abstract
Background Rheumatoid arthritis (RA) is a systemic and chronic autoimmune disease that is characterized by persistent joint inflammation. RA patients experience a considerably increased risk of cardiovascular-related morbidity and mortality. The current study investigated the association between triglyceride glucose (TyG) index and major adverse cardiovascular events (MACEs) in a predominantly male cohort of RA patients. Methods A total of 1613 RA patients (81.53% male) were selected from the Kailuan study. The TyG index was calculated as the logarithmic product of fasting blood triglyceride and fasting blood glucose divided by two. MACEs were defined as the composite of non-fatal myocardial infarctions and non-fatal strokes. Cox proportional hazards analysis was performed to study the association between the TyG index and MACEs. Results A total of 59 MACEs occurred during the median follow-up time of 5.32 years. Following adjustment for age and gender, analysis by multivariable Cox proportional hazards (model 1) showed that an elevated TyG index was associated with an increased risk of MACEs (quartile 2, hazard ratio (HR): 2.741, 95% confidence interval (CI): 1.220-6.157, p = 0.015; quartile 4, HR: 2.521, 95% CI: 1.074-5.917, p = 0.034). After adjustment for other variables, Cox proportional hazards analysis (model 2) showed that an elevated TyG index was independently associated with an increased risk of MACEs (quartile 2, HR: 2.348, 95% CI: 1.009-5.465, p = 0.048). In addition, subgroup analysis showed a higher TyG index was significantly linked to an increased risk of MACEs in patients aged more than 65 years (quartile 2, HR: 6.048, 95% CI: 1.311-27.908, p = 0.021; quartile 4, HR: 12.074, 95% CI: 1.438-101.358, p = 0.022). Conclusions The TyG index was associated with an increased risk of MACEs in a predominantly male cohort of RA patients. This index may be helpful for the prediction of MACEs in male patients with RA. Clinical Trial Registration Registration number in the Chinese clinical trial registry: ChiCTR-TNRC-11001489.
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Affiliation(s)
- Jiawei Zhang
- Department of Rehabilitation Medicine, Kailuan Tangjiazhuang Hospital, 063000 Tangshan, Hebei, China
| | - Qiqi Hou
- Hebei Medical University, 050017 Shijiazhuang, Hebei, China
| | - Quanle Han
- Department of Cardiology, Tangshan Gongren Hospital, 063000 Tangshan, Hebei, China
| | - Xu Peng
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hongxia Cao
- Catheterization Unit, Tangshan Gongren Hospital, 063000 Tangshan, Hebei, China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, 063000 Tangshan, Hebei, China
- School of Clinical Medicine, North China University of Science and Technology, 063000 Tangshan, Hebei, China
| | - Kangbo Li
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- School of Clinical Medicine, North China University of Science and Technology, 063000 Tangshan, Hebei, China
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Parmar SS, Mohamed MO, Mamas MA, Wilkie R. The clinical characteristics, managements, and outcomes of acute myocardial infarction in osteoarthritis patients; a cross-sectional analysis of 6.5 million patients. Expert Rev Cardiovasc Ther 2024; 22:121-129. [PMID: 38284347 DOI: 10.1080/14779072.2024.2311696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/25/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The prevalence of osteoarthritis (OA) and cardiovascular disease are increasing and both conditions share similar risk factors. We investigated the association between OA and receipt of invasive managements and clinical outcomes in patients with acute myocardial infarction (AMI). METHODS Using the National Inpatient Sample, adjusted binary logistic regression determined the association between OA and each outcome variable. RESULTS Of 6,561,940 AMI hospitalizations, 6.3% had OA. OA patients were older and more likely to be female. OA was associated with a decreased odds of coronary angiography (adjusted odds ratio 0.91; 95% confidence interval 0.90, 0.92), PCI (0.87; 0.87, 0.88), and coronary artery bypass grafting (0.98; 0.97, 1.00). OA was associated with a decreased odds of adverse outcomes (in-hospital mortality: 0.68; 0.67, 0.69; major acute cardiovascular and cerebrovascular events: 0.71; 0.70, 0.72; all-cause bleeding: 0.76; 0.74, 0.77; and stroke/TIA: 0.84; 0.82, 0.87). CONCLUSIONS This study of a representative sample of the US population highlights that OA patients are less likely to be offered invasive interventions following AMI. OA was also associated with better outcomes post-AMI, possibly attributed to a misclassification bias where unwell patients with OA were less likely to receive an OA code because codes for serious illness took precedence.
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Affiliation(s)
- Simran Singh Parmar
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Keele University, Staffordshire, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Staffordshire, UK
| | - Ross Wilkie
- School of Medicine, Keele University, Staffordshire, UK
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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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McDowell B, Marr C, Holmes C, Edwards CJ, Cardwell C, McHenry M, Meenagh G, McGuinness B. Prevalence of cognitive impairment in patients with rheumatoid arthritis: a cross sectional study. BMC Psychiatry 2022; 22:777. [PMID: 36494656 PMCID: PMC9733399 DOI: 10.1186/s12888-022-04417-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To explore the role of chronic inflammation in rheumatoid arthritis (RA) on cognition. METHODS AND ANALYSIS Six hundred sixty-one men and women aged ≥55 years who fulfilled the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for RA were recruited from three healthcare trusts in the United Kingdom (UK) between May 2018 and March 2020. Study participants took part in interviews which captured sociodemographic information, followed by an assessment of cognition. RA specific clinical characteristics were obtained from hospital medical records. Participants were cognitively assessed using the Montreal Cognitive Assessment (MoCA) and were classified as cognitively impaired if they scored ≤27/30 points. Linear regression analyses were conducted to identify which demographic and clinical variables were potential predictors of cognitive impairment. RESULTS The average age of participants was 67.6 years and 67% (444/661) were women. 72% (458/634; 95% CI 0.69 to 0.76) of participants were classified as cognitively impaired (MoCA≤27). Greater cognitive impairment was associated with older age (p = .006), being male (p = .041) and higher disease activity score (DAS28) (with moderate (DAS28 > 3.1) (p = 0.008) and high (DAS28 > 5.1) (p = 0.008)) compared to those in remission (DAS28 ≤ 2.6). There was no association between MoCA score and education, disease duration, RF status, anti-cyclic citrullinated peptide (anti-CCP) status, RA medication type or use of glucocorticoids or non-steroidal anti-inflammatory drugs (p > 0.05). CONCLUSION This study suggests that cognitive impairment is highly prevalent in older adults with RA. This impairment appears to be associated with higher RA disease activity and supports the concept that chronic systemic inflammation might accelerate cognitive decline. This underlines the importance of controlling the inflammatory response.
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Affiliation(s)
- Bethany McDowell
- grid.4777.30000 0004 0374 7521Queen’s University Belfast, Belfast, Northern Ireland
| | - Calum Marr
- grid.4777.30000 0004 0374 7521Queen’s University Belfast, Belfast, Northern Ireland
| | - Clive Holmes
- grid.5491.90000 0004 1936 9297University of Southampton, Southampton, England ,grid.467048.90000 0004 0465 4159Southern Health NHS Foundation Trust, Southampton, England
| | - Christopher J. Edwards
- grid.5491.90000 0004 1936 9297University of Southampton, Southampton, England ,NIHR Southampton Clinical Research Facility, Southampton, England ,grid.430506.40000 0004 0465 4079University Hospital Southampton NHS Foundation Trust, Southampton, England
| | - Christopher Cardwell
- grid.4777.30000 0004 0374 7521Queen’s University Belfast, Belfast, Northern Ireland
| | - Michelle McHenry
- grid.412915.a0000 0000 9565 2378Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Gary Meenagh
- grid.413824.80000 0000 9566 1119Northern Health and Social Care Trust, Antrim, Northern Ireland
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Palomäki A, Kerola AM, Malmberg M, Rautava P, Kytö V. Patients with rheumatoid arthritis have impaired long-term outcomes after myocardial infarction - a nationwide case-control registry study. Rheumatology (Oxford) 2021; 60:5205-5215. [PMID: 33667301 PMCID: PMC8566209 DOI: 10.1093/rheumatology/keab204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/14/2021] [Indexed: 01/06/2023] Open
Abstract
Objective To investigate the long-term outcomes of patients with RA after myocardial infarction (MI). Methods All-comer, real-life MI patients with RA (n = 1614, mean age 74 years) were retrospectively compared with propensity score (1:5) matched MI patients without RA (n = 8070) in a multicentre, nationwide, cohort register study in Finland. The impact of RA duration and the usage of corticosteroids and antirheumatic drugs on RA patients’ outcomes were also studied. The median follow-up was 7.3 years. Results RA was associated with an increased 14-year mortality risk after MI compared with patients without RA [80.4% vs 72.3%; hazard ratio (HR) 1.25; CI: 1.16, 1.35; P <0.0001]. Patients with RA were at higher risk of new MI (HR 1.22; CI: 1.09, 1.36; P =0.0001) and revascularization (HR 1.28; CI: 1.10, 1.49; P =0.002) after discharge from index MI. Cumulative stroke rate after MI did not differ between RA and non-RA patients (P =0.322). RA duration and corticosteroid usage before MI, but not use of methotrexate or biologic antirheumatic drugs, were independently associated with higher mortality (P <0.001) and new MI (P =0.009). A higher dosage of corticosteroids prior to MI was independently associated with higher long-term mortality (P =0.002) and methotrexate usage with lower stroke rate (P =0.034). Serological status of RA was not associated with outcomes. Conclusion RA is independently associated with poorer prognosis after MI. RA duration and corticosteroid usage and dosage were independent predictors of mortality after MI in RA. Special attention is needed for improvement of outcomes after MI in this vulnerable population.
