Cardiovascular Manifestations of Inflammatory Bowel Disease: Pathogenesis, Diagnosis, and Preventive Strategies

Inflammatory bowel disease and cardiac function: a systematic review of literature with meta-analysis

Background

Morphological and functional cardiac involvement is rarely described in patients with inflammatory bowel disease (IBD) but there is evidence that they have an increased risk of cardiovascular (CV) events despite the lower prevalence of traditional CV risk factors.

Objectives

Our systematic review and meta-analysis examined the relationship between IBD and cardiac function, namely the incidence of heart failure (HF) and subclinical echocardiographic changes.

Data sources and methods

Two medical databases, PubMed and Scopus, were systematically searched up to September 2022 to identify all studies reporting HF and/or echocardiographic changes in IBD patients.

Results

The qualitative analysis comprised a total of 18 studies (14 retrospective and 4 prospective studies) involving 59,838 patients. IBD was associated with subtle systolic and diastolic alterations, vascular dysfunction, increased risk for HF hospitalizations, and globally worse CV outcomes. Nine studies were included in the meta-analysis. In the IBD population, we found statistically significant reduced early to late diastolic transmitral flow (E/A), higher E to early diastolic mitral annular tissue velocity (E/e'), and decreased global longitudinal strain. Increased left atrial diameter and area were also present in IBD patients but no statistical significance was reached. Inter-atrial and right intra-atrial conduction delays were observed.

Conclusion

The IBD population has an increased risk for left ventricular and atrial dysfunction, vascular changes, arrhythmias, and HF hospitalization. Screening with sensitive imaging like speckle tracking echocardiography could identify early subclinical changes. IBD is in fact a CV risk factor and tight inflammation control may reduce CV risk.

Bioinformatics analysis reveals potential crosstalk genes and molecular mechanisms between ulcerative colitis and psoriasis

Ulcerative colitis (UC) and psoriasis are highly correlated clinically; however, it is unclear whether they have a common pathophysiological mechanism. The purpose of this study is to investigate the important molecules and pathways that mediate the coexistence of UC and psoriasis through quantitative bioinformatics analysis of public RNA-sequencing databases. The UC (GSE38713) and psoriasis (GSE30999) datasets were downloaded from the Gene Expression Omnibus database. Differentially expressed genes were analysed using the "limma" package and their biological functions were investigated using Gene Ontology and the Kyoto Encyclopedia of Genes and Genomes. The Search Tool for the Retrieval of Interacting Genes database was used to create the protein-protein interaction (PPI) network, which was visualised by Cytoscape. The CytoHubba plugin was used to select the hub genes. The hub genes of psoriasis and UC were verified in GSE75214, GSE78097, GSE14905, and GSE87466. The predicted value of the hub gene was evaluated by the receiver operating characteristic curve (ROC). Gene Set Enrichment Analysis (GSEA) and immune infiltration were performed for the hub genes. Finally, we performed transcription factor (TF)-gene interaction network analysis, TF-miRNA co-regulation network analysis and candidate drug prediction. A total of 114 genes (89 ascending genes and 25 descending genes) with similar expression trends between UC and psoriasis were identified. Enrichment analysis revealed that the two signaling pathways were primarily related to immune and inflammatory responses. PPI network screened 13 hub genes (IL-1B, CXCL10, TLR2, CD274, CXCR2, CXCL9, MMP9, CXCL1, CASP1, IL-7R, IL-1RN, CCL18 and LCN2). Using NetworkAnalyst, we constructed a co-regulatory network diagram of TF-gene and TF-miRNA. Finally, diacerein was predicted to be effective in the treatment of UC and psoriasis. Our research revealed the common pathogenesis of UC and psoriasis, and examined the hub genes, TF and miRNA and potential therapeutic drugs (diacerein). These findings may provide new perspectives for further mechanism research and clinical treatment.

Incidence, Predictors, and Outcomes of Acute Pericarditis in Patients with Inflammatory Bowel Disease: A 10-Year Nationwide Analysis

Background

Inflammatory bowel disease (IBD) is a chronic condition characterized primarily by inflammation of the gastrointestinal tract. Pericarditis is a rare but important extraintestinal manifestation of IBD that is poorly understood yet is associated with significant morbidity. The objectives of this study were to identify the factors associated with pericarditis in IBD and associated complications.

Methods

Hospitalized adult patients (aged ≥ 18 years) with a diagnosis of acute pericarditis in the IBD cohort, 2011-2020, were identified from the National Inpatient Sample using codes from the International Classification of Diseases (revision 9 or 10). Multivariable logistic regression was performed to identify clinical factors associated with pericarditis among IBD patients and in-hospital complications.

Results

During the period 2011-2020, among 3,236,747 IBD patients, 9113 (0.28%) had pericarditis, with a mean patient age of 54.08 ± 0.48 years, and 53.1% females. Patients with IBD and coexisting diagnoses of systemic lupus erythematosus (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.03-2.15, P = 0.033), rheumatoid arthritis and/or collagen vascular disorders (OR 1.75, 95% CI [1.41-2.17], P < 0.001), or postcardiotomy syndrome (OR 67.13, 95% CI [30.08-149.80], P < 0.001), were each associated with a higher risk of pericarditis. Compared to IBD patients without pericarditis, patients with IBD and pericarditis had an increased associated incidence of inpatient mortality (OR 1.65, 95% CI [1.25-2.18], P < 0.001).

Conclusions

Pericarditis is an uncommon but important manifestation of IBD. The presence of a concomitant autoimmune condition led to a higher likelihood of developing pericarditis among IBD patients, and IBD patients who develop pericarditis had a higher incidence of inpatient mortality compared to IBD patients without pericarditis. Providers should be aware of the connection between IBD and pericarditis to identify individuals at risk of adverse complications.

Diverticular disease and risk of incident major adverse cardiovascular events: A nationwide matched cohort study

BACKGROUND

An increased risk of cardiovascular disease (CVD) has been reported in patients with diverticular disease (DD). However, there are knowledge gaps about specific risks of each major adverse cardiovascular event (MACE) component.

METHODS

This nationwide cohort study included Swedish adults with DD (1987-2017, N=52,468) without previous CVD. DD was defined through ICD codes in the National Patient Register and colorectal histopathology reports from the ESPRESSO study. DD cases were matched by age, sex, calendar year and county of residence to ≤5 population reference individuals (N=194,525). Multivariable-adjusted hazard ratios (aHRs) for MACE up until December 2021 were calculated using stratified Cox proportional hazard models.

RESULTS

Median age at DD diagnosis was 62 years and 61% were females. During a median follow-up of 8.6 years, 16,147 incident MACE occurred in individuals with DD, and 48,134 in reference individuals (incidence rates (IRs)=61.4 vs. 43.8/1,000 person-years) corresponding to an aHR of 1.24 (95%CI=1.22-1.27), equivalent to one extra case of MACE for every 6 DD patients followed for 10 years. The risk was increased for ischemic heart disease (IR=27.9 vs. 18.6; aHR=1.36, 95%CI=1.32-1.40), congestive heart failure (IR=23.2 vs. 15.8; aHR=1.26, 95%CI=1.22-1.31), and stroke (IR=18.0 vs. 13.7; aHR=1.15, 95%CI=1.11-1.19). DD was not associated with cardiovascular mortality (IR=18.9 vs. 15.3; aHR=1.01, 95%CI=0.98-1.05). Results remained robust in sibling-controlled analyses.

CONCLUSIONS

Patients with DD had a 24% increased risk of MACE compared with reference individuals, but no increased cardiovascular mortality. Future research should confirm these data and examine underlying mechanisms and shared risk factors between DD and CVD.

Analysis of tofacitinib safety in ulcerative colitis from the completed global clinical developmental program up to 9.2 years of drug exposure

BACKGROUND AND AIMS

Tofacitinib is an oral Janus kinase inhibitor for the treatment of ulcerative colitis (UC). We report an integrated summary of tofacitinib safety from the completed global UC clinical program (9.2 years maximum tofacitinib exposure).

METHODS

This analysis included patients receiving tofacitinib 5 or 10 mg twice daily (b.i.d.) from completed phase 2/3 placebo-controlled studies, an open-label, long-term extension study and a randomized phase 3b/4 study. Proportions and incidence rates (IRs; unique patients with events/100 patient-years [PY] of exposure) were evaluated for deaths and adverse events (AEs) of special interest (AESI).

