Risk of peripheral arterial occlusive disease in patients with rheumatoid arthritis

Accelerated Atherosclerosis and Management of Cardiovascular Risk in Autoimmune Rheumatic Diseases: An Updated Review

Even though diagnosis and management pathways have been substantially improved over the last years, autoimmune rheumatic diseases (AIRDs) such as rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren's syndrome, and systemic vasculitides have been linked to elevated rates of cardiovascular morbidity and mortality, primarily secondary to accelerated atherosclerosis. This phenomenon can be partially attributed to the presence of established cardiovascular risk factors but may also be a result of other inflammatory and autoimmune mechanisms that are enhanced in AIRDs. According to the current guidelines, the recommendations regarding cardiovascular disease prevention in patients with AIRDs are not significantly different from those applied to the general population. Herein, we present a review of the current literature on the risk of accelerated atherosclerosis in AIRDs and provide a summary of available recommendations for the management of cardiovascular risk in rheumatic diseases.

Foot Temperature by Infrared Thermography in Patients with Peripheral Artery Disease before and after Structured Home-Based Exercise: A Gender-Based Observational Study

Decreased arterial perfusion is a typical condition of patients with peripheral artery disease (PAD), with the microvascular picture particularly present among women. This observational study aimed to detect foot perfusion changes by infrared thermography (IRT) after a home-based exercise program in both sexes. A total of 76 PAD patients with claudication (72 ± 4 years; 52 males) were enrolled in a structured in-home exercise program composed of two daily 8 min interval walking sessions (1:1 walk:rest ratio) with progressively increasing speed. Outcome measures collected at baseline (T0) and at each hospital visit after 5 weeks, 12 weeks and 20 weeks included foot temperature measured by IRT (anterior tibial, posterior tibial, dorsalis pedis and arcuate artery regions), ankle brachial index and the 6 min walking test. After 20 weeks, foot temperature in both limbs showed a significant increasing trend, with a mean variation of 1.3 °C for the more impaired limb and 0.9 °C for the contralateral limb (t = 8.88, p < 0.001 and t = 5.36; p < 0.001, respectively), with significant changes occurring after 5 weeks of training. The sex-oriented analysis did not highlight any significant difference, with an improvement of mean foot temperature of 1.5 ± 0.6 °C in females versus 1.2 ± 0.5 °C in males (p = 0.42). Ankle brachial index and performance also significantly improved over time (p < 0.001) without gender differences. In patients with PAD, a structured low-intensity exercise program significantly improved foot temperature and exercise capacity without any sex-related difference.

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

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

Disease-modifying anti-rheumatic drugs improve the cardiovascular profile in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting about 0. 5–1% of the adult population and manifesting as persistent synovitis, systemic inflammation and production of autoantibodies. Patients affected by RA not only experience chronic disease progression, but are also burdened by a 1.5-fold increased cardiovascular (CV) risk, which is comparable to the risk experienced by patients with type 2 diabetes mellitus. RA patients also have a higher incidence and prevalence of coronary artery disease (CAD). Although RA patients frequently present traditional CV risk factors such as insulin resistance and active smoking, previous studies have clarified the pivotal role of chronic inflammation–driven by proinflammatory cytokines such as interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha)–in accelerating the process of atherosclerosis and impairing the coagulation system. Over the last years, a number of studies have shown that disease-modifying anti-rheumatic drugs (DMARDs) reducing the inflammatory state in general improve the CV risk, however some drugs may carry some apparent negative effects. Thus, RA is a model of disease in which targeting inflammation may counteract the progression of atherosclerosis and reduce CV risk. Clinical and experimental evidence indicates that the management of RA patients should be tailored based on the positive and negative effects of DMARDs on CV risk together with the individual traditional CV risk profile. The identification of genetic, biochemical and clinical biomarkers, predictive of evolution and response to treatment, will be the next challenge for a precision approach to reduce the burden of the disease.

Risk of non-typhoidal Salmonella infection in patients with cholecystectomy: Results from a nationwide matched cohort study in Taiwan

BACKGROUND

The current study was designed to investigate the association between cholecystectomy and the risk of non-typhoidal Salmonella (NTS) infection.

