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Giannelou M, Skarlis C, Stamouli A, Antypa E, Moutsopoulos HM, Mavragani CP. Atherosclerosis in SLE: a potential role for serum parathormone levels. Lupus Sci Med 2020; 7:7/1/e000393. [PMID: 32913010 PMCID: PMC7484862 DOI: 10.1136/lupus-2020-000393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/28/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
Abstract
Objective A link between bone metabolism and cardiovascular (CV) disease has been suggested mainly in the general population. In the current study we explored whether altered bone metabolism influence CV risk in patients with SLE. Methods In 138 consecutive patients with SLE, atherosclerosis was assessed by the presence of plaque and/or arterial wall thickening in carotid/femoral arteries by ultrasound. Bone mineral density (BMD) levels and hip/spinal cord fractures together with classical CV disease and osteoporosis risk factors including serum 25(OH) vitamin D3 and parathormone (PTH) levels were recorded in all patients. Serum osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-Β ligand were quantitated by commercial ELISA. Statistical analysis included both univariate and multivariate models. Results Abnormal PTH serum concentrations (>65 pg/mL)—but not 25(OH) vitamin D3 serum levels—were identified as a risk factor for both plaque formation and arterial wall thickening in patients with SLE (ORs (95% CIs): 8.2 (1.8 to 37.4) and 3.9 (1.3 to 11.8), respectively). This association remained significant following adjustment for vitamin D3 levels and classical CV risk factors. Moreover, an independent association between osteoporosis with plaque formation and arterial wall thickening was detected following adjustment for total steroid dose, premature menopause and disease duration (ORs (95% CIs): 5.3 (1.1 to 26.2) and 3.5 (1.1 to 11.4), respectively). An inverse correlation between femoral neck BMD values and intima–medial thickness scores was also observed (r: −0.42, p=0.008). Conclusions These findings further strengthen the concept of shared pathophysiological mechanisms between atherogenesis and altered bone metabolism in autoimmune populations, revealing heightened PTH levels as a potential marker for atherosclerosis among patients with SLE.
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Affiliation(s)
- Mayra Giannelou
- Department of Rheumatology, Peripheral General Hospital Athens Georgios Gennimatas, Athens, Greece.,Department of Pathophysiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Charalampos Skarlis
- Department of Physiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Eleni Antypa
- Department of Radiology, Peripheral General Hospital Athens Georgios Gennimatas, Athens, Greece
| | | | - Clio P Mavragani
- Department of Physiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece .,Joint Academic Rheumatology Program, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Rodríguez-Carrio J, Martínez-Zapico A, Cabezas-Rodríguez I, Benavente L, Pérez-Álvarez ÁI, López P, Cannata-Andía JB, Naves-Díaz M, Suárez A. Clinical and subclinical cardiovascular disease in female SLE patients: Interplay between body mass index and bone mineral density. Nutr Metab Cardiovasc Dis 2019; 29:135-143. [PMID: 30559042 DOI: 10.1016/j.numecd.2018.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/27/2018] [Accepted: 09/18/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Since accelerated atherosclerosis has been reported in systemic lupus erythematosus (SLE), predictive biomarkers of cardiovascular disease (CVD) are needed. Among non-traditional risk factors, bone mineral density (BMD) has been related to CVD. However, its role in SLE remains controversial. This study aims to analyze the associations of subclinical atherosclerosis with traditional and non-traditional CV risk factors. METHODS AND RESULTS In a cross-sectional study, atherosclerosis burden was compared between 112 female SLE patients and 31 controls. Plaque number and carotid intima-media wall thickness (cIMT) were assessed by ultrasonography. In a retrospective study, BMD determinations obtained 5-years before the ultrasonography assessment were analyzed in a subgroup of 62 patients. Plaque frequency was increased in SLE, even in patients without CV events or carotid wall thickening. cIMT was increased in patients with CVD, positively correlated with body mass index (BMI). Interestingly, a paradoxical effect of BMI on carotid parameters was observed. Whereas underweight patients (BMI < 20) showed increased prevalence of carotid plaques with low cIMT, those with BMI > 30 showed higher cIMT and plaque burden. Overweight patients (25 < BMI<30) exhibited both elevated cIMT and plaque number. BMI was an independent predictor of BMD. In our retrospective study, patients with either clinical or subclinical CVD exhibited lower BMD levels than their CV-free counterparts. A low lumbar spine BMD independently predicted CVD development after adjusting for confounders. CONCLUSION SLE was associated with a higher subclinical atherosclerosis burden, a bimodal effect being observed for BMI. Decreased BMD can be a CV risk biomarker in SLE.