RESULTS

Overall, 1157 patients received ≥1 dose of tofacitinib 5 or 10 mg b.i.d.; 938 (81.1%) were in the predominant dose tofacitinib 10 mg b.i.d. group; 552 (47.7%) received tofacitinib for ≥2 years; total exposure: 3202.0 PY; 994 (85.9%) experienced AEs; 254 (22.0%) experienced serious AEs. Median treatment duration: 1.7 (range 0.0-9.2) years. IRs (95% CI) for combined tofacitinib doses: deaths 0.24 (0.10-0.48); serious infections (SIs) 1.80 (1.37-2.32); herpes zoster (HZ; non-serious and serious) 3.24 (2.63-3.94); serious HZ 0.24 (0.10-0.48); opportunistic infections 0.96 (0.65-1.36); malignancies (excluding non-melanoma skin cancer [NMSC]) 0.88 (0.59-1.26); NMSC 0.71 (0.45-1.07); major adverse cardiovascular events 0.27 (0.12-0.52); deep vein thrombosis 0.06 (0.01-0.22); pulmonary embolism 0.18 (0.07-0.40); and gastrointestinal perforations 0.09 (0.02-0.27).

CONCLUSIONS

Except for HZ and SIs, IRs for AESI were <1 case/100 PY. Safety was consistent with previous analyses of shorter exposure and tofacitinib's known safety profile, including real-world data.

CLINICALTRIALS

GOV: NCT00787202; NCT01465763; NCT01458951; NCT01458574; NCT01470612; NCT03281304.

Inflammatory Bowel Disease and Cardiovascular Disease: An Integrative Review With a Focus on the Gut Microbiome

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic inflammatory condition of the gastrointestinal tract. Recent research indicates a significant link between IBD and cardiovascular disease (CVD), the leading cause of global morbidity and mortality. This review examines the association between IBD and CVD, emphasizing the role of the gut microbiome in this relationship. IBD patients have a higher risk of cardiovascular events, such as coronary artery disease, heart failure, and cerebrovascular incidents, primarily due to chronic systemic inflammation, genetic factors, and gut microbiota imbalance (dysbiosis). Dysbiosis in IBD increases intestinal permeability, allowing bacterial products to enter the bloodstream, which promotes inflammation and endothelial dysfunction, contributing to CVD. Understanding the gut microbiome's role in IBD and CVD suggests new therapeutic interventions. Modulating the microbiome through diet, probiotics, and fecal microbiota transplantation (FMT) are promising research avenues. These interventions aim to restore a healthy gut microbiota balance, potentially reducing inflammation and improving cardiovascular outcomes. Additionally, the review emphasizes the importance of regular cardiovascular risk assessments and personalized preventive measures in managing IBD patients. Such measures include routine monitoring of cardiovascular health, tailored lifestyle modifications, and early intervention strategies to mitigate cardiovascular risk. By integrating current knowledge, this review aims to improve understanding and management of the interconnected pathophysiology of IBD and CVD. This approach will ultimately enhance patient outcomes and provide a foundation for future research and clinical practice guidelines in this area.

Eosinophilic esophagitis and risk of incident major adverse cardiovascular events: a nationwide matched cohort study

BACKGROUND

Inflammatory diseases have been associated with an increased cardiovascular risk. However, data on incident major adverse cardiovascular events (MACE) from large population-based cohorts of patients with eosinophilic esophagitis (EoE) is lacking.

METHODS

This study included all Swedish adults with EoE without a record of previous cardiovascular disease (CVD) (1990-2017, N = 1546) with follow-up until 2019. Individuals with EoE were identified from prospectively recorded histopathology reports from all Swedish pathology departments (n = 28). EoE patients were matched at index date for age, sex, calendar year and county with up to five general population reference individuals (N = 7281) without EoE or CVD. Multivariable-adjusted hazard ratios (aHRs) for MACE (ischemic heart disease, congestive heart failure, stroke and cardiovascular mortality) were calculated using Cox proportional hazards models. Full sibling comparisons and adjustment for cardiovascular medication were performed.

RESULTS

During a median follow-up of 6.0 years, we observed 65 incident MACE in patients with EoE (6.4/1000 person-years (PY)) and 225 in reference individuals (4.7/1000 PY). EoE was not associated with a higher risk of MACE (aHR = 1.14, 95% CI = 0.86-1.51) or any of its components. No differences between age, sex and follow-up time were observed. The results remained stable in sensitivity analyses, including when adjusting for relevant cardiovascular medications and a full sibling comparison.

CONCLUSIONS

In this large population-based cohort study, patients with EoE had no increased risk of MACE compared to reference individuals and full siblings. The results are reassuring for patients with EoE.

Systematic Review and Meta-Analysis on the Impact of Atrial Fibrillation on Outcomes in Patients With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory condition affecting the gastrointestinal tract, often leading to symptoms like abdominal pain and diarrhea. Given the increasing evidence linking systemic inflammation to atrial fibrillation development, investigating IBD as a potential risk factor for atrial fibrillation becomes imperative. This meta-analysis aims to evaluate the impact of atrial fibrillation on inpatient outcomes, resource utilization, and length of hospital stays among IBD patients. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines, a systematic literature search was conducted across multiple databases, including Embase, PubMed, Scopus, and Web of Science, from the inception of databases to June 5, 2024. Eligible studies included prospective or retrospective studies with definitive diagnoses of ulcerative colitis, Crohn's disease, or IBD, demonstrating the influence of atrial fibrillation. Data were extracted, and quality assessment was performed using the Newcastle-Ottawa Scale. The meta-analysis comprised 842,149 IBD patients, with 71,221 having atrial fibrillation. Pooled analysis revealed a significant association between atrial fibrillation and heightened all-cause mortality risk (risk ratio (RR): 1.42, 95% confidence interval (CI): 1.16 to 1.74, p<0.01). However, no significant differences were observed in the incidence of acute myocardial infarction, acute kidney injury, or acute respiratory failure between patients with and without atrial fibrillation. IBD patients with comorbid atrial fibrillation face higher mortality rates, potentially due to systemic inflammation, thromboembolism risks, polypharmacy, and the complexities of managing both conditions concurrently. Early identification and integrated management of atrial fibrillation in IBD patients are crucial to improving outcomes. Larger, multi-center studies are needed to explore the underlying mechanisms and develop tailored treatment strategies.

Leukocytoclastic Vasculitis-Associated Myocarditis as an Extraintestinal Manifestation of Crohn's Disease

Cardiac extraintestinal manifestations (EIMs) of Crohn's disease (CD) are uncommon. They include pericarditis, myocarditis, and arrhythmias; however, distinguishing these from alternative causes including medication-related adverse effects is often challenging. Leukocytoclastic vasculitis is another uncommon EIM of CD that may present with systemic involvement. We present a rare case of myocarditis associated with leukocytoclastic vasculitis occurring as EIMs of CD. The myocarditis proved refractory to standard therapy and biologics targeting underlying gut inflammation. She developed an inflammatory cardiomyopathy and symptoms consistent with heart failure with preserved ejection fraction. Anakinra was tried, but despite the initial response, it should be used cautiously in patients with CD.

Evaluation of QRS duration and presence of fragmented QRS in patients with inflammatory bowel disease

Background: Inflammatory Bowel Disease (IBD) is mostly characterized by gastrointestinal tract involvement, however can also be accompanied with cardiac manifestations. QRS prolongation and the presence of QRS fragmentation (fQRS) have been previously evaluated in many chronic inflammatory diseases, as an independent predictor of cardiac events. In this study, we aimed to evaluate the QRS duration and fQRS in patients with IBD. Methods: The presented study was designed as a single-center retrospective cohort study. The study population consisted of 217 patients with IBD and 195 healthy controls. QRS duration and presence of fQRS were evaluated using a 12-lead electrocardiogram. These parameters were compared between groups. Results: QRS duration was demonstrated to be higher in the IBD group compared to the control group (92 (86-98) vs. 82 (75-90), p<0.001). The presence of fQRS was significantly higher in the IBD group (n=101 (47%) vs n=59 (30%), p=0.006). In addition, a positive correlation was demonstrated between QRS duration and disease duration (Spearman's Rho= 0.4, p<0.001). Notably, disease and QRS duration were significantly higher in the fQRS (+) group (102 (56.5-154) vs. 55 (24.3-118.3), <0.001; 94 (86-100) vs. 92 (84-96), 0.016; respectively). Conclusion: Our results demonstrated that QRS prolongation and the presence of fQRS (+) were more common in IBD patients, and associated with longer disease duration. These findings may indicate subclinical cardiac involvement in IBD. Therefore, IBD patients, especially those with long-standing disease, should be followed more closely in terms of cardiac manifestations.