METHODS

We obtained claims-based data from the Taiwan National Health Insurance Research Database (NHIRD) to perform a nationwide cohort study. A propensity score (PS)-matching analysis was performed with a ratio of 1:2 in the cholecystectomy cohort and cholecystectomy-free group to reduce selection bias. Both groups were followed until NTS diagnosis, a dropout from the insurance programme or the end of 2013. Cox proportional hazard regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the risk of NTS infection between the cholecystectomy and cholecystectomy-free groups.

RESULTS

Our study enrolled 197 444 patients who had undergone cholecystectomy and 394 888 patients who did not receive cholecystectomy. The adjusted HR (aHR) of NTS infection was 1.34 (95% CI, 1.13-1.58; P < .001) for the cholecystectomy group after adjusting for demographical characteristics and relevant comorbidities. The study population is predominantly female patients (55%) and older (58% older than 50 years). The subgroup analysis revealed that both sexes and notably, patients aged >50, who underwent cholecystectomy had a higher risk of NTS infection than the matched controls. Follow-up of patients who underwent cholecystectomy showed that they had a significantly higher risk of NTS infection for more than 6 months after the procedure.

CONCLUSIONS

Our study showed that cholecystectomy might be an independent risk factor for subsequent NTS infection.

Extrinsic and Intrinsic Responses in the Development and Progression of Atherosclerosis

Atherosclerosis is a multifactorial disease that is thought to be primarily inflammatory in origin. Given the contribution of inflammation to the development and progression of atherosclerosis, other conditions that are characterised by a dysregulated inflammatory response have also been proposed to play a role. The purpose of this review is to organise and present the various inflammatory processes that can affect atherosclerosis into two broad categories: extrinsic or host-independent and intrinsic or host-dependent. Within these two categories, we will discuss various processes that may contribute to the development and progression of atherosclerosis and the clinical studies describing these associations. Although the clinical trials investigating anti-inflammatory therapies have to date provided mixed results, further studies, particularly in conjunction with lipid-lowering and blood pressure lowering therapies should be considered.

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

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

Risk of biliary tract disease in living liver donors: A population-based cohort study

BACKGROUND & AIMS

Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown.

METHODS

Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios.

RESULTS

The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years.

CONCLUSION

Living liver donors had a higher risk of biliary tract disease compared with non-donors.

Risk of Dementia in Patients with Leptospirosis: A Nationwide Cohort Analysis

Background: Studies have linked some bacterial infections with an increased likelihood for development of dementia. However, there is a paucity of data on the relationship between dementia and leptospirosis. In view of this, we conducted a retrospective cohort study to determine whether leptospirosis is a risk factor for dementia. Methods: Data were collected from the Taiwan National Health Insurance Research Databases (2000–2010) to investigate the incidence of and risk factors for dementia in patients with leptospirosis. Patients with leptospirosis who did not have a history of dementia were enrolled in the study. For each leptospirosis patient, four controls were randomly selected after frequency matching of age, sex, and index date. Cox proportional hazard regression models were used for the analyses of dementia risk. Results: A greater risk of dementia was observed in the leptospirosis cohort than in the non-leptospirosis cohort both in patients without any comorbidity (adjusted HR (aHR) = 1.23, 95% CI = 1.06–1.43) and with a comorbidity (aHR = 2.06, 95% CI = 1.7–2.5). Compared with the non-leptospirosis cohort without these comorbidities, the leptospirosis cohort with ≥2 comorbidities exhibited a significantly increased risk of dementia (aHR = 6.11, 95% CI = 3.15–11.9), followed by those with any one comorbidity (adjusted HR = 3.62, 95% CI = 1.76–7.46). Conclusions: Patients with leptospirosis were at a 1.89-fold greater risk of subsequent dementia, but potential genetic susceptibility bias in the study group is a major confound.

Trends of Cardiac Complications in Patients With Rheumatoid Arthritis: Analysis of the United States National Inpatient Sample; 2005-2014

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory condition. Chronic inflammation is associated with atherosclerosis, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease. But sparse data are available regarding the trends of cardiovascular diseases and complications in RA. We conducted a National Inpatient Sample database analysis to demonstrate the trends of cardiac complications in patients with RA.