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Affiliation(s)
- Antti Palomäki
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland.,Department of Medicine, University of Turku, Turku, Finland.,Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Anne M Kerola
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Department of Rheumatology, Päijät-Häme Joint Authority for Health and Wellbeing, Lahti, Finland
| | - Markus Malmberg
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland.,Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Centre, Hospital District of Southwest Finland, Turku, Finland
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Jang SY, Kang KW, Jo M, Park M. Risk of New-Onset Acute Coronary Syndrome and Atrial Fibrillation in Patients With Rheumatoid Arthritis Compared With a Risk-Set and Propensity Score-Matched Cohort - A Nationwide Cohort Study. Circ J 2021; 85:194-200. [PMID: 33328426 DOI: 10.1253/circj.cj-20-0825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) has extra-articular manifestations of cardiovascular diseases and is associated with a high mortality rate in Western populations. This study aimed to investigate the risk of acute coronary syndrome (ACS) and atrial fibrillation (AF) associated with RA in a Korean population.Methods and Results:Patients were selected from a senior cohort from the Korean National Health Insurance Service in 2002, and followed until 31 December 2015. Patients with newly developed ACS and AF were identified and compared with controls for a 10-year period using time-dependent propensity and risk-set matching. A total of 4,217 incident RA patients and their 8,432 controls comprised the incident RA and matched cohorts, respectively. ACS was identified during 24,642 person-years [incidence rate (IR) 402 per 10,000 person-years, 95% confidence interval (CI) 330-489] among the RA cohort. In the matched cohort, 141 ACS patients were identified during 50,011 person-years (IR 282 per 100,000 person-years, 95% CI 239-333). RA patients were 1.43-fold more likely to develop ACS than the matched controls [hazard ratio (HR) 1.43, 95% CI 1.10-1.84], but showed similar occurrence risk of AF (HR 1.06, 95% CI 0.83-1.35). CONCLUSIONS A higher risk for ACS and a similar risk for AF were found by risk-set matched analysis in a senior RA cohort compared with the control, using Korean nationwide long-term data.
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Affiliation(s)
- Suk-Yong Jang
- Department of Preventive Medicine, Eulji University School of Medicine
| | - Ki-Woon Kang
- Division of Cardiology, Department of Internal Medicine, Eulji University School of Medicine
| | - Mirae Jo
- Graduate School, College of Nursing, Eulji University
| | - Mira Park
- Department of Preventive Medicine, Eulji University School of Medicine
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Robert M, Hot A, Mifsud F, Ndongo-Thiam N, Miossec P. Joint Destruction Is Associated With All Types of Cardiovascular Events in French Rheumatoid Patients: A Real-Life Study With Very Long Follow-Up. Front Med (Lausanne) 2020; 7:556086. [PMID: 33195306 PMCID: PMC7661545 DOI: 10.3389/fmed.2020.556086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/30/2020] [Indexed: 01/02/2023] Open
Abstract
Objective: Rheumatoid arthritis (RA) leads not only to joint destruction but also to systemic manifestations, with an increased incidence of cardiovascular events (CVE). Many studies have shown a link between RA severity and CV risk, but the duration of follow-up remains often insufficient to allow a conclusion. The CVE definition was generally reduced to myocardial infarction and stroke, and few studies were conducted in non-Anglo-Saxon countries with low CV incidence. This study aimed to assess the relationship between joint destruction and the occurrence of different types of CVE in a large cohort of French RA patients with a long-term follow-up. Methods: This historical cohort study included 571 RA patients followed between 1992 and 2012 in Lyon, France. The primary endpoint was the first occurrence of a CVE. Logistic regressions were used to identify factors associated with CVE occurrence. Cox proportional hazard models were performed as a separate analysis to take advantage of the long-term follow-up. Results: During a mean follow-up of 16.1 years, 30.3% of patients experienced a CVE, mostly acute arterial events. Joint destruction was associated with an increased risk of CVE [odds ratio = 3.72; 95% confidence interval (CI), 1.09–15.35; p = 0.047] among non-smoker RA patients. A survival analysis revealed that joint destruction was associated with a shorter time to onset of the first CVE only among non-smokers (hazard ratio = 3.44; 95% CI, 1.07–11.04; p = 0.038). Conclusion: Joint destruction is associated with CVE occurrence in RA patients from a population with a lower incidence of CV disease. This study suggests that RA patients, especially those with destruction, merit the institution of precise guidelines to manage this CV risk, and trials are required to evaluate them.
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Affiliation(s)
- Marie Robert
- Department of Clinical Immunology and Rheumatology, Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon 1, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Hot
- Department of Internal Medicine, Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon 1, Hôpital Edouard Herriot, Lyon, France
| | - François Mifsud
- Department of Clinical Immunology and Rheumatology, Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon 1, Hôpital Edouard Herriot, Lyon, France
| | - Ndiémé Ndongo-Thiam
- Department of Clinical Immunology and Rheumatology, Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon 1, Hôpital Edouard Herriot, Lyon, France
| | - Pierre Miossec
- Department of Clinical Immunology and Rheumatology, Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon 1, Hôpital Edouard Herriot, Lyon, France
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Lai CH, Hsieh CY, Barnado A, Huang LC, Chen SC, Tsai LM, Shyr Y, Li CY. Outcomes of acute cardiovascular events in rheumatoid arthritis and systemic lupus erythematosus: a population-based study. Rheumatology (Oxford) 2020; 59:1355-1363. [PMID: 31600392 DOI: 10.1093/rheumatology/kez456] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/04/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Patients with RA and SLE have an excess cardiovascular risk. We aimed to evaluate outcomes of acute cardiovascular events in these patients. METHODS Using a nationwide database of Taiwan, we identified adult patients who experienced first-time acute myocardial infarction (n = 191 008), intracranial haemorrhage (n = 169 923) and ischaemic stroke (n = 486 890) over a 13-year period. Odds ratios (ORs) of in-hospital mortality and hazard ratios (HRs) of overall mortality and adverse outcomes during long-term follow-up in relation to RA and SLE were estimated with adjustment for potential confounders. RESULTS In each cohort, 748, 410 and 1419 patients had established RA; 256, 292 and 622 patients had SLE. Among acute myocardial infarction patients, RA and SLE were associated with in-hospital mortality (RA: OR 1.61, 95% CI 1.33, 1.95; SLE: OR 2.31, 95% CI 1.62, 3.28) and overall mortality. Additionally, RA (HR 1.28, 95% CI 1.18, 1.38) and SLE (HR 1.46, 95% CI 1.27, 1.69) increased the risk of major adverse cardiac events. After intracranial haemorrhage, patients with RA and SLE had higher risks of in-hospital mortality (RA: OR 1.61, 95% CI 1.26, 2.06; SLE: OR 3.00, 95% CI 2.33, 3.86) and overall mortality. After ischaemic stroke, RA and SLE increased in-hospital mortality (RA: OR 1.45, 95% CI 1.15, 1.83; SLE: OR 2.18, 95% CI 1.57, 3.02), overall mortality and recurrent cerebrovascular events (RA: HR 1.10, 95% CI 1.002, 1.21; SLE: HR 1.31, 95% CI 1.14, 1.51), among which ischaemic stroke (HR 1.39, 95% CI 1.19, 1.62) was more likely to recur in SLE patients. CONCLUSION Both RA and SLE are consistently associated with adverse outcomes following acute cardiovascular events, highlighting the necessity of integrated care for affected patients.
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Affiliation(s)
- Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - April Barnado
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li-Ching Huang
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liang-Miin Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
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Immunotherapy for the rheumatoid arthritis-associated coronary artery disease: promise and future. Chin Med J (Engl) 2020; 132:2972-2983. [PMID: 31855971 PMCID: PMC6964948 DOI: 10.1097/cm9.0000000000000530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective: To review the latest progress on the pathogenic mechanism and management of rheumatoid arthritis (RA)-associated coronary artery disease (CAD), and propose advice on future management optimization as well as prospects for research and development of new therapeutic regimen. Data sources: This study was based on data obtained from PubMed up to May 2019 using various search terms and their combinations, including coronary artery disease, myocardial ischemia, cardiovascular diseases, RA, rheumatic diseases, treatment, therapy, strategies, immunotherapy, inflammation, and anti-inflammation. Study selection: All retrieved literature was scrutinized, most relevant articles about the pathogenic mechanism and clinical management, especially anti-inflammatory therapy of RA-associated CAD were reviewed. Results: RA is an immune-mediated chronic inflammatory disease which has a great social disease burden. In addition to typical arthritic manifestations, RA also affects extra-articular tissues and organs, within which the involvement of the cardiovascular system, especially incorporating CAD, is the leading cause of death for patients with RA. Recently, numerous basic and clinical studies have been carried out on the mechanism of CAD development and progression under the inflammatory cascade of RA. The effect of traditional RA drugs on CAD risk management has been gradually clarified, and more emerging biologic agents are being explored and studied, which have also achieved satisfactory outcomes. Furthermore, with the success of the CANTOS clinical trial, novel anti-inflammatory therapy for the prevention of cardiovascular disease is believed to have a broad prospect. Conclusions: RA is an independent risk factor for CAD, which mainly results from the underlying inflammatory cascade; therefore, anti-inflammatory therapy, especially the emerging novel biologic drugs, is important for CAD management in patients with RA and may also be a promising approach among the general population.
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Inflammatory rheumatic disorders and readmission following acute myocardial infarction: analysis from the Nationwide Readmissions Database. Coron Artery Dis 2020; 31:739-741. [PMID: 32168055 DOI: 10.1097/mca.0000000000000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Skielta M, Söderström L, Rantapää-Dahlqvist S, Jonsson SW, Mooe T. Trends in mortality, co-morbidity and treatment after acute myocardial infarction in patients with rheumatoid arthritis 1998-2013. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:931-938. [PMID: 31990203 DOI: 10.1177/2048872619896069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS Rheumatoid arthritis may influence the outcome after an acute myocardial infarction. We aimed to compare trends in one-year mortality, co-morbidities and treatments after a first acute myocardial infarction in patients with rheumatoid arthritis versus non-rheumatoid arthritis patients during 1998-2013. Furthermore, we wanted to identify characteristics associated with mortality. METHODS AND RESULTS Data for 245,377 patients with a first acute myocardial infarction were drawn from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions for 1998-2013. In total, 4268 patients were diagnosed with rheumatoid arthritis. Kaplan-Meier analysis was used to study mortality trends over time and multivariable Cox regression analysis was used to identify variables associated with mortality. The one-year mortality in rheumatoid arthritis patients was initially lower compared to non-rheumatoid arthritis patients (14.7% versus 19.7%) but thereafter increased above that in non-rheumatoid arthritis patients (17.1% versus 13.5%). In rheumatoid arthritis patients the mean age at admission and the prevalence of atrial fibrillation increased over time. Congestive heart failure decreased more in non-rheumatoid arthritis than in rheumatoid arthritis patients. Congestive heart failure, atrial fibrillation, kidney failure, rheumatoid arthritis, prior diabetes mellitus and hypertension were associated with significantly higher one-year mortality during the study period 1998-2013. CONCLUSIONS The decrease in one-year mortality after acute myocardial infarction in non-rheumatoid arthritis patients was not applicable to rheumatoid arthritis patients. This could partly be explained by an increased age at acute myocardial infarction onset and unfavourable trends with increased atrial fibrillation and congestive heart failure in rheumatoid arthritis. Rheumatoid arthritis per se was associated with a significantly worse prognosis.