Extraintestinal Manifestations of Inflammatory Bowel Disease: Unraveling Valvulopathy Connections

The clinical presentation of inflammatory bowel disease (IBD) includes both gastrointestinal manifestations and extraintestinal manifestations (EIM). Over the past years, a growing number of studies have indicated that patients suffering from IBD have an increased risk of developing cardiovascular disease. Although the precise prevalence of cardiac complications in IBD remains uncertain, emerging evidence suggests a heightened incidence compared to the general population. Valvular heart disease (VHD) in IBD encompasses calcific aortic valve disease, mitral valve prolapses, and endocarditis, potentially associated with chronic inflammation. Considering the role of inflammation in developing cardiovascular manifestations, the management should include preventing flares and maintaining remission for as long as possible. This case highlights the intricate interplay between IBD and cardiovascular complications, particularly valvular abnormalities. We present a 37-year-old male with a history of ulcerative colitis (UC) who was found to have multiple valvular diseases.

Simultaneous Presentation of Takayasu Arteritis and Crohn's Disease in a Middle-Aged Patient: Are they two sides of the same coin?

Autoimmune disorders have a wide spectrum of symptoms, often with multiorgan involvement. Multiple autoimmune disorders also often occur concurrently in the same patient. These two possibilities must be distinguished in patients with multiorgan involvement to ensure early diagnosis and treatment. Here, we report a case of a previously healthy man who presented with simultaneous Takayasu arteritis and Crohn's disease. He presented with heart failure with reduced ejection fraction and severe aortic regurgitation. An echocardiogram demonstrated a greatly dilated aorta, and a diagnosis of Takayasu arteritis was made, confirmed with CT aortogram. Inpatient treatment was begun, but the patient subsequently developed bloody diarrhoea a few days after admission. Colonoscopy done to locate the source of bleeding showed colonic ulcers; a biopsy confirmed a diagnosis of Crohn's disease. The patient was successfully managed with medical management of heart failure, steroids, mesalamine and azathioprine, and has been in remission for the last 2 years.

Acute Severe Ulcerative Colitis Flare Complicated by Myopericarditis and Infliximab-Induced Hepatitis

Ulcerative colitis (UC) is an autoimmune disease associated with both intestinal and extraintestinal manifestations. The latter may include heart complications, such as myopericarditis leading to life-threatening arrythmias. Nowadays, UC is commonly treated with biologic medications and infliximab is the first line therapy in an outpatient setting, while it is also used as rescue therapy in acute severe UC. However, it has been associated with severe immunosuppression, cytomegalovirus (CMV) reactivation and drug-induced hepatitis. We report a case of UC flare in a biologic naïve patient admitted with myopericarditis, which was further complicated by positive CMV biopsies and infliximab-induced transaminitis.

LEARNING POINTS

In acute inflammatory bowel disease (IBD) flare presentation with tachycardia and chest pain, an underlying myocardial injury should be investigated.Mucosal healing should be evaluated endoscopically in cases of partial response to biologics.Both cytomegalovirus (CMV) infection and infliximab-induced liver injury may lead to acute hepatitis.

Patients With Microscopic Colitis Are at Higher Risk of Major Adverse Cardiovascular Events: A Matched Cohort Study

BACKGROUND AND AIMS

Inflammatory diseases are associated with an increased risk of incident major adverse cardiovascular events (MACE). However, data on MACE are lacking in large population-based histopathology cohorts of microscopic colitis (MC).

METHODS

This study included all Swedish adults with MC without previous cardiovascular disease (1990-2017; N = 11,018). MC and subtypes (collagenous colitis and lymphocytic colitis) were defined from prospectively recorded intestinal histopathology reports from all pathology departments (n = 28) in Sweden. MC patients were matched for age, sex, calendar year, and county with up to 5 reference individuals (N = 48,371) without MC or cardiovascular disease. Sensitivity analyses included full sibling comparisons, and adjustment for cardiovascular medication and healthcare utilization. Multivariable-adjusted hazard ratios for MACE (any of ischemic heart disease, congestive heart failure, stroke, and cardiovascular mortality) were calculated using Cox proportional hazards modelling.

RESULTS

Over a median of 6.6 years of follow-up, 2181 (19.8%) incident cases of MACE were confirmed in MC patients and 6661 (13.8%) in reference individuals. MC patients had a higher overall risk of MACE outcomes compared with reference individuals (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.21-1.33) and higher risk of its components: ischemic heart disease (aHR, 1.38; 95% CI, 1.28-1.48), congestive heart failure (aHR, 1.32; 95% CI, 1.22-1.43), and stroke (aHR, 1.12; 95% CI, 1.02-1.23) but not cardiovascular mortality (aHR, 1.07; 95% CI, 0.98-1.18). The results remained robust in the sensitivity analyses.

CONCLUSIONS

Compared with reference individuals, MC patients had a 27% higher risk of incident MACE, equal to 1 extra case of MACE for every 13 MC patients followed for 10 years.

Cardiovascular implications of inflammatory bowel disease: An updated review

Emerging data highlights the heightened risk of atherosclerotic cardiovascular diseases (ASCVD) in patients with chronic inflammatory disorders, particularly those afflicted with inflammatory bowel disease (IBD). This review delves into the epidemiological connections between IBD and ASCVD, elucidating potential underlying mechanisms. Furthermore, it discusses the impact of current IBD treatments on cardiovascular risk. Additionally, the cardiovascular adverse effects of novel small molecule drugs used in moderate-to-severe IBD are investigated, drawing parallels with observations in patients with rheumatoid arthritis. This article aims to comprehensively evaluate the existing evidence supporting these associations. To achieve this, we conducted a meticulous search of PubMed, spanning from inception to August 2023, using a carefully selected set of keywords. The search encompassed topics related to IBD, such as Crohn's disease and ulcerative colitis, as well as ASCVD, including coronary artery disease, cardiovascular disease, atrial fibrillation, heart failure, conduction abnormalities, heart blocks, and premature coronary artery disease. This review encompasses various types of literature, including retrospective and prospective cohort studies, clinical trials, meta-analyses, and relevant guidelines, with the objective of providing a comprehensive overview of this critical intersection of inflammatory bowel disease and cardiovascular health.

Novel Findings of Early Cardiac Dysfunction in Patients With Childhood-Onset Inflammatory Bowel Disease Using Layer-Specific Strain Analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at a higher risk of developing cardiovascular diseases than healthy individuals, owing to persistent chronic inflammation and treatment effects. This study aimed to assess left ventricular function in patients with childhood-onset IBD using layer-specific strain analysis and to identify early indicators of cardiac dysfunction in them.

METHODS

A total of 47 patients with childhood-onset ulcerative colitis (UC), 20 patients with Crohn's disease (CD), and 75 age- and sex-matched healthy control subjects were included in this study. Conventional echocardiographic measurements of layer-specific (ie, endocardium, midmyocardium, and epicardium) global longitudinal strain and global circumferential strain (GCS) were evaluated in these participants.

RESULTS

Layer-specific strain analysis showed that global longitudinal strain was lower in all layers for the UC (P < .001) and CD (P < .001) groups, regardless of the age at onset, but that GCS was only lower in the midmyocardial (P = .032) and epicardial (P = .018) layers in the CD group than in the control group. Although the mean left ventricular wall thickness was not significantly different among the groups, it was significantly correlated with the GCS of the endocardial layer in the CD group (ρ= -0.615; P = .004), suggesting that thickening of the left ventricular wall occurred as a compensatory mechanism to maintain the endocardial strain in the CD group layer.