METHODS

We used National Inpatient Sample data from 2005 to 2014 to identify admissions with the diagnosis of RA and identified who had associated cardiovascular complications also. The International Classification of Diseases-9th Revision-Clinical Modification codes were used for the diagnoses of RA; congestive heart failure (CHF), acute myocardial infarction (AMI), and atrial fibrillation (AF).

RESULTS

A statistically significant increasing trend of AMI, CHF, and AF was found. Independent predictors of mortality in RA patients with AMI were age (OR 1.03, CI 1.02-1.04; P < 0.001), COPD (OR 1.67, CI 1.40-2.00; P < 0.001), cerebrovascular disease (OR 2.207, CI 1.71-2.86; P < 0.001), renal disease (OR 1.42, CI 1.16-1.75; P = 0.001), and alcohol abuse (OR 2.73, CI 1.73-4.32; P < 0.001). Independent predictors of mortality in RA patients with CHF were age (odds ratio [OR] 1.02, confidence interval [CI] 1.017-1.024; P < 0.001]), COPD (OR 1.09, CI 1.01-1.18; P = 0.023), cerebrovascular disease (OR 1.67, CI 1.44-1.95; P < 0.001), renal disease (OR 1.16, CI 1.07-1.27; P = 0.001). Independent predictors of mortality in RA patients with AF were age (OR 1.02, CI 1.02-1.03; P < 0.001), race (OR 1.16, CI 1.02-1.31; P = 0.022), COPD (OR 1.56, CI 1.42-1.71; P < 0.001), peripheral arterial disease (OR 1.34, CI 1.16-1.53; P < 0.001), cerebrovascular disease (OR 2.27, CI 1.0-2.58; P < 0.001), renal disease (OR 1.60, CI 1.44-1.80; P < 0.001). The mortality trend has increased significantly in the CHF (P = 0.025) and AF (P = 0.042) groups during this study period.

CONCLUSIONS

We have found a significant increase in trend of cardiovascular complications in RA patients. The proportion of patients, with cardiovascular comorbidities, have also been increased significantly.

Risk of Parkinson disease in Sjögren syndrome administered ineffective immunosuppressant therapies: A nationwide population-based study

To determine the incidence and risk of Parkinson disease (PD) in patients with Sjögren syndrome (SS) according to a nationwide population-based database.In total, 12,640 patients in the SS cohort and 50,560 in the non-SS cohort were enrolled from Taiwan's National Health Insurance Research Database from 2000 to 2010. We used the Cox multivariable proportional hazards model to determine the risk factors for PD in the SS cohort.We observed an increased incidence of PD in patients with SS, with a crude hazard ratio (HR) of 1.40 and an adjusted HR (aHR) of 1.23. The cumulative incidence of PD was 1.95% higher in the SS cohort than in the non-SS cohort. The SS cohort had an elevated HR under medication use, namely cevimeline and pilocarpine (crude HR, 1.28), hydroxychloroquine (crude HR, 1.43; aHR, 1.46), and methylprednisolone (crude HR, 2.21; aHR, 1.49). Patients receiving other non-hydroxychloroquine immunosuppressant therapies had a lower risk (aHR, 0.86) of PD. Furthermore, patients with SS aged 20 to 49 years had a 1.93-fold higher risk of PD than did those without SS (aHR, 1.93). The risk of PD was higher (aHR, 2.20) in patients with SS without comorbidities than in those with comorbidities. The aHR of PD significantly increased when the follow-up period exceeded 9 years (aHR, 1.93).We determined an increased risk of PD in patients with SS. Further investigation is warranted to determine the possible underlying mechanisms and the potential role of non-hydroxychloroquine immunosuppressants in ameliorating PD.

