Enhanced cardiovascular risk in rheumatoid arthritis: elucidation, assessment, and management

Managing rheumatoid arthritis and cardiovascular disease: the role of physical medicine and rehabilitation

INTRODUCTION

Cardiovascular disease (CVD) presents a significant challenge in rheumatoid arthritis (RA), a systemic chronic ailment affecting the joints and causing systemic inflammation. Effective RA management, including pharmacological and non-pharmacological interventions, is crucial for mitigating cardiac risk. Pharmacotherapy, though effective, can have adverse effects, leading many patients to seek complementary therapies. This study investigates the impact of physical medicine and rehabilitation on RA management in patients with cardiovascular disease, analyzing clinical data to assess the efficacy of integrated therapeutic approaches.

METHODS

This retrospective monocentric study draws upon data from patient records at the Rheumatology Department of the Regional Clinical Hospital of Shymkent, Kazakhstan, spanning 2019 to 2022. Data collected included demographic information, diagnoses, comorbidities, medical anamneses, lab results, and treatment regimens, including physical medicine and rehabilitation interventions. Data were summarized in Microsoft Excel. Statistical analysis was performed using IBM SPSS Statistics (version 26.0).

RESULTS

An analysis of 350 patients with RA identified 143 cases of concomitant CVD, with arterial hypertension being the most common cardiovascular disease. The prevalence of CVD among patients with RA was 40%, with a mean age of 58 years, peaking between 50 and 65 years. The majority of patients were women. A strong association was found between increased RA activity and elevated cardiovascular risk. Despite the widespread use of glucocorticosteroid therapy, rehabilitation coverage remained limited. A significant proportion of patients had elevated cholesterol and C-reactive protein levels, while those who engaged in physical therapy and rehabilitation had lower cholesterol levels. Comparative analysis of yoga integration into rehabilitation programs for patients with RA, alongside other modalities (kinesiotherapy, balneotherapy, and pilates), showed that yoga participants exhibited lower pain levels, reduced morning stiffness duration, and lower mean DAS-28 scores compared to those using alternative rehabilitation methods.

CONCLUSION

Integrating physical medicine and rehabilitation, particularly yoga, with pharmacological treatments appears promising for improving patient outcomes. Yoga has demonstrated benefits in reducing pain, morning stiffness, and disease activity. Continued research is essential to refine these approaches and enhance RA and CVD management in patients.

Lumbar spine bone mineral density and trabecular bone score-adjusted FRAX, but not FRAX without bone mineral density, identify subclinical carotid atherosclerosis

PURPOSE

Osteoporosis and atherosclerosis share common risk factors. Aim of this study was to test if FRAX (which is an algorithm that can identify subjects at risk of fracture), without or with BMD values, also adjusted for trabecular bone score (TBS) was able to identify subclinical atherosclerosis, evaluated by measurement of carotid intima media thickness (cIMT ≥ 0.9 mm) as compared to DXA values.

METHODS

Ninety postmenopausal women underwent DXA measurement and cIMT evaluation. For each patient, the FRAX algorithm for major osteoporotic fracture (M) and for hip fracture (H) without BMD was computed, together with FRAX with BMD and TBS-adjusted FRAX. Serum levels of osteoprotegerin, sRANKL, and interleukin-6 were also measured.

RESULTS

There were no differences in anthropometric parameters and cardiovascular risk factors between subjects with cIMT ≥ 0.9 mm (35% of subjects, group A) compared to those with cIMT < 0.9 mm (group B). The prevalence of osteoporosis and FRAX BMD, TBS-adjusted FRAX both for M and H were higher in group A compared to group B. The best ROC curves to identify subjects with a cIMT ≥ 0.9 mm were: lumbar spine T-score, with a threshold of - 2.5 SD (area under the curve, AUC 0.64; p = 0.02) with a sensibility of 50% and a specificity of 76%; TBS-adjusted FRAX H with a sensibility of 50% and a specificity of 72% (AUC 0.64; p = 0.01 with a threshold of 3%). Interleukin-6 positively correlated with FRAX BMD H and M.

CONCLUSIONS

FRAX without BMD does not identify subclinical carotid atherosclerosis, while lumbar spine T-score and TBS-adjusted FRAX H similarly detected it with higher specificity for T-score.

Deep surgical site infection after posterior instrumented fusion for rheumatoid upper cervical subluxation treated with antibiotic-loaded bone cement: Three case reports

INTRODUCTION

Patients with rheumatoid arthritis (RA) tend to be immunosuppressed due to RA itself and the therapeutic drugs administered. The management of surgical site infection (SSI) following upper cervical spinal instrumented fusion in RA patients is challenging; however, literature on the treatment for such conditions is scarce. We report 3 consecutive patients with RA, who developed deep SSI following upper cervical posterior fusion and were treated using antibiotic-loaded bone cement (ALBC).

PATIENT CONCERNS

All 3 patients reported in the current study experienced compression myelopathy with upper cervical spinal deformity and received prednisolone and methotrexate for controlling RA preoperatively. The patient in Case 1 underwent C1-2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 3 months postoperatively; the patient in Case 2 underwent occipito-C2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 2 weeks postoperatively; and the patient in Case 3 underwent occipito-C2 posterior instrumented fusion and laminoplasty at C3-7, and developed deep SSI due to methicillin-resistant coagulase negative staphylococci at 3 weeks postoperatively.

DIAGNOSIS

All patients developed deep staphylococcal SSI in the postoperative period.

INTERVENTIONS

All 3 patients were treated using ALBC placed on and around the instrumentation to cover them and occupy the dead space after radical open debridement.

OUTCOMES

The deep infection was resolved uneventfully after the single surgical intervention retaining spinal instrumentation. Good clinical outcomes of the initial surgery were maintained until the final follow-up without recurrence of SSI in all 3 cases.

CONCLUSION

ALBC embedding spinal instrumentation procedure can be a viable treatment for curing SSI in complex cases, such as patients with RA who undergo high cervical fusion surgeries without implant removal.

Can active components of licorice, glycyrrhizin and glycyrrhetinic acid, lick rheumatoid arthritis?

OBJECTIVES

This review stated the possible application of the active components of licorice, glycyrrhizin (GL) and glycyrrhetinic acid (GA), in rheumatoid arthritis (RA) treatment based on the cyclooxygenase (COX)-2/thromboxane A2 (TxA2) pathway.

METHODS

The extensive literature from inception to July 2015 was searched in PubMed central, and relevant reports were identified according to the purpose of this study.

RESULTS

The active components of licorice GL and GA exert the potential anti-inflammatory effects through, at least in part, suppressing COX-2 and its downstream product TxA2. Additionally, the COX-2/TxA2 pathway, an auto-regulatory feedback loop, has been recently found to be a crucial mechanism underlying the pathogenesis of RA. However, TxA2 is neither the pharmacological target of non-steroidal anti-inflammatory drugs (NSAIDs) nor the target of disease modifying anti-rheumatic drugs (DMARDs), and the limitations and side effects of those drugs may be, at least in part, attributable to lack of the effects on the COX-2/TxA2 pathway. Therefore, GL and GA capable of targeting this pathway hold the potential as a novel add-on therapy in therapeutic strategy, which is supported by several bench experiments.

CONCLUSIONS

The active components of licorice, GL and GA, could not only potentiate the therapeutic effects but also decrease the adverse effects of NSAIDs or DMARDs through suppressing the COX-2/TxA2 pathway during treatment course of RA.