CONCLUSIONS

Children and young adults with childhood-onset IBD displayed decreased midmyocardial deformation. Layer-specific strain could also be useful to identify indicators of cardiac dysfunction in patients with IBD.

Long-term Risk of Stroke in Patients With Inflammatory Bowel Disease: A Population-Based, Sibling-Controlled Cohort Study, 1969-2019

BACKGROUND AND OBJECTIVES

Patients with inflammatory bowel disease (IBD) are at an increased risk of thromboembolic events, but evidence on the long-term risk of stroke remains scarce. We aimed to explore whether patients with a biopsy-confirmed IBD had an increased long-term risk of stroke.

METHODS

This cohort included all patients with biopsy-confirmed IBD in Sweden between 1969 and 2019 and up to 5 matched reference individuals per patient who were randomly selected from the general population and IBD-free full siblings. The primary outcome was incident overall stroke; secondary outcomes were ischemic and hemorrhagic strokes. Stroke was identified from the Swedish National Patient Register by using both primary and secondary diagnoses. Adjusted hazard ratios (aHRs) for stroke were estimated by flexible parametric survival models.

RESULTS

A total of 85,006 patients with IBD (including Crohn disease [CD, n = 25,257], ulcerative colitis [UC, n = 47,354], and IBD-unclassified [IBD-U, n = 12,395]), 406,987 matched reference individuals, and 101,082 IBD-free full siblings were included in the analysis. We observed 3,720 incident strokes in patients with IBD (incidence rate [IR] 32.6 per 10,000 person-years) and 15,599 in reference individuals (IR 27.7; aHR 1.13, 95% CI 1.08-1.17). The elevated aHR remained increased even 25 years after diagnosis, corresponding to 1 additional stroke case per 93 patients with IBD until then. The excess aHR was mainly driven by ischemic stroke (aHR 1.14; 1.09-1.18) rather than hemorrhagic stroke (aHR 1.06; 0.97-1.15). The risk of ischemic stroke was significantly increased across IBD subtypes (CD [IR 23.3 vs 19.2; aHR 1.19; 1.10-1.29], UC [IR 25.7 vs 22.6; aHR 1.09; 1.04-1.16], and IBD-U [IR 30.5 vs 22.8; aHR 1.22; 1.08-1.37]). Similar results were found when patients with IBD were compared with their siblings.

DISCUSSION

Patients with IBD were at an increased risk of stroke, especially of ischemic events, irrespective of the IBD subtype. The excess risk persisted even 25 years after diagnosis. These findings highlight the need for clinical vigilance about the long-term excess risk of cerebrovascular events in patients with IBD.

Isolated Aortitis: Workup and Management

The finding of aortitis, often incidentally noted on surgical resection, should prompt evaluation for secondary causes including large-vessel vasculitis. In a large proportion of cases, no other inflammatory cause is identified and the diagnosis of clinically isolated aortitis is made. It is unknown whether this entity represents a more localized form of large-vessel vasculitis. The need for immunosuppressive therapy in patients with clinically isolated aortitis remains unclear. Patients with clinically isolated aortitis warrant imaging of the entire aorta at baseline and regular intervals because a significant proportion of patients have or develop abnormalities in other vascular beds.

Myocarditis With Cardiogenic Shock in a Young Female With Severe Ulcerative Colitis Flare

Myocarditis is a rare extraintestinal manifestation of inflammatory bowel disease. Myopericarditis-associated inflammatory bowel disease can be a side effect of the medications used to treat inflammatory bowel disease or the disease process. We present a 25-year-old female with history of ulcerative colitis presented with abdominal pain associated with sharp and central chest pain. She was in a flare of ulcerative colitis with bloody diarrhea. She developed shock and was in intensive care unit. Echocardiogram showed reduced ejection fraction and pericardial effusion. Coronary artery disease, sepsis, thyroid disease were ruled out. She was treated with systemic antibiotics, intravenous steroids, and guideline-directed medical therapy for presumed ulerative colitis associated with myopericarditis and had symptomatic improvement. Treatment of IBD-associated myopericarditis includes the standard induction treatment for IBD with steroids and guideline-directed medical therapy for heart failure.

Review article: Risk of cardiovascular events in patients with inflammatory bowel disease receiving small molecule drugs

BACKGROUND

In the context of an ageing inflammatory bowel disease (IBD) population, cardiovascular comorbidities become particularly relevant. Novel small molecule drugs (SMDs) for the treatment of moderate-to-severe IBD have been recently approved, including Janus kinase (JAK) inhibitors and sphingosine-1-phosphate receptor (S1P) modulators. Data from rheumatoid arthritis population have raised concerns about the risk of cardiovascular events with the use of tofacitinib, which was extrapolated to other immune-mediated diseases and other JAK inhibitors. S1P receptor modulation has been associated with potential cardiovascular events, especially bradycardia and cardiac conduction abnormalities.

AIM

To review the incidence of cardiovascular events with the use of SMDs in patients with IBD and to provide practical recommendations on mitigation strategies.

METHODS

Published literature was reviewed; recommendations were synthesised by experts in both cardiovascular diseases and IBD.

RESULTS

Evidence from the IBD population does not indicate a higher risk of cardiovascular events with tofacitinib and other JAK inhibitors. The risk is higher in patients with intermediate to high cardiovascular risk. S1P modulators may be associated with a dose-dependent, first-dose effect, transient risk of conduction abnormalities (bradycardia and AV block). Screening and monitoring of cardiovascular risk factors should be done in all patients with IBD. Risk stratification for cardiovascular disease should be performed before starting treatment with SMDs.

CONCLUSIONS

Available evidence of both JAK inhibitors and S1P modulators indicates a reassuring safety profile of SMDs from the cardiovascular perspective in the overall IBD population. Efforts should be made to identify patients with IBD at a higher risk of cardiovascular events.

Myocarditis and inflammatory bowel diseases: A single-center experience and a systematic literature review

BACKGROUND

Myocarditis and inflammatory bowel diseases (IBD) are rare conditions, but may coexist. Myocarditis in IBD may be infective, immune-mediated, or due to mesalamine toxicity. A gap of knowledge exists on the clinical features of patients that present myocarditis in association with IBD, especially for endomyocardial biopsy-proven cases. Our aims are: 1) to describe the clinical characteristics of patients with an associated diagnosis of myocarditis and IBD in a single-center hospital, 2) to perform a systematic review of the literature of analogous cases.

METHODS

We retrospectively analyzed data of patients followed up at the outpatient Cardio-immunology and Gastroenterology Clinic of Padua University Hospital, to identify those with an associated diagnosis of myocarditis and IBD. In addition, a systematic review of the literature was conducted. We performed a qualitative analysis of the overall study population.

RESULTS

The study included 104 patients (21 from our single center cohort, 83 from the literature review). Myocarditis in IBD more frequently affects young (median age 31 years) males (72%), predominantly with infarct-like presentation (58%), within an acute phase of the IBD (67%) and with an overall benign clinical course (87%). Nevertheless, a not negligible quote of patients may present giant cell myocarditis, deserve immunosuppression and have a chronic, or even fatal course. Histological evidence of mesalamine hypersensitivity is scarce and its incidence may be overestimated.

CONCLUSIONS

Our study shows that myocarditis in association with IBD, if correctly managed, may have a spontaneous benign course, but predictors of worse prognosis must be promptly recognized.

Evaluation of Tp-e interval and Tp-e/QTc ratio in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), a multisystemic inflammatory disorder, has been associated with increased risk of cardiovascular problems, including complications such as conduction defects and arrhythmias. Therefore, the early assessment of the risk factors predisposing to ventricular arrhythmias is crucial, since it can improve clinical outcomes. The objective of the present study is to evaluate ventricular repolarization by using Tp‑e interval and Tp-e/QTc ratio as candidate markers of ventricular arrhythmias in patients with IBD.

METHODS

The presented study was designed as a single-center prospective cohort study. The study population consisted of 175 patients with IBD and 175 healthy volunteers. The Tp‑e interval, corrected QT (QTc), and Tp-e/QTc ratio were measured from the 12-lead electrocardiogram. These parameters were compared between groups.