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Affiliation(s)
- Mattias Skielta
- Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, Sweden
| | | | | | - Solveig W Jonsson
- Department of Public Health and Clinical Medicine, Rheumatology, Umeå University, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
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Hsieh MJ, Lee CH, Tsai ML, Kao CF, Lan WC, Huang YT, Tseng WY, Wen MS, Chang SH. Biologic Agents Reduce Cardiovascular Events in Rheumatoid Arthritis Not Responsive to Tumour Necrosis Factor Inhibitors: A National Cohort Study. Can J Cardiol 2020; 36:1739-1746. [PMID: 32603700 DOI: 10.1016/j.cjca.2020.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Tumour necrosis factor inhibitors (TNFis) improve joints outcomes and reduce cardiovascular (CV) risk in patients with rheumatoid arthritis (RA). However, 20%-45% of RA patients are TNFi poor responders and have a significantly higher risk of CV events. In these TNFi nonresponders, the use of second-line biologic agents to improve synovial outcomes is supported by clinical trials and real-world experience. However, it remains unknown what kind of immune-mediated agent has the best CV prevention effect in this high-risk population. METHODS A nationwide RA cohort obtained from Taiwan's National Health Insurance claims database was constructed. RA patients first treated with TNFis who then received either rituximab, tocilizumab, or abatacept were enrolled and followed for 2 years. RESULTS A total of 89,973 RA patients were screened and 1,584 patients ultimately included. The incidences of major adverse cardiac events (MACE) at 2 years in the rituximab, tocilizumab, and abatacept groups were 7.17%, 2.75% and 2.38%, respectively. Multivariate adjusted Cox analysis showed that tocilizumab had significantly lower risk than rituximab in myocardial infarction (hazard ratio [HR] 0.12, 95% confidence interval [CI] 0.02-0.56; P = 0.008), and MACE (HR 0.41, 95% CI 0.23-0.72; P = 0.002). In addition, abatacept also had significant lower adjusted risk than rituximab in stroke (HR 0.18, 95% CI 0.05-0.64; P = 0.008), heart failure (HR 0.20, 95% CI 0.05-0.83; P = 0.027), and MACE (HR 0.25, 95% CI 0.11-0.55; P < 0.001) in multivariate analysis. CONCLUSIONS TNFi-nonresponder patients with RA who received second-line tocilizumab or abatacept had more benefit on CV events prevention compared with those who received rituximab.
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Affiliation(s)
- Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Lung Tsai
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Rheumatology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wen-Ching Lan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Wen-Yi Tseng
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Rheumatology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
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15
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Plasma from Patients with Rheumatoid Arthritis Reduces Nitric Oxide Synthesis and Induces Reactive Oxygen Species in A Cell-Based Biosensor. BIOSENSORS-BASEL 2019; 9:bios9010032. [PMID: 30818887 PMCID: PMC6468433 DOI: 10.3390/bios9010032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/08/2019] [Accepted: 02/13/2019] [Indexed: 12/29/2022]
Abstract
Rheumatoid arthritis (RA) has been associated with a higher risk of developing cardiovascular (CV) diseases. It has been proposed that systemic inflammation plays a key role in premature atherosclerosis development, and is therefore crucial to determine whether systemic components from RA patients promotes endothelial cell-oxidative stress by affecting reactive oxygen species (ROS) and nitric-oxide (NO) production. The aim of this study was to evaluate whether plasma from RA patients impair NO synthesis and ROS production by using the cell-line ECV-304 as a biosensor. NO synthesis and ROS production were measured in cells incubated with plasma from 73 RA patients and 52 healthy volunteers by fluorimetry. In addition, traditional CV risk factors, inflammatory molecules and disease activity parameters were measured. Cells incubated with plasma from RA patients exhibited reduced NO synthesis and increased ROS production compared to healthy volunteers. Furthermore, the imbalance between NO synthesis and ROS generation in RA patients was not associated with traditional CV risk factors. Our data suggest that ECV-304 cells can be used as a biosensor of systemic inflammation-induced endothelial cell-oxidative stress. We propose that both NO and ROS production are potential biomarkers aimed at improving the current assessment of CV risk in RA.
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Zeng F, Wen W, Cui W, Zheng W, Liu Y, Sun X, Hou N, Ma D, Yuan Y, Shi H, Wang Z, Li Z, Xiao Y, Wang C, Li Y, Shang H, Li C, Wang J, Zhang Y, Xiao RP, Zhang X. Central role of RIPK1-VDAC1 pathway on cardiac impairment in a non-human primate model of rheumatoid arthritis. J Mol Cell Cardiol 2018; 125:50-60. [DOI: 10.1016/j.yjmcc.2018.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
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17
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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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Mason A, Holmes C, Edwards CJ. Inflammation and dementia: Using rheumatoid arthritis as a model to develop treatments? Autoimmun Rev 2018; 17:919-925. [PMID: 30005856 DOI: 10.1016/j.autrev.2018.04.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022]
Abstract
Dementia is a major international public health problem which looks set to grow as the ageing population increases. Despite large amounts of investment there has been relatively little progress in developing new therapies to combat this. There is a growing body of evidence that both local and systemic inflammation are important in dementia; with cerebral inflammation occurring secondarily to beta-amyloid plaques, raised levels of serum inflammatory molecules and cytokines being present in Alzheimer's disease patients and systemic inflammation being associated with cerebral microvasculature disease in vascular dementia. Observational studies had suggested that non-steroidal anti-inflammatory drugs may reduce the risk of dementia, but subsequent interventional studies have been disappointing. More recently some observational studies have suggested a protective effect from conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS) and tumour necrosis factor inhibiting (TNFi) biological therapies. Treatments for inflammatory rheumatic diseases have previously been repurposed and used successfully in other diseases, such as TNFi for inflammatory bowel disease. There are also studies looking at the use of csDMARDs such as methotrexate to improve outcomes after cardiovascular events. Ongoing interventional trials are currently looking at whether therapies designed to treat inflammatory and autoimmune diseases have the potential to be used to treat dementia.
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Affiliation(s)
- Alice Mason
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Christopher J Edwards
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; MSK Research Unit, NIHR Clinical Research Facility, University of Southampton & University Hospital Southampton NHS Foundation Trust, UK.
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Li Q, Wang B, Mu K, Zhang J, Yang Y, Yao W, Zhu J, Zhang JA. Increased Risk of Thyroid Dysfunction Among Patients With Rheumatoid Arthritis. Front Endocrinol (Lausanne) 2018; 9:799. [PMID: 30687237 PMCID: PMC6336701 DOI: 10.3389/fendo.2018.00799] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Thyroid dysfunction seems to be common among rheumatoid arthritis (RA) patients, but the risk of thyroid dysfunction in RA has not been well-defined. Methods: We performed a case-control study of 65 RA patients and 550 matched non-RA subjects to assess the risk of thyroid dysfunction among Chinese RA patients. A systematic review and meta-analysis was also conducted to comprehensively define the relationship between RA and thyroid dysfunction. Results: The case-control study indicated that the prevalence of thyroid dysfunction was significantly higher in RA patients than controls (OR = 2.89, P < 0.001). Further subgroup analyses revealed positive correlations of RA with hypothyroidism (OR = 2.28, P = 0.006) and hyperthyroidism (OR = 8.95, P < 0.001). Multivariate logistic regression analysis revealed an independent association between RA and thyroid dysfunction (Adjusted OR = 2.89, 95%CI 1.63-5.12, P < 0.001). Meta-analysis of 15 independent studies also showed an obviously increased risk of thyroid dysfunction among RA patients (RR = 2.86, 95%CI 1.78-4.58, P < 0.001). Further subgroup analysis showed RA could obviously increase risk of hyperthyroidism (RR = 2.73, 95%CI 1.29-5.77, P = 0.043) and hypothyroidism (RR = 2.02, 95%CI 1.49-2.74, P < 0.001). Conclusion: Our study provides strong evidence for the increased risk of thyroid dysfunction among RA patients. Screening of thyroid dysfunction may be recommended for RA patients.
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Affiliation(s)
- Qian Li
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Bin Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Kaida Mu
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jing Zhang
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Yanping Yang
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Wei Yao
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jie Zhu
- Department of Endocrinology & Rheumatology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Jin-an Zhang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
- *Correspondence: Jin-an Zhang
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Mantel Ä, Holmqvist M, Jernberg T, Wållberg-Jonsson S, Askling J. Long-term outcomes and secondary prevention after acute coronary events in patients with rheumatoid arthritis. Ann Rheum Dis 2017; 76:2017-2024. [DOI: 10.1136/annrheumdis-2017-211608] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/14/2017] [Accepted: 07/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectivesPatients with rheumatoid arthritis (RA) are at increased risk of acute coronary syndrome (ACS) and suffer from poorer short-term outcomes after ACS. The aims of this study were to assess long-term outcomes in patients with RA with ACS compared with non-RA patients with ACS, and to investigate whether the use of secondary preventive drugs could explain any differences in ACS outcome.MethodsWe performed a cohort study based on 1135 patients with RA and 3184 non-RA patients who all developed an incident ACS between 2007 and 2010. We assessed 1-year and overall relative risks for ACS recurrence and mortality, as well as prescriptions of standard of care secondary preventive drugs.ResultsThe risk of ACS recurrence, and of mortality, was increased in RA, both at 1 year after adjusting for baseline comorbidities (HR=1.30(95% CI 1.04 to 1.62) and 1.38(95% CI 1.20 to 1.59), respectively) and throughout the complete (mean 2 years) follow-up (HR=1.27(95% CI 1.06 to 1.52) and 1.50(95% CI 1.34 to 1.68), respectively). Among certain subgroups of ACS, there was a tendency of lower usage of statins, whereas there were no apparent differences in others. The increased rates of ACS recurrence and mortality remained in subgroup analyses of individuals whose prescription pattern indicated both adequate initiation and persistence to secondary preventive treatments.ConclusionsPatients with RA suffer from an increased risk of ACS recurrence and of death following ACS compared with general population, which in the present study could not readily be explained by differences in usage of secondary preventive drugs.