CHADS₂, CHA₂DS₂ASc, and New ABCD Scores Predict the Risk of Peripheral Arterial Disease in Patients with Sleep Apnea

The association between sleep apnea (SA) and peripheral artery disease (PAD) remains debatable, and there is no clinical tool to predict incident PAD in SA patients. The CHADS₂ score has been found useful in predicting PAD risk. This study was designed to investigate the association between these diseases and the usefulness of CHADS₂ and CHA₂DS₂ASc scores in predicting subsequent PAD in SA patients. From a population-based database of one-million representative subjects, adult patients with SA diagnosis were enrolled as the suspected SA group, and those having SA diagnosis after polysomnography were further extracted as the probable SA group. Twenty sex- and age-matched control subjects were randomly selected for each SA patients. The occurrence of PAD after SA was taken as the primary endpoint. Totally, 10,702 and 4242 patients were enrolled in the suspected and probable SA groups, respectively. The cumulative incidence of PAD was similar between SA patients and the corresponding control groups. Multivariable Cox regression analyses showed that SA was not an independent risk factor for subsequent PAD. Sensitivity analyses using propensity score-matched cohorts showed consistent results. Furthermore, in stratifying the SA patients by CHADS₂, CHA₂DS₂ASc, or a newly-proposed ABCD (composed of Age, high Blood pressure, Cerebral vascular disease, and Diabetes mellitus) score, patients with higher scores predicted higher risks of subsequent PAD, while the ABCD score appeared to be the most robust. Aggressive risk modification is suggested to reduce the subsequent PAD risk in SA patients with a higher CHADS₂, CHA₂DS₂ASc, or ABCD score.

Scrub typhus and depression: a nationwide cohort analysis

BACKGROUND

Studies on the relationship between depression and scrub typhus are limited. We conducted a retrospective cohort study to investigate whether scrub typhus is a risk factor for depression.

METHODS

Using Taiwan's National Health Insurance Research Database, this study investigated the incidence of depression, and its risk factors, in patients diagnosed with scrub typhus between 2000 and 2010. Scrub typhus patients who did not have a history of depression before the index date were enrolled. For each patient with scrub typhus, four controls without a history of scrub typhus and depression were randomly selected and frequency matched by sex, age, year of the index date, and comorbidities. The follow-up period was from the time of initial scrub typhus diagnosis to the date of diagnosis of depression, censoring, or December 31, 2010. Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities.

RESULTS

The study comprised a 5238-patient scrub typhus group and a 20,952-patient non-scrub typhus group with similar sex and age distributions. During the follow-up period, the cumulative incidence of depression was higher in the scrub typhus than the non-scrub typhus group (log-rank test P < 0.001). In the scrub typhus group, 45 patients developed depression, yielding an incidence rate of 1.67 per 1000 person-years, and in the non-scrub typhus group, 117 patients developed depression, yielding an incidence rate of 1.08 per 1000 person-years. This yielded a crude hazard ratio (HR) of 1.55 (95% confidence interval [CI] 1.41-1.70) and adjusted HR (aHR) of 1.56 (95% CI 1.42-1.71). Compared with the non-scrub typhus group, the risk of depression in the scrub typhus group was higher in patients of both sexes (men: aHR = 1.46, 95% CI 1.29-1.64; women: aHR = 1.68, 95% CI 1.45-1.96), in patients aged younger than 65 (≤ 49 years: aHR = 1.95, 50-64 years: aHR = 1.73), and in patients without comorbidities (aHR = 2.06, 95% CI 1.85-2.29).

CONCLUSIONS

The risk of depression was 1.56-fold higher in patients with scrub typhus than in the general population.

Risk of Obstructive Sleep Apnea and Its Association with Cardiovascular and Noncardiac Vascular Risk in Patients with Rheumatoid Arthritis: A Population-based Study

OBJECTIVE

To define the incidence of obstructive sleep apnea (OSA) in patients with rheumatoid arthritis (RA) and determine whether OSA diagnosis predicts future cardiovascular disease (CVD) and noncardiac vascular events.

METHODS

Medical information pertaining to RA, OSA, CVD, and vascular diagnoses was extracted from a comprehensive medical record system for a geographically defined population of 813 patients previously diagnosed with RA and 813 age- and sex-matched comparator subjects.