RESULTS

The groups were similar in terms of electrocardiographic findings such as heart rate, QRS interval, and QTc interval. However, Tp‑e interval (87.0 ms, interquartile range, IQR 81.0-105.0 ms vs. 84.0 ms, IQR 74.0-92.0 ms; p < 0.001) and Tp-e/QTc ratio (0.21 ± 0.04 vs. 0.19 ± 0.05; p < 0.001) were significantly increased in IBD patient group compared to control group. Notably, a positive correlation was demonstrated between Tp‑e interval, Tp-e/QTc ratio and disease duration (Spearman's Rho = 0.36, p < 0.001 for Tp‑e; Spearman's Rho = 0.28, p < 0.001 for Tp-e/QTc).

CONCLUSION

This study demonstrated that IBD patients are at increased risk of disrupted ventricular repolarization (increased Tpe, Tpe/QTc ratio). In addition, a positive correlation was demonstrated between Tp‑e interval, Tp-e/QTc ratio, and disease duration. Therefore, IBD patients, especially those with long-standing diseases, should be more closely screened for ventricular arrhythmias.

The Role of Gut Microbiota in Heart Failure: When Friends Become Enemies

Heart failure is a complex health issue, with important consequences on the overall wellbeing of patients. It can occur both in acute and chronic forms and, in the latter, the immune system appears to play an important role in the pathogenesis of the disease. In particular, in the forms with preserved ejection fraction or with only mildly reduced ejection fraction, some specific associations with chronic inflammatory diseases have been observed. Another interesting aspect that is worth considering is the role of microbiota modulation, in this context: given the importance of microbiota in the modulation of immune responses, it is possible that changes in its composition may somewhat influence the progression and even the pathogenesis of heart failure. In this narrative review, we aim to examine the relationship between immunity and heart failure, with a special focus on the role of microbiota in this pathological condition.

Tofacitinib for the treatment of ulcerative colitis: an integrated summary of up to 7.8 years of safety data from the global clinical program

BACKGROUND AND AIMS

Tofacitinib is an oral small molecule JAK inhibitor for the treatment of ulcerative colitis. We report an integrated summary of tofacitinib safety [exposure:≤7.8 years] from the global clinical program.

METHODS

Patients receiving tofacitinib 5 or 10 mg twice daily (BID) from completed phase [P]2/3 placebo-controlled studies, open-label, long-term extension study [final data cut-off: August 24, 2020], and interim analysis of a P3b/4 study [interim data cut-off: February 20, 2020; Overall plus P3b/4 (2020) Cohort], were included. Proportions with adverse events [AEs] and serious AEs, and incidence rates [IRs; unique patients with events/100 patient-years] for deaths and AEs of special interest [AESI] were evaluated. Opportunistic infections, malignancies, major adverse cardiovascular events [MACE], and gastrointestinal perforations were adjudicated.

RESULTS

In total, 1157 patients received ≥1 dose of tofacitinib (mean duration: 946.9 days); 955/1157 [83%] received a predominant dose of 10 mg BID; 412/1157 [35.6%] received tofacitinib for >4 years; 992/1157 [85.7%] had AEs, 244/1157 [21.1%] had serious AEs, and 134/1157 (11.6%) discontinued due to AEs. IRs [95% CIs] for all tofacitinib doses: deaths, 0.23 [0.09-0.46]; serious infections, 1.69 [1.26-2.21]; herpes zoster [non-serious and serious], 3.30 [2.67-4.04]; opportunistic infections, 1.03 [0.70-1.46]; malignancies [excluding nonmelanoma skin cancer (NMSC)], 0.84 [0.55-1.24]; NMSC, 0.73 [0.45-1.10]; MACE, 0.29 [0.13-0.55]; deep vein thrombosis, 0.03 [0.00-0.18]; pulmonary embolism, 0.19 [0.07-0.42]; gastrointestinal perforations, 0.10 [0.02-0.28].

CONCLUSIONS

AESI IRs were stable to 7.8 years and generally <2.0 in the Overall plus P3b/4 (2020) Cohort, with the exception of herpes zoster [a known risk of tofacitinib treatment].

Prevalence of Self-Reported Venous Thromboembolism and Cardiovascular Risk Factors in Patients with Ulcerative Colitis: The GETAID FOCUS Study

BACKGROUND AND AIMS

Patients with inflammatory bowel disease have an increased risk of venous thromboembolism (VTE) and cardiovascular disease (CVD). The study aims to determine the prevalence of CVD and VTE risk factors in a large population of patients with ulcerative colitis (UC).

METHODS

We conducted a cross-sectional study in 33 French and Belgium referral centers. A questionnaire was developed to explore self-reported risk factors for VTE and CVD, based on the latest international guidelines, in consecutive patients with UC.

RESULTS

A total of 1071 patients with UC were included. There were 539 women (50.3%), and the median age of patients was 44 years [32; 57]. The median disease duration was 10 years [6; 17]. In the cohort, 36.5% of patients reported no cardiovascular risk factor (CVRF) and 72% had ≤ 1 CVRF. Regarding cardiovascular risk markers (CVRM) 36.9% of patients reported no CVRM and 78% had ≤ 1 CVRM. Of the 1071 patients, 91.3% of patients reported no VTE strong risk factor and 96% had ≤ 1 VTE moderate risk factor.

CONCLUSION

This is the first cohort specifically designed to assess both VTE and CVD risks in patients with UC. More than one third of patients with UC had no CVRF and around three quarters had ≤ 1 CVRF. In addition, more than nine out of ten patients had no VTE strong risk factor and ≤ 1 moderate risk factor. Physicians should be aware of these factors in their patients.

Linalyl acetate restores colon contractility and blood pressure in repeatedly stressed-ulcerative colitis rats

Background

Ulcerative colitis (UC) is related to stress, but few studies have evaluated the influence of stress on factors affecting colon contractility in rats with UC. Also, there have been no studies investigating beneficial effects of linalyl acetate (LA), the major component of lavender essential oil, in repeatedly stressed-ulcerative colitis rats. Therefore, we investigated the differences in factors affecting colon contractility of UC rats with or without repeated restraint stress (RRS) and the effects of LA on these parameters in repeatedly stressed-UC rats.

Methods

Rats were assigned to following groups: control, RRS, UC, RRS+UC, and RRS+UC treated with LA or sulfasalazine. To induce UC, rats were administered 2% dextran sodium sulfate (DSS) water on days 1–5, followed by tap water on days 6–15 and DSS water on days 16–20. RRS was induced by immobilizing rats for 2 hr/day on days 1–20. LA or sulfasalazine were daily administered on days 16–20.

Results

Disease activity index (DAI) was markedly increased in RRS+UC. Serum interleukin-6 levels and acetylcholine-induced colon contraction were higher in RRS+UC than in control, RRS and UC. Colon nitrite levels also significantly increased in RRS+UC compared to the control and RRS. Blood pressure (BP) was higher in RRS+UC than in the control and UC. Both LA and sulfasalazine was effective in decreasing DAI, colon nitrite levels, acetylcholine-induced colon contraction in RRS+UC. Sulfasalazine significantly reduced serum IL-6 levels in RRS+UC with decreasing tendency in RRS+UC treated by LA. Only LA significantly reduced BP in RRS+UC.

Conclusions

Our findings emphasize the importance of stress management in UC patients. Also, LA may be beneficially used in repeatedly stressed-UC patients with high BP.

Neutrophil Infiltration Characterized by Upregulation of S100A8, S100A9, S100A12 and CXCR2 Is Associated With the Co-Occurrence of Crohn’s Disease and Peripheral Artery Disease

Background

Crohn’s disease (CD) and peripheral arterial disease (PAD) are closely related. The pathophysiological mechanisms underlying the coexistence of CD and PAD are unknown. The aim of this study was to investigate the key molecules and pathways mediating the co-occurrence of CD and PAD through quantitative bioinformatic analysis of a public RNA sequencing database.

Methods

Datasets of CD (GSE111889) and PAD (GSE120642) were downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were analyzed using the ‘edgeR’ and ‘limma’ packages of R. Gene Ontology and Kyoto Encyclopedia analyses of common DEGs were performed to explore the functions of DEGs. Protein–protein interaction (PPI) networks were established by the Search Tool for the Retrieval of Interacting Genes (STRING) database and visualized by Cytoscape. Hub genes were selected using the plugin cytoHubba. Hub gene validation was performed in GSE95095 for CD and GSE134431 for PAD. Receiver operating characteristic curves were used to evaluate the predictive values of the hub genes. Gene set enrichment analysis and immune infiltration of the hub genes were performed.