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Schieir O, Tosevski C, Glazier RH, Hogg-Johnson S, Badley EM. Incident myocardial infarction associated with major types of arthritis in the general population: a systematic review and meta-analysis. Ann Rheum Dis 2017; 76:1396-1404. [PMID: 28219882 DOI: 10.1136/annrheumdis-2016-210275] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 01/16/2017] [Accepted: 01/22/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To synthesise, quantify and compare risks for incident myocardial infarction (MI) across five major types of arthritis in population-based studies. METHODS A systematic search was performed in MEDLINE, EMBASE and CINAHL databases with additional manual/hand searches for population-based cohort or case-control studies published in English of French between January 1980 and January 2015 with a measure of effect and variance for associations between incident MI and five major types of arthritis: rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), gout or osteoarthritis (OA), adjusted for at least age and sex. All search screening, data abstraction quality appraisals were performed independently by two reviewers. Where appropriate, random-effects meta-analysis was used to pool results from studies with a minimum of 10 events. RESULTS We identified a total of 4, 285 articles; 27 met review criteria and 25 criteria for meta-analyses. In studies adjusting for age and sex, MI risk was significantly increased in RA (pooled relative risk (RR): 1.69, 95% CI 1.50 to 1.90), gout (pooled RR: 1.47, 95% CI 1.24 to 1.73), PsA (pooled RR: 1.41, 95% CI 1.17 to 1.69), OA (pooled RR: 1.31, 95% CI 1.01 to 1.71) and tended towards increased risk in AS (pooled RR: 1.24, 95% CI 0.93 to 1.65). Traditional risk factors were more prevalent in all types of arthritis. MI risk was attenuated for each type of arthritis in studies adjusting for traditional risk factors and remained significantly increased in RA, PsA and gout. CONCLUSIONS MI risk was consistently increased in multiple types of arthritis in population-based studies, and was partially explained by a higher prevalence of traditional risk factors in all types of arthritis. Findings support more integrated cardiovascular (CV) prevention strategies for arthritis populations that target both reducing inflammation and enhancing management of traditional CV risk factors.
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Affiliation(s)
- Orit Schieir
- Division of Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Richard H Glazier
- Department of Family and Community Medicine, Institute for Clinical Evaluative Sciences, Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth M Badley
- Division of Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada.,Division of Health Care & Outcomes Research, Toronto Western Research Institute, Toronto, Ontario, Canada
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Isogai T, Matsui H, Tanaka H, Yokogawa N, Fushimi K, Yasunaga H. Treatments and in-hospital mortality in acute myocardial infarction patients with rheumatoid arthritis: a nationwide retrospective cohort study in Japan. Clin Rheumatol 2017; 36:995-1004. [PMID: 28124758 DOI: 10.1007/s10067-017-3555-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/09/2016] [Accepted: 01/18/2017] [Indexed: 01/29/2023]
Abstract
No previous study has examined the differences in treatments and outcomes after acute myocardial infarction (AMI) between patients with and without rheumatoid arthritis (RA) in a setting where coronary reperfusion therapy was readily available. This study aimed to examine whether coexisting RA affected likelihood of receiving coronary reperfusion therapy and in-hospital mortality among AMI patients in a Japanese nationwide setting where coronary reperfusion therapy was readily available. Using the Diagnosis Procedure Combination database, we retrospectively identified patients admitted with AMI between 2010 and 2014 and created a matched-pair cohort of patients with and without RA based on age, sex, hospital, and admission year at a maximum ratio of 1:5. We performed multivariable logistic regression analyses for associations of RA with likelihood of coronary reperfusion therapy and 30-day in-hospital mortality. There were no significant differences between the RA group (n = 938) and non-RA group (n = 3839) in the proportions of patients receiving coronary reperfusion therapy (on the day of admission 75.8% vs. 77.2%, P = 0.364; during hospitalization 87.1% vs. 87.3%, P = 0.913) and 30-day in-hospital mortality (5.9% vs. 5.9%, P = 1.000). Multivariable logistic regression analyses showed that RA was not significantly associated with either likelihood of receiving coronary reperfusion therapy during hospitalization (odds ratio 1.02; 95% confidence interval 0.82-1.27; P = 0.837) or 30-day in-hospital mortality (odds ratio 1.16; 95% confidence interval 0.81-1.65; P = 0.419). Coexisting RA did not affect likelihood of receiving coronary reperfusion therapy or in-hospital mortality among AMI patients in a setting where reperfusion therapy was readily available.
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Affiliation(s)
- Toshiaki Isogai
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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23
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Barnes EL, Beery RM, Schulman AR, McCarthy EP, Korzenik JR, Winter RW. Hospitalizations for Acute Myocardial Infarction Are Decreased Among Patients with Inflammatory Bowel Disease Using a Nationwide Inpatient Database. Inflamm Bowel Dis 2016; 22:2229-37. [PMID: 27542135 PMCID: PMC6044732 DOI: 10.1097/mib.0000000000000899] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Questions remain regarding the true prevalence of cardiovascular events such as myocardial infarction (MI) among patients with inflammatory bowel disease (IBD). Using the Nationwide Inpatient Sample (NIS), we aimed to compare the proportion of hospitalizations for acute MI among patients with IBD with that of the general population. METHODS This study used data from years 2000 to 2011 in Nationwide Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. International Classification of Diseases, Ninth Revision, Clinical Modification discharge codes were used to identify adult patients with discharge diagnoses of IBD (ulcerative colitis or Crohn's disease), acute MI, and multiple comorbid risk factors for cardiovascular disease. The independent effect of a diagnosis of IBD on risk of acute MI was examined using a multivariable logistic regression model controlling for multiple confounders. Data were analyzed using SAS survey procedures and weighted to reflect national estimates. RESULTS We identified 567,438 hospitalizations among patients with IBD and 78,121,000 hospitalizations among the general population. Patients with IBD were less likely to be hospitalized for acute MI than patients in the general population (1.3% versus 3.1%, P < 0.001). In adjusted analyses, the odds of hospitalization for acute MI among patients with IBD were decreased when compared with the general population (odds ratio, 0.51; 95% confidence interval, 0.50-0.52). CONCLUSIONS Despite prior reports of a potentially increased risk of acute MI among patients with IBD, in a nationwide inpatient database, lower rates of acute MI were demonstrated in the IBD population when compared with the general population.
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Affiliation(s)
- Edward L. Barnes
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Renee Marchioni Beery
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Allison R. Schulman
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ellen P. McCarthy
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center; Office for Diversity Inclusion and Community Partnership, Harvard Medical School, Boston, MA, USA
| | - Joshua R. Korzenik
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rachel W. Winter
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Svensson AL, Christensen R, Persson F, Løgstrup BB, Giraldi A, Graugaard C, Fredberg U, Blegvad J, Thygesen T, Hansen IMJ, Colic A, Bagdat D, Ahlquist P, Jensen HS, Hørslev-Petersen K, Sheetal E, Christensen TG, Svendsen L, Emmertsen H, Ellingsen T. Multifactorial intervention to prevent cardiovascular disease in patients with early rheumatoid arthritis: protocol for a multicentre randomised controlled trial. BMJ Open 2016; 6:e009134. [PMID: 27098820 PMCID: PMC4838680 DOI: 10.1136/bmjopen-2015-009134] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Cardiovascular morbidity is a major burden in patients with rheumatoid arthritis (RA). In this study, we compare the effect of a targeted, intensified, multifactorial intervention with that of conventional treatment of modifiable risk factors for cardiovascular disease (CVD) in patients with early RA fulfilling the 2010 American College of Rheumatology European League Against Rheumatism (ACR/EULAR) criteria. METHODS AND ANALYSIS The study is a prospective, randomised, open label trial with blinded end point assessment and balanced randomisation (1:1) conducted in 10 outpatient clinics in Denmark. The primary end point after 5 years of follow-up is a composite of death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke and cardiac revascularisation. Secondary outcomes are: the proportion of patients achieving low-density lipoprotein cholesterol <2.5 mmol/L, glycated haemoglobin <48 mmol/mol, blood pressure <140/90 mm Hg for patients without diabetes and <130/80 mm Hg for patients with diabetes and normoalbuminuria (urinary albumin creatinine ratio <30 mg/g) after 1 year of follow-up and the proportion of patients in each treatment group achieving low RA disease activity after 1 year, defined as a disease activity score C-reactive protein (DAS28-CRP) <3.2 and a DAS28-CRP score <2.6 after 12, 24 and 60 months. Furthermore, all hospitalisations for acute and elective reasons will be adjudicated by the event committee after 12, 24 and 60 months. Three hundred treatment-naive patients with early RA will be randomly assigned (1:1) to receive either conventional treatment administered and monitored by their general practitioner according to national guidelines (control group) or a stepwise implementation administered and monitored in a quarterly rheumatological nurse-administered set-up of behaviour modification and pharmacological therapy targeting (1) hyperlipidaemia, (2) hypertension, (3) hyperglycaemia and (4) microalbuminuria (intervention group). ETHICS AND DISSEMINATION This protocol is approved by the local ethics committee (DK-S-2014007) and The Danish Health and Medicines Authority. Dissemination will occur through presentations at National and International conferences and publications in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02246257.