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Affiliation(s)
- J Rodríguez-Carrio
- Area of Immunology, Department of Functional Biology, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación Nefrológica, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - A Martínez-Zapico
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - I Cabezas-Rodríguez
- Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación Nefrológica, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - L Benavente
- Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Á I Pérez-Álvarez
- Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - P López
- Area of Immunology, Department of Functional Biology, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - J B Cannata-Andía
- Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación Nefrológica, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - M Naves-Díaz
- Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación Nefrológica, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - A Suárez
- Area of Immunology, Department of Functional Biology, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.
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Barzilay JI, Buzkova P, Cauley JA, Robbins JA, Fink HA, Mukamal KJ. The associations of subclinical atherosclerotic cardiovascular disease with hip fracture risk and bone mineral density in elderly adults. Osteoporos Int 2018; 29:2219-2230. [PMID: 30132027 PMCID: PMC6487649 DOI: 10.1007/s00198-018-4611-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/18/2018] [Indexed: 01/27/2023]
Abstract
UNLABELLED In the absence of clinically recognized cardiovascular disease, increased carotid artery intimal medial thickness was associated with higher hip fracture risk in older adults, despite its association with higher bone mineral density (BMD). Low ankle brachial index and aortic wall thickness were not associated with fracture risk or BMD. INTRODUCTION Clinically recognized cardiovascular disease (CVD) is associated with osteoporosis and hip fracture risk, but the relationship of subclinical atherosclerosis to bone health is not certain. METHODS We followed 3385 participants from the Cardiovascular Health Study (mean age 74.7 ± 5.3 years) with a median time to fracture of 12.1 years who underwent baseline carotid artery and aortic wall ultrasound scanning and ankle brachial blood pressure index (ABI) determinations. A subset underwent bone mineral density (BMD) testing. RESULTS There were 494 hip fractures during follow-up. Among persons without clinical CVD, an average standard-deviation increase in a composite score of maximal common and internal carotid artery intimal medial thickness (cIMT) was associated with increased risk of hip fracture [(HR 1.18 [1.04, 1.35]), even though cIMT was positively associated with BMD. Neither aortic wall thickness nor ABI were associated with hip fracture risk or BMD. Among participants with clinical CVD, cIMT and aortic wall thickness, but not ABI, were associated with increased hip fracture risk. CONCLUSION Subclinical cIMT is associated with an increased risk of hip fractures despite being associated with increased BMD. This finding suggests that vascular health, even in its early stages, is linked to bone health, by pathways other than BMD.
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Affiliation(s)
- J I Barzilay
- Kaiser Permanente of Georgia, Division of Endocrinology and the Division of Endocrinology, Emory University School of Medicine, 3650 Steve Reynolds Blvd, Duluth, GA, 30096, USA.