Results

A total of 54 common DEGs (2 downregulated and 52 upregulated) were identified. Pathways of neutrophil chemotaxis, neutrophil migration and cytokine and cytokine receptors were enriched in CD and PAD. S100A8, S100A9, S100A12 and CXCR2 were identified as hub genes after validation, with all area under the curve > 0.7 for both CD and PAD. Neutrophil infiltration was associated with upregulation of the hub genes. Pathways of immune processes, including neutrophil activation, neutrophil chemotaxis, neutrophil migration were significantly correlated with high expression of S100A8, S100A9, S100A12 and CXCR2 in both CD and PAD.

Conclusions

This bioinformatic study elucidates S100A8, S100A9, S100A12 and CXCR2 as hub genes for the co-occurrence of Crohn’s disease and peripheral artery disease. Inflammation and immune regulation modulated by neutrophil infiltration play a central role in the development of CD and PAD and may be potential targets for diagnosis and treatment.

Impact of Inflammatory Bowel Disease (IBD) and IBD Medications on Risk of Hyperlipidemia and in vitro Hepatic Lipogenic-Related Gene Expression: A Population-Based Cohort Study

Patients with inflammatory bowel disease (IBD) present a higher risk of developing cardiovascular diseases (CVDs) due to chronic inflammation, which plays an essential role in atherogenesis. Hyperlipidemia is another risk factor for CVDs; however, the association between IBD, IBD medications, and hyperlipidemia remains controversial. We conducted a nationwide, population-based, retrospective, cohort study to examine the effect of IBD and IBD medications on the risk of developing hyperlipidemia. The effects of IBD medications on the expression of lipogenesis-related hepatic genes were also evaluated. We obtained data from the Longitudinal Health Insurance Database of Taiwan from patients with new-onset IBD and a comparison cohort of patients without IBD. A Cox proportional hazards regression model was used to analyze the difference in the risk of developing hyperlipidemia between the two cohorts. We also examined the influence of IBD medications on the expression of lipogenesis-related hepatic genes. After adjusting for comorbidities and confounding factors, the case group (N = 14,524) had a higher risk for hyperlipidemia than the control group (N = 14,524) [adjusted hazards ratio (aHR), 2.18]. Patients with IBD that did not receive IBD medications exhibited a significantly higher risk of hyperlipidemia (aHR, 2.20). In those treated with IBD medications, the risk of developing hyperlipidemia was significantly lowered than those without such medications (all aHR ≤ 0.45). Gene expression analysis indicated that IBD medications downregulated the expression of lipogenesis-related genes. Screening blood lipids in IBD patients is needed to explore the specific role and impact of IBD medications in the development of CVD.

Moringa Oleifera Lam. in Cardiometabolic Disorders: A Systematic Review of Recent Studies and Possible Mechanism of Actions

Cardiometabolic disorders (CMD) have become a global emergency and increasing burden on health and economic problems. Due to the increasing need for new drugs for cardiometabolic diseases, many alternative medicines from plants have been considered and studied. Moringa oleifera Lam. (MO), one of the native plants from several Asian countries, has been used empirically by people for various kinds of illnesses. In the present systematic review, we aimed to investigate the recent studies of MO in CMD and its possible mechanism of action. We systematically searched from three databases and summarized the data. This review includes a total of 108 papers in nonclinical studies and clinical trials of MO in cardiometabolic-related disorders. Moringa oleifera, extracts or isolated compound, exerts its effect on CMD through its antioxidative, anti-inflammatory actions resulting in the modulation in glucose and lipid metabolism and the preservation of target organ damage. Several studies supported the beneficial effect of MO in regulating the gut microbiome, which generates the diversity of gut microbiota and reduces the number of harmful bacteria in the caecum. Molecular actions that have been studied include the suppression of NF-kB translocation, upregulation of the Nrf2/Keap1 pathway, stimulation of total antioxidant capacity by reducing PKCζ activation, and inhibiting the Nox4 protein expression and several other proposed mechanisms. The present review found substantial evidence supporting the potential benefits of Moringa oleifera in cardiovascular or metabolic disorders.

Grape Pomace Extract Attenuates Inflammatory Response in Intestinal Epithelial and Endothelial Cells: Potential Health-Promoting Properties in Bowel Inflammation

Inflammatory bowel disease (IBD) implies the chronic inflammation of the gastrointestinal tract, combined with systemic vascular manifestations. In IBD, the incidence of cardiovascular disease appears to be related to an increase of oxidative stress and endothelial dysfunction. Grape pomace contains high levels of anti-oxidant polyphenols that are able to counteract chronic inflammatory symptoms. The aim of this study was to determine whether grape pomace polyphenolic extract (GPE) was able to mitigate the overwhelming inflammatory response in enterocyte-like cells and to improve vascular function. Intestinal epithelial Caco-2 cells, grown in monolayers or in co-culture with endothelial cells (Caco-2/HMEC-1), were treated with different concentrations of GPE (1, 5, 10 µg/mL gallic acid equivalents) for 2 h and then stimulated with lipopolysaccharide (LPS) and tumor necrosis factor (TNF)-α for 16 h. Through multiple assays, the expression of intestinal and endothelial inflammatory mediators, intracellular reactive oxygen species (ROS) levels and NF-κB activation, as well as endothelial-leukocyte adhesion, were evaluated. The results showed that GPE supplementation prevented, in a concentration-dependent manner, the intestinal expression and release of interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1, and matrix metalloproteinases (MMP)-9 and MMP-2. In Caco-2 cells, GPE also suppressed the gene expression of several pro-inflammatory markers, such as IL-1β, TNF-α, macrophage colony-stimulating factor (M-CSF), C-X-C motif ligand (CXCL)-10, intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, and cyclooxygenase (COX)-2. The GPE anti-inflammatory effect was mediated by the inhibition of NF-κB activity and reduced intracellular ROS levels. Furthermore, transepithelial GPE suppressed the endothelial expression of IL-6, MCP-1, VCAM-1, and ICAM-1 and the subsequent adhesion of leukocytes to the endothelial cells under pro-inflammatory conditions. In conclusion, our findings suggest grape pomace as a natural source of polyphenols with multiple health-promoting properties that could contribute to the mitigation of gut chronic inflammatory diseases and improve vascular endothelial function.

Dilated Cardiomyopathy in Pediatric Crohn's Patient: Is It a Manifestation or Consequence of Therapy?

Inflammatory bowel disease (IBD) is a debilitating chronic disorder that is classified into Crohn's disease, ulcerative colitis, and unspecified which are marked by recurrent gastrointestinal inflammatory episodes. Anti-tumor necrosis agents, especially infliximab, are considered the cornerstone in disease management. However, rare but serious adverse effects related to infliximab have been reported. Limited studies reported cardiac adverse effects as a result of using infliximab in IBD especially in the pediatric age group. Here, we report a case of an 11-year-old boy known to have Crohn's disease, who was on a regular infusion of infliximab at a monthly basis which developed dilated cardiomyopathy with severe depression of myocardial function.

Etiopathogenic and Clinical Aspects in Inflammatory Bowel Disease – Literature Review

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which encompasses Crohn’s disease and ulcerative colitis. IBD does not only affect the gastrointestinal system, but also associates many extraintestinal complications that can affect almost any organ. A large number of patients may have these complications before or after the diagnosis of IBD. Early diagnosis and management of these complications involves a multidisciplinary team and contributes to decrease patient morbidity and mortality, but also to increase the quality of life. The purpose of this extensive literature review is to present systematically and comprehensively the latest data on the extraintestinal manifestations of IBD, and to draw clinicians’ attention to the fact that this condition can have extradigestive manifestations that can be misleading and delay the diagnosis.

The role of multimodality imaging in diagnosing acute perimyocarditis secondary to Crohn's disease

Background

Acute perimyocarditis is a rare extra-intestinal manifestation in Crohn’s disease which required multimodality imaging to confirm the diagnosis. Here we present a case of acute perimyocarditis as the first presentation of Crohn’s disease. To date, this is the first case presentation reporting the use of ¹⁸F-FDG PET/CT Scan for diagnosing such condition.