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Affiliation(s)
- Annemarie Lyng Svensson
- Department of Rheumatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, Department of Rheumatology, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | | | - Annamaria Giraldi
- Psychiatric Center, Sexological Clinic, Copenhagen University Hospital, Denmark
| | - Christian Graugaard
- Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
| | - Ulrich Fredberg
- Department of Rheumatology, Diagnostic Centre, Regional Hospital Silkeborg, Denmark
| | - Jesper Blegvad
- Department of Rheumatology, Diagnostic Centre, Regional Hospital Silkeborg, Denmark
| | - Tina Thygesen
- Department of Rheumatology, Diagnostic Centre, Regional Hospital Silkeborg, Denmark
| | | | - Ada Colic
- Department of Rheumatology Sydvestjysk Sygehus, Esbjerg/Varde, Denmark
| | - Döne Bagdat
- Department of Rheumatology Sydvestjysk Sygehus, Esbjerg/Varde, Denmark
| | | | - Hanne Slott Jensen
- Department of Rheumatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | - Ekta Sheetal
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | | | | | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Danbio National Registry, Glostrup University Hospital, Denmark
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25
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Lindhardsen J, Kristensen SL, Ahlehoff O. Management of Cardiovascular Risk in Patients with Chronic Inflammatory Diseases: Current Evidence and Future Perspectives. Am J Cardiovasc Drugs 2016; 16:1-8. [PMID: 26293235 DOI: 10.1007/s40256-015-0141-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An increased risk of cardiovascular disease (CVD) has been observed in a range of chronic inflammatory diseases (CID), including rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases (IBD), and systemic lupus erythematosus (SLE). The increased risk of CVDs and reduced life expectancy in these conditions has stimulated considerable research and started an ongoing discussion on the need for a multidisciplinary approach and dedicated guidelines on CVD prevention in these patients. In addition, the possibility of inhibiting inflammation as a means to preventing CVD in these patients has gained considerable interest in recent years. We briefly summarize the current level of evidence of the association between CIDs and CVD and cardiovascular risk management recommendations. Perspectives of ongoing and planned trials are discussed in consideration of potential ways to improve primary and secondary CVD prevention in patients with CID.
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Affiliation(s)
- Jesper Lindhardsen
- Department of Internal Medicine, Copenhagen University Hospital Slagelse, 4200, Slagelse, Denmark
| | - Søren Lund Kristensen
- Department of Cardiology, Copenhagen University Hospital Gentofte, 2900, Hellerup, Denmark
| | - Ole Ahlehoff
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 7, 2100, Copenhagen, Denmark.
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26
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Innala L, Sjöberg C, Möller B, Ljung L, Smedby T, Södergren A, Magnusson S, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Co-morbidity in patients with early rheumatoid arthritis - inflammation matters. Arthritis Res Ther 2016; 18:33. [PMID: 26818851 PMCID: PMC4730785 DOI: 10.1186/s13075-016-0928-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 01/07/2016] [Indexed: 01/10/2023] Open
Abstract
Background Patients with rheumatoid arthritis (RA) suffer from co-morbidities that contribute to a shortened lifespan. Inflammation is important for the development of cardiovascular disease, but little is known on its relationship with other co-morbidities. We investigated the role of inflammation for the development of new comorbidities in early RA. Methods Since 1995, all patients with early RA in Northern Sweden are included in a prospective study on co-morbidities, with a total of 950 patients being included. At the time for this study, 726 had been ill for ≥5 years. Data on co-morbidities, clinical and laboratory disease activity and pharmacological therapy were collected from patient records and further validated using a questionnaire at RA onset (T0) and after 5 years (T5). Results Of the patients, 53.2 % of the patients had one or more co-morbidity at onset, the commonest being: hypertension (27.3 %), obstructive pulmonary disease (13.9 %), diabetes (8.0 %), hypothyroidism (6.3 %) and malignancy (5.0 %). After 5 years, 41.0 % had developed at least one new co-morbidity, the most common being: hypertension (15.1 %), malignancy (7.6 %), stroke/transient ischemic accident (5.1 %), myocardial infarction (4.3 %) and osteoporosis (3.7 %). Age at disease onset, a raised erythrocyte sedimentation rate (ESR) at inclusion, previous treatment with glucocorticoids (GC; p < 0.001 for all), extra-articular RA (Ex-RA; p < 0.01), DAS28 (area under the curve) at 24 months (p < 0.05), previous smoking at inclusion (p = 0.058) and male gender (p < 0.01) were associated with a new co-morbidity overall at T5. Treatment with biologics (p < 0.05) reduced the risk. In multiple logistic regression modelling, ESR (p = 0.036) at inclusion was associated with a new co-morbidity after 5 years, adjusted for age, sex, smoking and GC treatment. In a similar model, Ex-RA (p < 0.05) was associated with a new co-morbidity at T5. In a third model, adjusted for age and sex, a new pulmonary co-morbidity was associated with a smoking history at inclusion (p < 0.01), but not with ESR. Conclusion There was substantial co-morbidity among early RA patients already at disease onset, with considerable new co-morbidity being added during the first five years. Measures of disease activity were associated with the occurrence of a new co-morbidity indicating that the inflammation is of importance in this context.
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Affiliation(s)
- Lena Innala
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Clara Sjöberg
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Bozena Möller
- Department of Rheumatology, Sunderby Hospital, Luleå, 97180, Sweden.
| | - Lotta Ljung
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Torgny Smedby
- Department of Rheumatology, Östersund Hospital, Östersund, 83183, Sweden.
| | - Anna Södergren
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Staffan Magnusson
- Department of Rheumatology, Sundsvall Hospital, Sundsvall, 85186, Sweden.
| | | | - Solveig Wållberg-Jonsson
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
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27
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Houri Levi E, Watad A, Whitby A, Tiosano S, Comaneshter D, Cohen AD, Amital H. Coexistence of ischemic heart disease and rheumatoid arthritis patients-A case control study. Autoimmun Rev 2016; 15:393-6. [PMID: 26808075 DOI: 10.1016/j.autrev.2016.01.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Over the last few decades, several studies have demonstrated the connection between Rheumatoid Arthritis (RA) and Ischemic Heart Disease (IHD). The additional risk for RA patients to also suffer from IHD varies based on the definition of the diseases in question, the populations evaluated, and the variables included in the studies. OBJECTIVES To quantify the association between RA and IHD according to certain demographics as well as traditional cardiovascular risk factors in order to determine their roles in the development of coronary artery disease among patients with RA. METHODS Using data from the largest HMO in Israel, the Clalit Health Services, we selected for patients with RA. These patients were compared with age and sex matched controls with regards to the prevalence of IHD in a case-control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. RESULTS The study included 11,782 patients with RA and 57,973 age and sex matched controls. The prevalence of IHD in patients with RA was increased compared with the prevalence in controls (16.6% and 12.8% respectively, P<0.001). In a multivariate analysis, RA was associated with higher proportions of IHD (OR 1.346, 95% confidence interval 1.255-1.431).
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Affiliation(s)
- Esther Houri Levi
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Aaron Whitby
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Shmuel Tiosano
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Doron Comaneshter
- Chief Physician's Office, Clalit Health Services Tel Aviv, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Arnon D Cohen
- Chief Physician's Office, Clalit Health Services Tel Aviv, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel; Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Howard Amital
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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28
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Close H, Mason JM, Wilson DW, Hungin APS, Jones R, Rubin G. Risk of Ischaemic Heart Disease in Patients with Inflammatory Bowel Disease: Cohort Study Using the General Practice Research Database. PLoS One 2015; 10:e0139745. [PMID: 26461954 PMCID: PMC4604089 DOI: 10.1371/journal.pone.0139745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/15/2015] [Indexed: 11/19/2022] Open
Abstract
Objective Patients with inflammatory bowel disease (IBD) demonstrate an inflammatory response which bears some similarities to that seen in ischaemic heart disease (IHD). The nature of the association of IBD with IHD is uncertain. We aimed to define the extent and direction of that association. Design This retrospective cohort study examined records from patients aged ≥ 15 years with IBD from 1987–2009 (n = 19163) who were age and gender matched with patients without IBD (n = 75735) using the General Practice Research Database. The primary outcome was the hazard ratio for IHD. Results A higher proportion of IBD patients had a recorded diagnosis of IHD ever, 2220 (11.6%) compared with 6504 (8.6%) of controls. However, the majority (4494, 51.5%) developed IHD prior to IBD diagnosis (1404 (63.2%) of IBD cases and 3090 (47.5%) of controls). There was increased IHD incidence in the first year after IBD diagnosis. Mean age at IHD diagnosis was statistically similar across all IBD groups apart from for those with Ulcerative Colitis (UC) who were slightly younger at diagnosis of angina compared to controls (64.5y vs. 67.0y, p = 0.008) and coronary heart disease (65.7y vs.67.9y, p = 0.015). Of those developing IHD following IBD diagnosis, UC patients were at higher risk of IHD (unadjusted HR 1.3 (95% CI 1.1–1.5), p<0.001) or MI (unadjusted HR 1.4 (95% CI 1.1–1.6), p = 0.004). Conclusion Although IHD prevalence was higher in IBD patients, most IHD diagnoses predated the diagnosis of IBD. This implies a more complex relationship than previously proposed between the inflammatory responses associated with IHD and IBD, and alternative models should be considered.
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Affiliation(s)
- Helen Close
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
| | - James M. Mason
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
| | - Douglas W. Wilson
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
| | - A. Pali S. Hungin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
| | - Roger Jones
- Department of General Practice and Primary Care, King’s College, London, United Kingdom
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
- * E-mail:
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29
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Mantel Ä, Holmqvist M, Jernberg T, Wållberg-Jonsson S, Askling J. Rheumatoid arthritis is associated with a more severe presentation of acute coronary syndrome and worse short-term outcome. Eur Heart J 2015; 36:3413-22. [PMID: 26400826 DOI: 10.1093/eurheartj/ehv461] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/19/2015] [Indexed: 12/18/2022] Open
Abstract
AIMS Despite a wealth of studies describing an increased incidence of acute coronary syndromes (ACSs) in rheumatoid arthritis (RA), considerably less is known about the clinical characteristics and their association with short-term outcome of such ACS. The aims of this study were therefore to investigate clinical characteristics and case-fatality rates following ACS in patients with RA. METHODS AND RESULTS We compared the clinical presentation of incident ACS between 2007 and 2010 and their short-term mortality in a cohort of 1135 subjects with prevalent RA and in a cohort of 3184 matched general population comparators. Rheumatoid arthritis subjects more frequently presented with sudden cardiac death, ST-segment elevation myocardial infarctions, had higher levels of troponin and higher frequencies of in-hospital complications compared with the general population comparators. Furthermore, the short-term mortality was higher among RA-associated ACS (7-day hazard ratio (HR) = 1.65 [95% CI 1.32-2.08]; 30-day HR = 1.57 [95% CI 1.30-1.89]), which were somewhat attenuated but remained statistically significantly increased following adjustment for previous comorbidities, demographics, and educational level (7-day HR = 1.50 [95% CI 1.19-1.90]; 30-day HR = 1.43 [95% CI 1.18-1.72]), and for ACS type (7-day HR = 1.44 [95% CI 1.14-1.82]; 30-day HR = 1.36 [95% CI 1.13-1.64]). CONCLUSION Patients with prevalent RA suffer more severe ACSs compared with the general population and also have poorer outcomes after the events, which can only partly be explained by increased event severity.