| | - P Buzkova
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - J A Cauley
- Department of Epidemiology, Graduate School, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - J A Robbins
- Department of Medicine, University of California at Davis, Modesto, CA, USA
| | - H A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN, USA
| | - K J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Brookline, MA, USA
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Giannelou M, Mavragani CP. Cardiovascular disease in systemic lupus erythematosus: A comprehensive update. J Autoimmun 2017; 82:1-12. [PMID: 28606749 DOI: 10.1016/j.jaut.2017.05.008] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
Heightened rates of both cardiovascular (CV) events and subclinical atherosclerosis, documented by imaging and vascular function techniques are well established in systemic lupus erythematosus (SLE). While traditional CV factors such as smoking, dyslipidemia, diabetes mellitus (DM), hypertension, central obesity and hyperhomocysteinemia have been reported to be prevalent in lupus patients, they do not fully explain the high rates of ischemic events so far reported, implying that other factors inherent to disease itself could account for the enhanced risk, including disease duration, activity and chronicity, psychosocial factors, medications, genetic variants and altered immunological mechanisms. Though the exact pathogenesis of atherosclerosis in the setting of lupus remains ill defined, an imbalance between endothelial damage and atheroprotection seems to be a central event. Insults leading to endothelial damage in the setting of lupus include oxidized low density lipoprotein (oxLDL), autoantibodies against endothelial cells and phospholipids, type I interferons (IFN) and neutrophil extracellular traps (NETs) directly or through activation of type I IFN pathway. Increased oxidative stress, reduced levels of the normally antioxidant high density lipoprotein (HDL), increased levels of proinflammatory HDL (piHDL) and reduced paraoxonase activity have been related to increased oxLDL levels. On the other hand, impaired atheroprotective mechanisms in lupus include decreased capacity of endothelial repair-partly mediated by type I IFN- and dampened production of atheroprotective autoantibodies. In the present review, traditional and disease related risk factors for CV disease (CVD) in the setting of chronic autoimmune disorders with special focus on SLE will be discussed.
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Affiliation(s)
- Mayra Giannelou
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Rheumatology, General Hospital of Athens "G. Gennimatas", Greece
| | - Clio P Mavragani
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Physiology, School of Medicine, National and Kapodistrian University of Athens, Greece; Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Sacre K, Escoubet B, Zennaro MC, Chauveheid MP, Gayat E, Papo T. Overweight Is a Major Contributor to Atherosclerosis in Systemic Lupus Erythematosus Patients at Apparent Low Risk for Cardiovascular Disease: A Cross-Sectional Controlled Study. Medicine (Baltimore) 2015; 94:e2177. [PMID: 26632902 PMCID: PMC4674205 DOI: 10.1097/md.0000000000002177] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease (CVD) is the main cause of death in systemic lupus erythematosus (SLE) patients. We aimed to determine whether overweight (defined as a body mass index [BMI] > 25 kg/m(2)) contributed to subclinical atherosclerosis in SLE patients at low risk for CVD according to traditional factors. Wall thickness of the internal carotid artery (ICWT) measured at the carotid bulb and carotid plaques were assessed in 49 SLE patients asymptomatic for CVD and 49 controls matched on Framingham score. Factors associated to ICWT were identified and multivariate analysis was performed.SLE patients and controls displayed a low 10-year risk for CVD according to Framingham score (mean 1.9 ± 3.5 in SLE vs 1.8 ± 3.2% in controls, P = 0.37). ICWT (P < 0.001) and number of patients with carotid plaques (P = 0.015) were, however, higher in SLE patients as compared to controls. In multivariable analysis, SLE was an independent risk for a carotid atherosclerosis (OR [95% confidence interval, CI]: 3.53 [1.36-9.14]; P = 0.009). Older age, higher BMI, and higher Framingham score were associated with atherosclerosis in SLE patients in univariate analysis. In multivariate analysis, only the association with overweight remained significant (OR [95% CI]: 4.13 [1.02-16.75]; P = 0.047). Overweight is a major contributor to atherosclerosis in SLE patients at apparent low risk for CVD.
