Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations

Assessment of Intramuscular Fat and Correlation with Body Composition in Patients with Rheumatoid Arthritis and Spondyloarthritis: A Pilot Study

Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are associated with changes in body composition. Ectopic intramuscular fat (IMAT) may alter muscle function and contribute to cardiometabolic disorders. In a pilot study, we analyzed IMAT in the calf with peripheral quantitative computed tomography (pQCT) and examined correlations between IMAT quantity and body composition parameters. In 20 patients with active RA and 23 with active SpA, IMAT was correlated with visceral fat (VAT; r = 0.5143 and 0.6314, respectively; p < 0.05) and total lean mass (r = 0.5414 and 0.8132, respectively; p < 0.05), but not with whole body fat mass. Total lean mass mediated 16% and 33% of the effects of VAT on IMAT in RA and SpA, respectively. In both RA and SpA, calf muscle area was correlated with total lean mass (r = 0.5940 and r = 0.8597, respectively; p < 0.05) and fat area was correlated with total body fat (r = 0.6767 and 0.5089, respectively; p < 0.05) and subcutaneous fat (r = 0.6526 and 0.5524, respectively; p < 0.05). Fat area was inversely correlated with handgrip and walking tests, and it was associated with disease activity and disability. We showed that ectopic IMAT, measured with pQCT, was correlated with VAT, but not with total body fat, in RA and SpA. This result suggests that metabolically active fat was specifically associated with IMAT.

Cardiovascular risk estimation in young patients with ankylosing spondylitis: A new model based on a prospective study in Constanta County, Romania

Cardiovascular (CV) risk assessment charts are useful in establishing a patient therapeutic plan, but the most commonly used charts have essential limitations when applied to special populations. Our aim was to determine whether the Systematic Coronary Risk Evaluation (SCORE) chart underestimates the CV risk in young patients with ankylosing spondylitis (AS) and to promote the necessity of new risk assessment models. We conducted a prospective study in Constanta County, Romania including 70 consecutive patients ≤50 years of age, previously diagnosed with AS, without a history of established CV disease, diabetes mellitus and chronic kidney disease. We estimated the CV risk using SCORE based on total cholesterol, applied for a high-risk population, such as the Romanian population. Estimation of CV risk was also conducted with the relative risk (RR) chart, considering the following variables: Smoking, systolic blood pressure and total cholesterol. The majority of patients (n=46, 65.71%) had low risk according to the SCORE chart and only 24 (34.28%) were found to have moderate CV risk; none of them with high or very high CV risk. Ten patients (21.74%) of the 46 who were considered to have a low risk based on the SCORE system presented with carotid plaques. Twelve patients (50%) of the remaining 24 with moderate CV risk were found to have carotid plaques. According to 2016 'European Society of Cardiology' (ESC) guidelines, 22 of all 70 patients were at high/very high CV risk due to the presence of carotid plaques. Comparing the RR chart with carotid plaque detection, only 4 out of 30 (13.3%) patients with RR=1 had carotid plaques; the frequency was higher in those with RR>1. Our results attested that the SCORE system underestimates the risk in patients with carotid plaques. Carotid ultrasound provided a more heightened sensitivity of the RR chart. C-reactive protein (CRP) >3 mg/dl is associated with RR>1, making this chart a better CV risk predictive system in this particular category of patients.

RxIALTA: evaluating the effect of a pharmacist-led intervention on CV risk in patients with chronic inflammatory diseases in a community pharmacy setting: a prospective pre-post intervention study

Patients with inflammatory conditions are at high risk for cardiovascular (CV) disease. Despite such elevated risk, their CV risk factors are suboptimally managed.

OBJECTIVE

To evaluate the effect of a pharmacist-led intervention on CV risk in patients with inflammatory conditions.

METHODS

DESIGN: Prospective pre-postintervention.

SETTING

17 community pharmacies across Alberta.

POPULATION

Adults with inflammatory conditions (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, systemic lupus erythematosus, psoriasis vulgaris) who had at least one uncontrolled risk factor (A1C, blood pressure, LDL-cholesterol or current tobacco users).