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Affiliation(s)
- Ängla Mantel
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Stockholm SE-171 76, Sweden
| | - Marie Holmqvist
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Stockholm SE-171 76, Sweden
| | - Tomas Jernberg
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | | | - Johan Askling
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Stockholm SE-171 76, Sweden
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30
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Cuende JI, Pérez de Diego IJ, Godoy D. [Cardiovascular disease and systemic inflammatory diseases]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2015; 28:94-101. [PMID: 26364962 DOI: 10.1016/j.arteri.2015.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/01/2015] [Accepted: 07/06/2015] [Indexed: 11/25/2022]
Abstract
More than a century of research has shown that atherosclerosis is an inflammatory process more than an infiltrative or thrombogenic process. It has been demonstrated epidemiologically and by imaging techniques, that systemic inflammatory diseases (in particular, but not exclusively, rheumatoid arthritis and systemic lupus erythematosus) increase the atherosclerotic process, and has a demonstrated pathophysiological basis. Furthermore, treatments to control inflammatory diseases can modify the course of the atherosclerotic process. Although there are no specific scales for assessing cardiovascular risk in patients with these diseases, cardiovascular risk is high. A number of specific risk scales are being developed, that take into account specific factors such as the degree of inflammatory activity.
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Affiliation(s)
- José I Cuende
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España.
| | - Ignacio J Pérez de Diego
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - Diego Godoy
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital General de Valencia, Valencia, España
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Lai CH, Lai WW, Chiou MJ, Lin WC, Yang YJ, Li CY, Tsai LM. Outcomes of percutaneous coronary intervention in patients with rheumatoid arthritis and systemic lupus erythematosus: an 11-year nationwide cohort study. Ann Rheum Dis 2015; 75:1350-6. [DOI: 10.1136/annrheumdis-2015-207719] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/30/2015] [Indexed: 12/17/2022]
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Hollan I, Dessein PH, Ronda N, Wasko MC, Svenungsson E, Agewall S, Cohen-Tervaert JW, Maki-Petaja K, Grundtvig M, Karpouzas GA, Meroni PL. Prevention of cardiovascular disease in rheumatoid arthritis. Autoimmun Rev 2015; 14:952-69. [PMID: 26117596 DOI: 10.1016/j.autrev.2015.06.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 06/17/2015] [Indexed: 12/12/2022]
Abstract
The increased risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) has been recognized for many years. However, although the characteristics of CVD and its burden resemble those in diabetes, the focus on cardiovascular (CV) prevention in RA has lagged behind, both in the clinical and research settings. Similar to diabetes, the clinical picture of CVD in RA may be atypical, even asymptomatic. Therefore, a proactive screening for subclinical CVD in RA is warranted. Because of the lack of clinical trials, the ideal CVD prevention (CVP) in RA has not yet been defined. In this article, we focus on challenges and controversies in the CVP in RA (such as thresholds for statin therapy), and propose recommendations based on the current evidence. Due to the significant contribution of non-traditional, RA-related CV risk factors, the CV risk calculators developed for the general population underestimate the true risk in RA. Thus, there is an enormous need to develop adequate CV risk stratification tools and to identify the optimal CVP strategies in RA. While awaiting results from randomized controlled trials in RA, clinicians are largely dependent on the use of common sense, and extrapolation of data from studies on other patient populations. The CVP in RA should be based on an individualized evaluation of a broad spectrum of risk factors, and include: 1) reduction of inflammation, preferably with drugs decreasing CV risk, 2) management of factors associated with increased CV risk (e.g., smoking, hypertension, hyperglycemia, dyslipidemia, kidney disease, depression, periodontitis, hypothyroidism, vitamin D deficiency and sleep apnea), and promotion of healthy life style (smoking cessation, healthy diet, adjusted physical activity, stress management, weight control), 3) aspirin and influenza and pneumococcus vaccines according to current guidelines, and 4) limiting use of drugs that increase CV risk. Rheumatologists should take responsibility for the education of health care providers and RA patients regarding CVP in RA. It is immensely important to incorporate CV outcomes in testing of anti-rheumatic drugs.
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Affiliation(s)
- I Hollan
- Lillehammer Hospital for Rheumatic Diseases, Norway
| | - P H Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N Ronda
- Department of Pharmacy, University of Parma, Italy
| | - M C Wasko
- Department of Rheumatology, West Penn Hospital Allegheny Health Network, USA
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - S Agewall
- Department of Cardiology, Oslo University Hospital Ullevål, University of Oslo, Oslo, Norway; Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - J W Cohen-Tervaert
- Clinical and Experimental Immunology, Maastricht University, Maastricht, The Netherlands
| | - K Maki-Petaja
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - M Grundtvig
- Department of Medicine, Innlandet Hospital Trust, Lillehammer, Norway
| | - G A Karpouzas
- Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, USA; Los Angeles Biomedical Research Institute, Torrance, USA
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Italy; IRCCS Istituto Auxologico Italiano, Italy
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Van Doornum S, Bohensky M, Tacey MA, Brand CA, Sundararajan V, Wicks IP. Increased 30-day and 1-year mortality rates and lower coronary revascularisation rates following acute myocardial infarction in patients with autoimmune rheumatic disease. Arthritis Res Ther 2015; 17:38. [PMID: 25879786 PMCID: PMC4372281 DOI: 10.1186/s13075-015-0552-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 02/06/2015] [Indexed: 01/28/2023] Open
Abstract
Introduction It is now well-recognised that patients with autoimmune rheumatic disease (AIRD) have a predisposition to cardiovascular disease that results in increased morbidity and mortality. Following myocardial infarction (MI), patients with rheumatoid arthritis have been shown to have an increased case fatality rate; however, this has not been demonstrated in other forms of AIRD. The aim of this study was to compare case fatality rates following a first MI in patients with AIRD versus the general population. The secondary aim was to compare revascularisation treatment following MI in patients with AIRD versus the general population. Methods A retrospective cohort study using two population-based linked databases was undertaken. Cases of first MI from July 2001 to June 2007 were identified based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification, codes. Thirty-day and one-year mortality rates were calculated (all-cause and cardiovascular causes of death). Logistic regression models were fitted to calculate the odds of mortality by AIRD status with adjustment for relevant characteristics. Results There were 79,390 individuals with a first MI, of whom 1,409 (1.8%) had AIRD. After adjusting for relevant covariates, the odds ratio (OR) for 30-day cardiovascular mortality in patients with AIRD was 1.44 (95% confidence interval (CI): 1.25 to 1.66), and the OR for 12-month cardiovascular mortality was 1.71 (95% CI: 1.51 to 1.94). The 90-day adjusted odds of percutaneous transluminal coronary angioplasty and coronary artery bypass graft were significantly lower in the AIRD group compared with controls (OR: 0.81, 95% CI: 0.70 to 0.94, and OR: 0.52, 95% CI: 0.39 to 0.69, respectively). Conclusions We identified a higher risk-adjusted mortality rate for the majority of patients with AIRD at 30 days and 12 months after first MI. We also identified lower post-MI revascularisation rates in the AIRD group, suggesting there may be current gaps in cardiovascular treatment for patients with AIRD. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0552-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sharon Van Doornum
- Melbourne EpiCentre, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3050, Australia. .,The University of Melbourne, Grattan Street, Parkville, Victoria, 3050, Australia.
| | - Megan Bohensky
- Melbourne EpiCentre, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3050, Australia.
| | - Mark A Tacey
- Melbourne EpiCentre, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3050, Australia.
| | - Caroline A Brand
- Melbourne EpiCentre, The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3050, Australia.
| | - Vijaya Sundararajan
- The University of Melbourne, Grattan Street, Parkville, Victoria, 3050, Australia.
| | - Ian P Wicks
- The University of Melbourne, Grattan Street, Parkville, Victoria, 3050, Australia.
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Abstract
Autoimmune rheumatic diseases can affect the cardiac vasculature, valves, myocardium, pericardium, and conduction system, leading to a plethora of cardiovascular manifestations that can remain clinically silent or lead to substantial cardiovascular morbidity and mortality. Although the high risk of cardiovascular pathology in patients with autoimmune inflammatory rheumatological diseases is not owing to atherosclerosis alone, this particular condition contributes substantially to cardiovascular morbidity and mortality-the degree of coronary atherosclerosis observed in patients with rheumatic diseases can be as accelerated, diffuse, and extensive as in patients with diabetes mellitus. The high risk of atherosclerosis is not solely attributable to traditional cardiovascular risk factors: dysfunctional immune responses, a hallmark of patients with rheumatic disorders, are thought to cause chronic tissue-destructive inflammation. Prompt recognition of cardiovascular abnormalities is needed for timely and appropriate management, and aggressive control of traditional risk factors remains imperative in patients with rheumatic diseases. Moreover, therapies directed towards inflammatory process are crucial to reduce cardiovascular disease morbidity and mortality. In this Review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders, their underlying pathophysiology, and available management strategies, with particular emphasis on the vascular aspects of the emerging field of 'cardiorheumatology'.