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Affiliation(s)
- Karim Sacre
- From the Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France (KS, M-PC, TP); INSERM U1149, Paris, France (KS, TP); Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France (KS, TP); Département de Physiologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, INSERM U1138, Paris, France (BE); INSERM UMRS970, Paris Cardiovascular Research Center, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Génétique, Paris, France (M-CZ); and Département d'Anesthésie-Réanimation, Hôpitaux Universitaires Saint Louis-Lariboisière, 2 UMR-S 942, INSERM, 3 Université Paris Diderot, Paris, France (EG)
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López-Robles C, Ríos-Fernández R, Callejas-Rubio JL, Moreno-Escobar E, Ortego-Centeno N. Low bone mass and carotid atherosclerosis in lupus erythematosus patients from Granada, a city in the south of Spain. Lupus 2015; 25:223-4. [DOI: 10.1177/0961203315608255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/25/2015] [Indexed: 11/15/2022]
Affiliation(s)
- C López-Robles
- Clinical Internal Medicine Unit, Hospital General de Antequera, Antequera, Málaga, Spain
| | - R Ríos-Fernández
- Autoimmune Diseases Unit, Hospital Universitario San Cecilio, Granada, Spain
| | - J L Callejas-Rubio
- Autoimmune Diseases Unit, Hospital Universitario San Cecilio, Granada, Spain
| | - E Moreno-Escobar
- Clinical Cardiology Unit, Hospital Universitario San Cecilio, Granada, Spain
| | - N Ortego-Centeno
- Autoimmune Diseases Unit, Hospital Universitario San Cecilio, Granada, Spain
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Ajeganova S, Gustafsson T, Jogestrand T, Frostegård J, Hafström I. Bone mineral density and carotid atherosclerosis in systemic lupus erythematosus: a controlled cross-sectional study. Arthritis Res Ther 2015; 17:84. [PMID: 25885788 PMCID: PMC4407386 DOI: 10.1186/s13075-015-0595-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 03/12/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION As osteoporosis is reported to be associated with atherosclerosis in the general population we examined the relationship between bone mass and carotid measurements in patients with systemic lupus erythematosus (SLE) and controls, and possible links between them in SLE. METHODS In a cross-sectional study, 111 SLE-patient were compared with 111 age- and sex-matched controls, mean age 48.7(12.9) years, 89% were women, of which 51% postmenopausal. Carotid intima media thickness (cIMT), carotid plaque occurrence and echogenicity were determined by B-mode ultrasound and bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA). RESULTS BMD and cIMT were inversely associated both in patients and controls. Patients, but not controls, with carotid plaque had higher cIMT at low BMD than at normal BMD, p = 0.010. Logistic regression indicated more than doubled odds ratio (OR) of carotid plaque in patients, particularly in post-menopausal women, than in controls in relation to all BMD measurements. For low BMD at hip, significant increased OR for echolucent plaque was shown for patients compared with controls. In patients, significant impact of age, body mass index, smoking, systolic blood pressure, blood lipids, diabetes mellitus, impaired renal function, low levels of complement C3 and C4, history of nephritis, SLE-damage index and ever use of antimalarial was found for association between BMD and higher cIMT and carotid plaque. In multivariate regression, low C4 was independent contributor to association between total BMD and upper cIMT tertile, accounted for OR (95% confidence interval) of 3.2 (1.03-10.01), and also for association with bilateral carotid plaque, OR of 4.8 (1.03-22.66). The contribution of low C4 for the association between BMD and carotid atherosclerosis was enhanced within the second and third tertiles of total BMD. CONCLUSION This study is the first to demonstrate inverse association between BMD and carotid measurements in both SLE-patients and controls. Our results suggest that SLE-patients may suffer higher burden of (sub)clinical atherosclerotic disease, especially presence of both echolucent and echogenic plaque, than controls with the same bone mineral status. Low complement C4 seems to play an important role in earlier development of carotid atherosclerosis already within (sub)normal ranges of total BMD in patients.
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Affiliation(s)
- Sofia Ajeganova
- Department of Medicine, Unit of Rheumatology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, 141 86, Sweden.
| | - Thomas Gustafsson
- Department of Clinical Physiology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, 141 86, Sweden.
| | - Tomas Jogestrand
- Department of Clinical Physiology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, 141 86, Sweden.
| | - Johan Frostegård
- Section of Immunology and Chronic disease, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, 171 77, Sweden.
| | - Ingiäld Hafström
- Department of Medicine, Unit of Rheumatology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, 141 86, Sweden.
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