Case presentation

A 25-year-old male presented to our hospital with severe persistent pleuritic sharp left-sided chest pain. This was his second hospital admission in the past 4 months for chest pain and diarrhea. At the first hospitalization, he was diagnosed with viral perimyocarditis and irritable bowel syndrome. Laboratory findings, electrocardiogram, and cardiac magnetic resonance imaging results confirm the diagnostic of perimyocarditis. Virology, bacteriology, parasitology, and autoimmune evaluations were unremarkable. Colonoscopy, colorectal biopsy, and ¹⁸FGD PET findings confirmed manifestation of perimyocarditis, Crohn’s disease, and negative for sarcoidosis.

Conclusions

Looking at the overall clinical picture and investigation results of colonoscopy, colorectal biopsy findings, as well as multi-modality imaging with echocardiography, ¹⁸FDG PET—scan and CMRI, the patient was diagnosed to have perimyocarditis attending Chron’s disease flare up as a rare extra-intestinal manifestation.

Crohn's disease with dilated cardiomyopathy in a child: An experience with heart transplantation

BACKGROUND

DCM has rarely been reported in children with CD, but is a recognized complication in adults. DCM with uncontrolled heart failure may need heart transplantation, which could be challenging in CD.

CASE DESCRIPTION

We present a 9-year-old female with CD who was diagnosed with DCM and a measured Ejection fraction ~25.8%. She was initiated on heart failure treatment, but continued to have progressive symptoms and underwent bicaval OHT three months after her initial presentation. Her post-operative course was complicated by perforation of the rectosigmoid junction requiring exploratory laparotomy and primary repair of the perforation. This was believed to be secondary to her underlying CD and possibly reperfusion injury after heart transplant. During the first-year post heart transplant, she had 4 episodes of acute cellular rejection. These episodes were treated with high dose steroids with good results. The patient has been in remission from CD since transplantation. For the last two years she is doing well, with no further rejection episodes on current immunosuppression.

CONCLUSION

DCM, though rare, can occur in patients with CD, whether active or in remission. The development of DCM could be insidious and keeping a high index of suspicion is important and subtle signs suggestive of cardiac involvement should warrant further investigation. The post-transplant management can be challenging with early morbidity in the first post-transplant year but overall good median survival and quality of life for our patient to date.

Simultaneous Presentation of Crohn's Disease and Takayasu Arteritis in a Teenage Patient

A 14-year-old female with no significant medical history presented with hypertensive urgency, in the setting of 4 to 6 weeks of diarrhea, abdominal pain, headaches, anemia, weight loss, and high blood pressures. Her evaluation revealed signs of a systemic inflammatory process that was most suspicious for inflammatory bowel disease. However, when her hypertension was evaluated with a renal Doppler ultrasound, there were signs of narrowing, stenosis, and hypoplasia that led to a diagnostic angiogram of the abdominal aorta. Full body positron emission tomography scan revealed multiple areas of stenosis and aortic thickening with enhancement compatible with Takayasu arteritis. She received prednisone, methotrexate, and infliximab with marked improvement in her clinical symptoms and inflammatory markers.

Cardiovascular Risk Assessment and Impact of Medications on Cardiovascular Disease in Inflammatory Bowel Disease

There is increased risk of cardiovascular disease in patients with chronic inflammatory disorders such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus. Studies have shown association between cardiovascular disease (eg, myocardial infarction, heart failure, stroke) and inflammatory bowel disease. Medications such as infliximab and adalimumab (monoclonal antibodies to tumor necrosis factor α) may help decrease the inflammatory burden and cardiovascular risk; however, there have been reports of hypertriglyceridemia and worsening of moderate to severe heart failure with these medications. Janus kinase inhibitors, such as tofacitinib, have been associated with hyperlipidemia and thromboembolism. We aim to discuss clinical and imaging modalities to assess cardiovascular risk in inflammatory bowel disease patients and review the role of various medications with respect to cardiovascular disease in this population.

Influence of systemic manifestations of inflammatory bowel diseases on endothelial function and cardiovascular risk

BACKGROUND

Inflammatory bowel diseases (IBD) may be complicated by extraintestinal manifestations (EIM). Both conditions may be implicated in the overall increase of cardiovascular (CV) risk profile of the patients. The study aimed to assess CV risk in IBD patients with EIMs in relation to the stages of both diseases.

METHODS

A total of 70 (38 men, mean age 51.7±12.4 years) patients with IBD and 22 controls (12 men, mean age 49.2±13.6 years) were enrolled. All patients and controls were screened for extraintestinal manifestations and underwent physical and anthropometric examinations, standard laboratory investigations, ultrasound evaluation of carotid arteries and flow-mediated vasodilatation (FMD). Patients were divided into four groups in relation to their active or remission stage of disease: 1. IBD+ EIM+; 2. IBD+ EIM-; 3. IBD- EIM+; 4. IBD- EIM-.

RESULTS

The groups were homogenous according to their clinical characteristics. Patients with both IBD and EIM in active phase showed significantly lower values in FMD than controls (p=0.024). Carotid intima-media thickness values (cIMT) were similar among groups. Patients with active phases of IBD and/or EIM showed statistically significant lower values in FMD measurements (p=0.0008 and p=0.0011, respectively). Multivariate regression did not reveal any independent predictors for FMD values.

CONCLUSIONS

The active phase of IBD or EIM or both may promote endothelial dysfunction in patients, thus increasing their CV risk profile. Patients in remission phase showed endothelial function similar at controls.

Cardiovascular Manifestations in Inflammatory Bowel Disease: A Systematic Review of the Pathogenesis and Management of Pericarditis

Inflammatory bowel disease (IBD) is a chronic condition of the bowel that can be further categorized into ulcerative colitis and Crohn’s disease. Rarely, this condition can be associated with pericarditis, which can be an extraintestinal manifestation of the disease or drug-induced. This review aims to determine the pathogenesis and management of pericarditis in IBD. In this review, the goal is to elucidate the pathogenesis of pericarditis in IBD and determine if pericarditis is an extraintestinal manifestation of IBD or a complication of current drug therapy used to manage IBD. Additionally, this review intends to explain the first-line management of pericarditis in IBD and explore the role of biologicals in attenuating pericarditis. An electronic search was conducted to identify relevant reports of pericarditis in IBD, and a quality assessment was conducted to identify high-quality articles according to the inclusion criteria. Full-text articles from inception to November 2020 were included, while non-English articles, gray literature, and animal studies were excluded. The majority of studies suggest that pericarditis arises as a complication of drug therapy by 5-aminosalicylic acid derivatives such as sulfasalazine, mesalamine, and balsalazide, and it occurs due to IgE-mediated allergic reactions, direct cardiac toxicity, cell-mediated hypersensitivity reactions, and humoral antibody response to therapy. Drug cessation or the initiation of a corticosteroid regimen seems to be the most effective means of managing pericarditis in IBD due to drug therapy or an extraintestinal manifestation.

Recurrent myocarditis in a patient with active ulcerative colitis: a case report and review of the literature

Inflammatory bowel diseases such as ulcerative colitis (UC) may be complicated by several extraintestinal manifestations. These involve joints, skin, eyes and less commonly lungs and heart. Myocarditis may result from the toxic effect of drugs (ie, mesalazine) commonly used for the treatment of UC or due to infections (eg, Coxsackieviruses, enteroviruses, adenovirus). Here, we report a case of a 26-year old man affected by UC and complicated by two episodes of myocarditis. Both episodes occurred during two severe exacerbations of UC. However, in both cases the aetiology of myocarditis remains uncertain being ascribable to extraintestinal manifestation, drug toxicity or both.

The interplay between gastrointestinal and cardiovascular diseases: a narrative review focusing on the clinical perspective

Both cardiovascular and gastrointestinal disorders represent considerable health burden on community clinics and hospitals with overwhelming economic cost. An overlap in the occurrence of these disorders is encountered in daily practice. Both affect each other in bidirectional manner through several mechanisms including altered hemodynamics, systemic inflammation, bacterial overgrowth and interactions and adverse effects of medications. In addition, to the known overlap in the symptoms occurrence of upper gastrointestinal tract diseases and cardiovascular diseases (CVDs). Awareness of this interplay and its clinical manifestations optimizes patient management, and could prevent catastrophic consequences and even save lives. In this review, we highlighted the clinical aspects of this bidirectional association between gastrointestinal and CVDs aiming to shed light on this topic and improve patients' care.