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 993] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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Ljung L, Askling J, Rantapää-Dahlqvist S, Jacobsson L. The risk of acute coronary syndrome in rheumatoid arthritis in relation to tumour necrosis factor inhibitors and the risk in the general population: a national cohort study. Arthritis Res Ther 2014; 16:R127. [PMID: 24941916 PMCID: PMC4095691 DOI: 10.1186/ar4584] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 06/11/2014] [Indexed: 01/05/2023] Open
Abstract
Introduction The elevated risk of ischaemic heart disease in patients with rheumatoid arthritis (RA) has been linked to inflammation and disease severity. Treatment with tumour necrosis factor inhibitors (TNFis) is often effective in reducing disease activity and could possibly modify cardiovascular risk. Our objective in the study was to evaluate the risk of acute coronary syndrome (ACS) in patients with RA treated with TNFis compared with the risk among biologic-naïve RA patients and the general population. Methods By linkage of the Swedish National Patient Register and the Swedish Biologics Register, we identified a cohort of patients who were started on their first biologic, a TNFi, between 2001 and 2010 (N = 7,704), and a cohort comprising matched biologic-naïve RA patient referents at a 3:1 ratio. Furthermore, a matched comparator cohort (5:1 ratio) was extracted from the Swedish population register. The incidence rates of a first ACS event were calculated and compared between cohorts using Cox proportional hazards regression in three different risk windows: ‘ever-exposed’, ‘actively on TNFi’ and ‘short-term exposure’ (active treatment maximized to 2 years). The models were adjusted for disease duration, joint surgery, comorbidity and socioeconomic factors, and, in a sensitivity analysis including a subpopulation started on therapy beginning 1 January 2006 or later, for dispensed drugs. Results Based on 221 events in 7,704 patients (comprising 32,621 person-years) treated with TNFi biologics, the hazard ratio ((HR); ever-exposed) for ACS among the TNFi-exposed RA patients compared with biologic-naïve RA patients was 0.8 (95% confidence interval (CI) = 0.7 to 0.95). In comparison with the general population referents, statistical analysis using fully adjusted models resulted in a HR of 2.0 (95% CI = 1.8 to 2.3) for biologic-naïve RA patients and a HR of 1.6 (95% CI = 1.4 to 1.9) for the TNFi-exposed group. Similar risk estimates were obtained using the other two risk windows. A sensitivity analysis in which we compared the TNFi-exposed patients included from 1 January 2006 onward with biologic-naïve patients resulted in a HR (ever-exposed) of 0.7 (95% CI = 0.5 to 1.0). Conclusions RA patients treated with TNFi had a lower risk of ACS compared with biologic-naïve RA patients. Compared with the general population, the risk among patients with RA was elevated, although the difference was less pronounced among the TNFi-exposed patients. This finding could be attributable to the TNFi as such, or it could correspond to a lower degree of inflammation in the TNFi-treated group.
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The impact of inflammatory rheumatic diseases on the presentation, severity, and outcome of acute coronary syndrome. Clin Rheumatol 2014; 35:233-7. [DOI: 10.1007/s10067-014-2695-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
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Abstract
Rheumatic diseases are associated with an increased risk of cardiovascular (CV) mortality attributed to a higher incidence of heart failure (HF) and ischemic heart disease. Although traditional CV risk factors contribute to the increased incidence seen in this population, by themselves they do not account for the increased risk; in fact, obesity and hyperlipidemia may play a paradoxic role. Immune-mediated mechanisms and chronic inflammation likely play a role in the pathogenesis of CV disease in patients with rheumatic diseases. The usual clinical features of ischemic heart disease and HF are less likely to be seen in this patient population.
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Affiliation(s)
- Kerry Wright
- Division of Rheumatology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Sherine E Gabriel
- Division of Rheumatology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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Soeiro ADM, Haddad M, de Almeida MCF, Ruppert AD, Serrano CV. [Rheumatoid arthritis and cardiovascular disease: what is known about this relationship and what can currently be done for affected patients?]. Rev Port Cardiol 2013; 31:225-32. [PMID: 22284683 DOI: 10.1016/j.repc.2012.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 09/22/2011] [Indexed: 10/14/2022] Open
Abstract
There is increasing interest in autoimmune diseases, especially their relationship with cardiovascular disease. Rheumatoid arthritis in particular has been considered an independent risk factor for coronary artery disease in recent years. Various studies have aimed to clarify important aspects of risk stratification and treatment options in patients with rheumatoid arthritis, and specific therapies are being studied that promise to reduce their long-term cardiovascular risk. We performed a wide-ranging review of the literature to highlight the importance of atherosclerotic and inflammatory mechanisms in coronary artery disease. We also suggest strategies for risk stratification and treatment of cardiovascular disease in patients with rheumatoid arthritis.
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Affiliation(s)
- Alexandre de Matos Soeiro
- Instituto do Coraçã do do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil.
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McCoy SS, Crowson CS, Maradit-Kremers H, Therneau TM, Roger VL, Matteson EL, Gabriel SE. Longterm outcomes and treatment after myocardial infarction in patients with rheumatoid arthritis. J Rheumatol 2013; 40:605-10. [PMID: 23418388 DOI: 10.3899/jrheum.120941] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the risk profiles, treatment, and outcomes of patients with rheumatoid arthritis (RA) with myocardial infarction (MI) and matched MI patients without RA. METHODS We used a population-based cohort of Olmsted County, Minnesota, residents with MI from the period 1979-2009. We identified 77 patients who fulfilled the American College of Rheumatology 1987 criteria for RA and 154 MI patients without RA matched for age, sex, and calendar year. Data collection from medical records included RA and MI characteristics, antirheumatic and cardioprotective medications, reperfusion therapy, and outcomes (mortality, heart failure, and recurrent ischemia). RESULTS The mean age at MI was 72.4 years and 55% of patients were female in both cohorts. Cardiovascular risk factor profiles, MI characteristics, and treatment with reperfusion therapy or cardioprotective medications were similar in MI patients with and those without RA. Patients with RA experienced poorer longterm outcomes compared to patients without RA--for mortality: hazard ratio (HR) 1.47; 95% CI 1.04, 2.08; and for recurrent ischemia: HR 1.51; 95% CI 1.04, 2.18. CONCLUSION MI patients with RA received similar treatment with reperfusion therapy and cardioprotective medications and had similar short-term outcomes compared to patients without RA. Patients with RA had poorer longterm outcomes. Despite similar treatment, MI patients with RA had worse longterm outcomes than MI patients without RA.
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Affiliation(s)
- Sara S McCoy
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Brunetti N, De Gennaro L, Cuculo A, Gaglione A, Di Biase M. History of allergy is a predictor of adverse events in unstable angina treated with coronary angioplasty. Allergol Immunopathol (Madr) 2013; 41:25-9. [PMID: 22417939 DOI: 10.1016/j.aller.2011.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/20/2011] [Accepted: 12/03/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND The aim was to investigate prognostic relevance of history of allergy in subjects with unstable angina treated with coronary angioplasty. METHODS Fifty-seven consecutive patients with unstable angina who underwent coronary angioplasty were enrolled in the study and were divided into two groups: those with a history of allergy (Group A, N = 15); and controls (Group C, N =42). Major adverse cardiac events were recorded over a six-month follow-up period. Patients with primary or unsuccessful angioplasty and patients treated with drug eluting stent were excluded from the study. RESULTS Group A patients (history of allergy) showed a 46.67% incidence of major adverse cardiac events at six-month follow-up (vs. 9.52% Group C, p < 0.01): results remained significant even in a multiple Cox regression analysis (hazard ratio 7.17, 95% CI 1.71-29.98, p < 0.01). CONCLUSION History of allergy is an independent predictor of major adverse cardiac events after coronary angioplasty in a six-month follow-up period in unstable angina.
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Ahlehoff O, Lindhardsen J, Gislason GH, Olesen JB, Charlot M, Skov L, Torp-Pedersen C, Hansen PR. Prognosis after percutaneous coronary intervention in patients with psoriasis: a cohort study using Danish nationwide registries. BMC Cardiovasc Disord 2012; 12:79. [PMID: 23006590 PMCID: PMC3507678 DOI: 10.1186/1471-2261-12-79] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023] Open
Abstract
Background Psoriasis is an inflammatory disease associated with increased risk of coronary artery disease. However, the potential impact of psoriasis on the prognosis following percutaneous coronary revascularization (PCI) is unknown. Methods The study comprised the entire Danish population undergoing first-time PCI in the period 2002–09. Cox regression models, controlling for age, gender, socioeconomic status, pharmacological treatment, and comorbidity were used to assess the risk of 1) all-cause mortality and 2) a composite endpoint of death, myocardial infarction, and stroke. Results A total of 53,141 patients with first-time PCI in the study period were identified. Of these, 1074 had mild psoriasis and 315 had severe psoriasis. Patients with severe psoriasis, but not those with mild disease had increased risk of both endpoints compared to patients without psoriasis. The incidence rates for all-cause mortality were 30.5 (CI 29.7-31.3), 29.9 (CI 24.7-36.1), and 47.2 (CI 35.0-63.6) per 1000 patient years for patients without psoriasis, with mild psoriasis, and with severe psoriasis, respectively. Hazard ratios were 1.10 (CI 0.91-1.33) and 1.67 (CI 1.24-2.26) for mild and severe psoriasis, respectively. Patients with severe psoriasis were less likely to receive secondary prevention pharmacotherapy with betablockers, statins and platelet inhibitors. Conclusion This first study of the prognosis following PCI in patients with psoriasis demonstrated an increased risk of all-cause mortality and of a composite of death, myocardial infarction and stroke, respectively, in patients with severe psoriasis compared to patients without psoriasis. Further studies of this novel association are needed.
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Affiliation(s)
- Ole Ahlehoff
- Department of Cardiology, Copenhagen University Hospital, Gentofte, Hellerup DK-2900, Denmark.
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Horton SC, Walsh CAE, Emery P. Established rheumatoid arthritis: rationale for best practice: physicians' perspective of how to realise tight control in clinical practice. Best Pract Res Clin Rheumatol 2012; 25:509-21. [PMID: 22137921 DOI: 10.1016/j.berh.2011.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 10/11/2011] [Indexed: 02/01/2023]
Abstract
Developments in the understanding of the pathogenesis of rheumatoid arthritis (RA) and the introduction of targeted biologic therapies have greatly advanced the management of RA in clinical practice. The management of RA is now aimed at achieving remission, to prevent joint damage and disability. In particular, a critical period early in disease is recognised, in which early aggressive treatment with disease-modifying therapy is advocated. Although a state of remission is the ideal, this chapter discusses the difficulties which may arise in achieving this goal in patients with established disease. The evidence for best management, aimed at achieving clinical remission in established disease, is reviewed. The consequences of incomplete control of chronic inflammation in established disease, including pain, disability and co-morbidities (such as cardiovascular disease and osteoporosis), also pose a significant clinical challenge. The rationale for a multidisciplinary team approach in reducing the associated morbidity and mortality of the disease are examined.