RESULTS

The risk for OSA in persons with RA versus comparators was elevated, although not reaching statistical significance (HR 1.32, 95% CI 0.98-1.77; p = 0.07). Patients with RA were more likely to be diagnosed with OSA if they had traditional risk factors for OSA, including male sex, current smoking status, hypertension, diabetes, dyslipidemia, and increased body mass index. Features of RA disease associated with OSA included large joint swelling and joint surgery. Patients with RA with decreased renal function were also at higher risk of OSA. The increased risk of overall CVD among patients with RA who have OSA was similar to the increased CVD risk associated with OSA in the comparator cohort (interaction p = 0.86). OSA diagnosis was associated with an increased risk of both CVD (HR 1.9, 95% CI 1.08-3.27), and cerebrovascular disease (HR 2.4, 95% CI 1.14-5.26) in patients with RA.

CONCLUSION

Patients with RA may be at increased risk of OSA secondary to both traditional and RA-related risk factors. Diagnosis with OSA predicts future CVD in RA and may provide an opportunity for CVD intervention.

Determining the presence of Peripheral Arterial Disease in patients with Rheumatoid Arthritis

OBJECTIVES

The aim of the study was to determine the manifestations of PAD in a population of RA participants with no history of cardiovascular events.

METHODS

A prospective observational non-experimental study was conducted on 100 participants presenting with RA and no history of significant cardiovascular events. Vascular assessment including Doppler spectral waveform analysis and Ankle Brachial Pressure Index was conducted.

RESULTS

Triphasic waveforms was found in the Posterior Tibial Artery (PT) in 70% right foot, 66% left foot and Dorsalis Pedis Artery (DP) in both feet in the64% of the patients. Twenty-nine per cent of the participants had biphasic PT right foot and 33% had biphasic PT left foot. Thirty-six per cent had biphasic DP both feet whilst only one participant (1%) had a discontinuous monophasic PT of both feet. The ABPI readings were found to be normal in 96% of participants and mild PAD was found in only 4% of the study population.

CONCLUSIONS

Results indicate that whilst the ABPI index was normal in the majority of participants, waveform analysis was suboptimal (biphasic) in approximately one-third of the study sample. These findings highlight that the assessment of peripheral arterial perfusion should utilize both modalities to identify patients with early PAD.

Inflammatory eye disease: Pre-treatment assessment of patients prior to commencing immunosuppressive and biologic therapy: Recommendations from an expert committee

AIM

To outline recommendations from an expert committee on the assessment and investigation of patients with severe inflammatory eye disease commencing immunosuppressive and/or biologic therapy.

METHOD

The approach to assessment is based on the clinical experience of an expert committee and a review of the literature with regard to corticosteroids, immunosuppressive drug and biologic therapy and other adjunct therapy in the management of patients with severe sight-threatening inflammatory eye disease.

CONCLUSION

We recommend a careful assessment and consultative approach by ophthalmologists or physicians experienced in the use of immunosuppressive agents for all patients commencing immunosuppressive and/or biologic therapy for sight threatening inflammatory eye disease with the aim of preventing infection, cardiovascular, metabolic and bone disease and reducing iatrogenic side effects.

Peptic Ulcer Disease in Living Liver Donors: A Longitudinal Population-Based Study

The objective of this nationwide cohort study was to investigate the risk of peptic ulcer disease (PUD) in living liver donors (LDs). A total of 1333 LDs and 5332 matched nondonors were identified during 2003-2011. Hospitalized patients identified as LDs were assigned to the LD cohort, and the non-LD comparison cohort comprised age- and sex-matched nondonors. Cumulative incidences and hazard ratios (HRs) were calculated. The overall incidence of PUD was 1.74-fold higher in the LD cohort than in the non-LD cohort (2.14 vs. 1.48 per 1000 person-years). After adjustment for age, sex, monthly income and comorbidities, we determined that the LD cohort exhibited a higher risk of PUD than did the non-LD cohort (adjusted HR 1.74, 95% confidence interval [CI] 1.45-2.09). The incidence of PUD increased with age; the risk of PUD was 2.53-fold higher in patients aged ≥35 years (95% CI 2.14-2.99) than in those aged ≤34 years. LDs with comorbidities of osteopathies, chondropathies and acquired musculoskeletal deformities exhibited a higher risk of PUD (adjusted HR 3.93, 95% CI 2.64-5.86) compared with those without these comorbidities. LDs are associated with an increased risk of PUD after hepatectomy.