Mesalazine-induced myopericarditis: a case report

Background

Mesalazine is a well-established 1st line treatment for inflammatory bowel disease (IBD). Cardiotoxicity following 5-aminosalicyclic-acid therapy remains a rare yet serious complication and can often be challenging to distinguish from myocarditis presenting as an extra-intestinal manifestation of IBD.

Case summary

We present a case of a 22-year-old man with a background of ulcerative colitis commenced on a mesalazine preparation for disease progression. He presented to our hospital 12 days following drug initiation with acute chest pain, peak troponin-T of 242 ng/L, dynamic electrocardiogram changes, and severe left ventricular systolic dysfunction on transthoracic echocardiogram. The clinical diagnosis of myopericarditis was suspected and mesalazine was stopped shortly after. Outpatient cardiac magnetic resonance performed 2 weeks following mesalazine cessation demonstrated a recovery of cardiac function with associated symptom and biochemical resolution.

Discussion

Clinicians should be aware of this potentially fatal adverse effect of a commonly prescribed medication. Symptoms of myocarditis often occur within the early stages of mesalazine initiation, which aids the clinical diagnosis. The mainstay of treatment is to simply discontinue the drug with rapid resolution of symptoms seen without any permanent or long-term cardiac dysfunction. Close liaison with the gastroenterology team is key, as 2nd line IBD therapies are often required for the ongoing management of the patient’s colitis.

Atherosclerosis and Inflammatory Bowel Disease-Shared Pathogenesis and Implications for Treatment

Atherosclerosis and inflammatory bowel disease (IBD) are often regarded as 2 distinct entities. The commonest manifestation of atherosclerosis is ischemic heart disease (IHD), and an association between IHD and IBD has been reported. Atherosclerosis and IBD share common pathophysiological mechanisms in terms of their genetics, immunology, and contributing environmental factors. Factors associated with atherosclerosis are implicated in the development of IBD and vice versa. Therefore, treatments targeting the common pathophysiology pathways may be effective in both conditions. The current review considers the pathophysiological pathways that are shared between the 2 conditions and discusses the implications for treatment and research.

An Investigation into the Association Between Inflammatory Bowel Disease and Cardiac Arrhythmias: An Examination of the United States National Inpatient Sample Database

Background:

Inflammatory bowel diseases (IBD) associated-chronic inflammation and autonomic dysregulation may predispose to arrhythmias. However, its exact prevalence is unknown. Thus, we aimed to ascertain the prevalence of arrhythmias in patients with IBD.

Methods:

We queried the Nationwide Inpatient Sample (the largest publicly available all-payer inpatient USA database) from 2012 to 2014. We used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) discharge codes to identify adult patients (⩾18 years) with IBD and dysrhythmias (supraventricular tachycardia (SVT), atrial fibrillation, atrial flutter, ventricular tachycardia (VT), or ventricular fibrillation). Furthermore, we identified risk factors for cardiovascular disease. We divided patients into 2 cohorts, IBD cohorts, and non-IBD cohort. The independent effect of a diagnosis of IBD on the risk of dysrhythmias was examined using a multivariable logistic regression model controlling for multiple confounders.

Results:

We identified 847 235 and 84 757 349 weighted hospitalizations among patients with IBD and non-IBD cohorts, respectively. Patients with IBD were less likely to be hospitalized for dysrhythmias than the non-IBD (9.7% vs 14.2%, P < .001). The hospitalization odds for dysrhythmias among patients with IBD were less than the general population (OR 0.87; 95% CI 0.85-0.88). However, the prevalence of SVT and VT was indifferent between the 2 groups. Male sex, age of over 60, and white race were risk factors for dysrhythmias.

Conclusion:

Despite prior reports of a higher prevalence of arrhythmias among patients with IBD, in a nationwide inpatient database, we found lower rates of hospitalization-related-arrhythmias in the IBD population compared to that of the general population.

Pro-Atherogenic Inflammatory Mediators in Inflammatory Bowel Disease Patients Increase the Risk of Thrombosis, Coronary Artery Disease, and Myocardial Infarction: A Scientific Dilemma

Inflammatory bowel disease (IBD), comprising ulcerative colitis and Crohn’s disease, is characterized by widespread inflammation of the gastrointestinal tract with systemic manifestations. Inflammation is one of the driving forces for the pathogenesis of atherosclerosis and its dreaded complications like myocardial infarction (MI). Yet, the association between IBD and myocardial infarction has not been thoroughly established.

Myocardial infarction in IBD patients was predominantly seen in young women during the active disease process. At the same time, elevated levels of C-reactive protein and other pro-inflammatory markers were observed in both IBD and atherosclerosis. Increasing evidence suggests inflammation inhibits fibrinolysis, expresses procoagulants, and suppresses anticoagulants promoting thrombosis formation. Moreover, the alteration of gut microbiota impacts the pathogenesis of inflammation and predisposes one to ischemic heart disease.

Accordingly, all IBD patients should be screened and counseled on lifestyle modifications for the traditional risk factors of atherosclerosis. Future researchers should consider conducting more clinical trials on anti-inflammatory medication targeting atherosclerosis and therapeutics, while targeting the gut microbiota to reverse the inflammatory atherosclerotic process.

Accelerated Idioventricular Rhythm in Inflammatory Bowel Disease: When the Gut Takes Charge

Accelerated idioventricular rhythm (AIVR) is an uncommon but benign rhythm, seen most commonly in children. It is associated with reperfusion injury after myocardial infarction in adults. In children, it is usually seen as an idiopathic finding in the absence of heart disease. We present a case of AIVR in an adolescent associated with acute presentation of inflammatory bowel disease. Prompt treatment of the systemic inflammation led to the remission of both inflammatory bowel disease and AIVR. This report emphasizes the diverse causes of AIVR in children and our limited understanding of its pathophysiology. Treatment of the underlying condition resolved the arrhythmia.

Aspirin, NSAIDs, and Inflammatory Bowel Disease: An Exercise Physiology Perspective

NSAID medication timing can impact intestinal injury and alter the microbiome. These mechanistic injuries may influence clinical outcomes. This brief letter aims to summarize a few key articles related to NSAID medication timing and intestinal injury.

Association between Corrected QT Interval and C-Reactive Protein in Patients with Inflammatory Bowel Diseases

Background and objectives: Electrocardiograph abnormalities (i.e., QT interval prolongation) have been described in inflammatory bowel diseases (IBD). We aimed to measure the QT interval in a cohort of patients with IBD and to analyze its relationship with clinical and inflammatory activity. Materials and Methods: We performed a cross-sectional study that included 38 IBD outpatients and 38 “age- and sex-matched” healthy controls. Nine patients had active IBD, and 29 were in clinical remission. Among the latter, 10 patients had sustained (lasting >1 year) and 19 had short-term remission (≤1 year). Corrected QT (QTc) interval was measured on standard 12-lead electrocardiograph. A systematic review of the literature on studies investigating the QT interval in patients with IBD was also performed. Results: QTc interval values were similar between IBD patients and healthy controls (417.58 ± 22.05 ms vs. 409.13 ± 19.61 ms, respectively; p: 0.479). Patients with active IBD had significantly higher QTc values (435.11 ± 27.31 ms) than both controls (409.13 ± 19.61 ms) and patients in remission (412.14 ± 17.33 ms) (p: 0.031). Post hoc analysis showed that the difference in QTc values between active IBD and remission was attributable to the group of patients with sustained remission (p < 0.05). Lastly, a significant correlation between QTc interval and C-reactive protein (CRP) values was observed (Spearman test: r = 0.563; p: 0.0005). Conclusions: Our study demonstrates an association between QTc duration and both clinical and inflammatory activity in patients with IBD. The higher the CRP value, the longer is the QTc duration. For practical purposes, all patients with active IBD should undergo a standard ECG. Prescription of drugs able to modify the QT interval should be avoided in patients with active IBD. The systematic review of the literature indicated that this is the first published study demonstrating an association between the QTc duration and CRP values in patients with IBD.