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Affiliation(s)
- S C Horton
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK
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de Matos Soeiro A, Haddad M, Feres de Almeida MC, Ruppert AD, Serrano CV. Rheumatoid arthritis and cardiovascular disease: What is known about this relationship and what can currently be done for affected patients? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Finckh A, Courvoisier DS, Pagano S, Bas S, Chevallier-Ruggeri P, Hochstrasser D, Roux-Lombard P, Gabay C, Vuilleumier N. Evaluation of cardiovascular risk in patients with rheumatoid arthritis: do cardiovascular biomarkers offer added predictive ability over established clinical risk scores? Arthritis Care Res (Hoboken) 2012; 64:817-25. [PMID: 22302385 DOI: 10.1002/acr.21631] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether adding C-reactive protein, anti-cyclic citrullinated peptide antibodies, rheumatoid factor, N-terminal pro-brain natriuretic peptide (NT-proBNP), oxidized low-density lipoprotein (ox-LDL), or anti-apolipoprotein A-I (anti-Apo A-I) IgG to the Framingham 10-year cardiovascular (CV) risk score (FRS) could improve its CV prognostic accuracy in rheumatoid arthritis (RA). METHODS We performed an ancillary study derived from a prospective single-center cohort consisting of 118 RA patients without CV disease at baseline. The FRS and the various biomarkers were assessed at enrollment and their prognostic accuracy was determined using receiver operating characteristic (ROC) curve analysis. The incremental predictive ability of biomarkers was assessed using the integrated discrimination improvement (IDI) statistics. RESULTS During a median followup period of 9 years, the incidence of CV events was 16%. Both the FRS and 3 of the biomarkers (NT-proBNP, ox-LDL, and anti-Apo A-I) were significant predictors of subsequent CV events (area under the ROC curve [AUC] between 0.68 and 0.73). Anti-Apo A-I was the only biomarker to significantly improve the prognostic ability of the FRS, with AUCs increasing from 0.72 to 0.81 and the IDI improving by 175% (P < 0.001). CONCLUSION Among the biomarkers tested, only anti-Apo A-I significantly improved the FRS predictive ability.
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Affiliation(s)
- Axel Finckh
- Geneva University Hospitals and University of Geneva School of Medicine, 26 Avenue Beau-Sejour, Geneva, Switzerland.
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Ahlehoff O, Gislason GH, Lindhardsen J, Olesen JB, Charlot M, Skov L, Torp-Pedersen C, Hansen PR. Prognosis following first-time myocardial infarction in patients with psoriasis: a Danish nationwide cohort study. J Intern Med 2011; 270:237-44. [PMID: 21362070 DOI: 10.1111/j.1365-2796.2011.02368.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The magnitude of cardiovascular risk associated with psoriasis has been debated and the prognostic impact of psoriasis following myocardial infarction (MI) is unknown. Therefore, we investigated the risk of mortality and adverse cardiovascular events in patients with psoriasis following first-time MI. DESIGN, SETTING AND PARTICIPANTS Cohort study of the entire Danish population including all individuals who experienced first-time MI during the period 2002-2006. Multivariable Cox regression models were used to assess the post-MI prognostic impact of psoriasis. Main outcome measures. All-cause mortality and a composite cardiovascular end-point of recurrent MI, stroke and cardiovascular death. RESULTS A total of 462 patients with psoriasis and 48 935 controls (mean age 69.5 and 70.6 years, respectively) were identified with first-time MI during the study period. The mean follow-up was 19.5 months [standard deviation (SD) 16.5] for patients with psoriasis and 22 .0 months (SD 18.7) for those without psoriasis. Incidence rates (IRs) per 1000 patient-years for all-cause mortality were 119.4 [95% confidence interval (CI) 117.2-138.3] and 138.3 (95% CI 114.1-167.7) for patients without and with psoriasis, respectively, and the adjusted hazard ratio (HR) associated with psoriasis was 1.18 (95% CI 0.97-1.43). For the composite end-point, the IRs were 149.7 (95% CI 147.1-152.4) and 185.6 (95% CI 155.8-221.0) for patients without and with psoriasis, respectively, with an HR of 1.26 (95% CI 1.04-1.54) for patients with psoriasis. CONCLUSION This first study of the impact of psoriasis on prognosis after first-time MI indicated a significantly impaired prognosis in patients with psoriasis. Further studies of this novel association are warranted.
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Affiliation(s)
- O Ahlehoff
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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Innala L, Möller B, Ljung L, Magnusson S, Smedby T, Södergren A, Öhman ML, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Cardiovascular events in early RA are a result of inflammatory burden and traditional risk factors: a five year prospective study. Arthritis Res Ther 2011; 13:R131. [PMID: 21843325 PMCID: PMC3239373 DOI: 10.1186/ar3442] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 05/18/2011] [Accepted: 08/15/2011] [Indexed: 11/15/2022] Open
Abstract
Introduction Co-morbidity and mortality due to cardiovascular disease (CVD) are increased in patients with rheumatoid arthritis (RA). Most published studies in this field are retrospective or cross sectional. We investigated the presence of traditional and disease related risk factors for CVD at the onset of RA and during the first five years following diagnosis. We also evaluated their potential for predicting a new cardiovascular event (CVE) during the five-year follow-up period and the modulatory effect of pharmacological treatment. Methods All patients from the four northern-most counties of Sweden with early RA are, since December 1995, consecutively recruited at diagnosis (T0) into a large survey on the progress of the disease. Information regarding cardiovascular co-morbidity and related predictors was collected from clinical records and supplemented with questionnaires. By April 2008, 700 patients had been included of whom 442 patients had reached the five-year follow-up (T5). Results Among the 442 patients who reached T5 during the follow-up period, treatment for hypertension increased from 24.5 to 37.4% (P < 0.001)), diagnosis of diabetes mellitus (DM) from 7.1 to 9.5% (P < 0.01) whilst smoking decreased from 29.8 to 22.4% (P < 0.001) and the BMI from 26.3 to 25.8 (P < 0.05), respectively. By T5, 48 patients had suffered a new CVE of which 12 were fatal. A total of 23 patients died during the follow-up period. Age at disease onset, male sex, a previous CVE, DM, treatment for hypertension, triglyceride level, cumulative disease activity (area under the curve (AUC) disease activity score (DAS28)), extra-articular disease, corticosteroid use, shorter duration of treatment with disease modifying anti-rheumatic drugs (DMARDs) and use of COX-2 inhibitors increased the hazard rate for a new CVE. A raised erythrocyte sedimentation rate (ESR) at inclusion and AUC DAS28 at six months increased the hazard rate of CVE independently whilst DMARD treatment was protective in multiple Cox extended models adjusted for sex and CV risk factors. The risk of a CVE due to inflammation was potentiated by traditional CV risk factors. Conclusions The occurrence of new CV events in very early RA was explained by traditional CV risk factors and was potentiated by high disease activity. Treatment with DMARDs decreased the risk. The results may have implications for cardio-protective strategies in RA.
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Affiliation(s)
- Lena Innala
- Institution of Public Health and Clinical Medicine/Rheumatology, University Hospital, Umeå, 901 85, Sweden
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Symmons DPM, Gabriel SE. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol 2011; 7:399-408. [PMID: 21629241 DOI: 10.1038/nrrheum.2011.75] [Citation(s) in RCA: 269] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The excess risk of cardiovascular disease (CVD) associated with inflammatory rheumatic diseases has long been recognized. Patients with established rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) have higher mortality compared with the general population. Over 50% of premature deaths in RA are attributable to CVD. Excess mortality in SLE follows a bimodal pattern, with the early peak predominantly a consequence of active lupus or its complications, and the later peak largely attributable to atherosclerosis. Patients with RA or SLE are also at increased risk of nonfatal ischemic heart disease. The management and outcome of myocardial infarction and congestive heart failure in patients with RA or SLE differs from that in the general population. Traditional CVD risk factors (TRF) include increasing age, male gender, smoking, hypertension, hypercholesterolemia and diabetes. Whereas some TRFs are elevated in patients with RA or SLE, several are not, and others exhibit paradoxical relationships. Risk scores developed for the general population based on TRFs are likely, therefore, to underestimate CVD risk in RA and SLE. Until additional research and disease-specific risk prediction tools are available, current evidence supports aggressive treatment of disease activity, and careful screening for and management of TRFs.
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Affiliation(s)
- Deborah P M Symmons
- Arthritis Research UK Epidemiology Unit, Manchester Academic Health Science Center, University of Manchester, Oxford Road, Manchester M13 0PT, UK. deborah.symmons@ manchester.ac.uk
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Kramer HR, Giles JT. Cardiovascular disease risk in rheumatoid arthritis: Progress, debate, and opportunity. Arthritis Care Res (Hoboken) 2011; 63:484-99. [DOI: 10.1002/acr.20386] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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van Vollenhoven RF. Unresolved issues in biologic therapy for rheumatoid arthritis. Nat Rev Rheumatol 2011; 7:205-15. [PMID: 21386796 DOI: 10.1038/nrrheum.2011.22] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The advent of biologic therapies for the treatment of rheumatoid arthritis (RA) has radically changed this therapeutic area. The currently available biologic agents have been studied extensively as part of their development and also during their subsequent years of use in clinical practice; as a result, the knowledge base regarding these therapeutics is very large. Nonetheless, a number of important questions remain and some key issues are still incompletely understood. In this Review, I discuss a number of these unresolved issues, including: the correct placement of biologic therapies in the long-term evolution of the RA disease process, and the expectations associated with such use; comparisons of therapeutic strategies that include conventional as well as biologic agents; optimal dosing of biologic agents; the elusive goal of personalized therapy; and an appraisal of the real impact of biologic therapy on patients' lives. It is concluded that, despite these unresolved issues, important progress has been made and many additional advances in our understanding can be expected during the coming years.
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Affiliation(s)
- Ronald F van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Diseases, The Karolinska Institute, Karolinska University Hospital, S-171 76 Stockholm, Sweden.
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