INTERVENTION

All patients enrolled in the study received: physical and laboratory assessment, individualised CV risk assessment and education regarding this risk, treatment recommendations, prescription adaptation and prescribing where necessary to meet treatment targets, regular communication with the patient's treating physician(s) and regular follow-up with all patients every month for 6 months.

OUTCOMES

Primary: change in estimated CV risk (risk of a major CV event in the next 10 years) after 6 months. Secondary: change in individual risk factors (blood pressure, LDL-cholesterol, A1C and tobacco cessation) over a 6-month period.

RESULTS

We enrolled 99 patients. The median age was 66.41 years (IQR 57.64-72.79), More than half of them (61%) were female and more than three-quarters (86%) were Caucasians. After adjusting for age, sex and ethnicity and centre effect, there was a reduction of 24.5% in CV risk (p<0.001); including a reduction of 0.3 mmol/L in LDL-c (p<0.001), 10.7 mm Hg in systolic blood pressure (p<0.001), 1.25% in A1C (p<0.001). There was a non-significant trend towards tobacco cessation.

CONCLUSION

This is the first study on CV risk reduction in patients with inflammatory conditions in a community pharmacy setting. RxIALTA provides evidence for the benefit of pharmacist care on global cardiovascular risk reduction as well as the individual cardiovascular risk factors in patients with inflammatory conditions.

TRIAL REGISTRATION NUMBER

NCT03152396.

Incidence of congestive heart failure in rheumatoid arthritis: a review of literature and meta-regression analysis

AIMS

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disorder that not only affects peripheral joints but also increases the risk for cardiovascular disease (CVD) and mortality. Heart failure (HF) appears to be one of the most important contributors to the excess mortality risk among patients with RA. We assessed the incidence of HF in patients with RA compared with age-matched and sex-matched non-RA subjects, after accounting for traditional cardiovascular risk factors and clinical ischemic heart disease.

METHODS AND RESULTS

We performed an aggregate analysis on three studies of RA patients having listed manifestations of HF. We performed a meta-regression analysis to evaluate the incidence of HF in RA patients with increased age and noted for any gender correlation. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using both fixed-effects and random-effects models. In the cumulative analysis of 5, 220, 883 patients, the incidence of HF was noted to be almost two-fold higher in patients with RA compared with a matched control population (OR 1.78, 95% CI 1.22-2.60, P < 0.003), HTN (OR 1.66, 95% CI 1.24-2.23, P < 0.001), and diabetes (OR 1.57, 95% CI 1.36-1.81, P < 0.001). Women had three-fold higher incidence of HF with RA (OR 3.38, 95% CI 2.59-4.40, P < 0.001). On meta-regression, the incidence of HF increased further with older age (coefficient = 0.12, P = 0.0004).

CONCLUSIONS

Our systematic review that included over 5 million subjects confirms the suspected increased incidence of HF in RA patients. Women have the greatest risk for HF. Our analysis advocates the need for updating the current guidelines to incorporate screening and preventive methods for HF in RA patients.

Could Omega 3 Fatty Acids Preserve Muscle Health in Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by a high prevalence of death due to cardiometabolic diseases. As observed during the aging process, several comorbidities, such as cardiovascular disorders (CVD), insulin resistance, metabolic syndrome and sarcopenia, are frequently associated to RA. These abnormalities could be closely linked to alterations in lipid metabolism. Indeed, RA patients exhibit a lipid paradox, defined by reduced levels of total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol whereas the CVD risk is increased. Moreover, the accumulation of toxic lipid mediators (i.e., lipotoxicity) in skeletal muscles can induce mitochondrial dysfunctions and insulin resistance, which are both crucial determinants of CVD and sarcopenia. The prevention or reversion of these biological perturbations in RA patients could contribute to the maintenance of muscle health and thus be protective against the increased risk for cardiometabolic diseases, dysmobility and mortality. Yet, several studies have shown that omega 3 fatty acids (FA) could prevent the development of RA, improve muscle metabolism and limit muscle atrophy in obese and insulin-resistant subjects. Thereby, dietary supplementation with omega 3 FA should be a promising strategy to counteract muscle lipotoxicity and for the prevention of comorbidities in RA patients.

Lipid accumulation and mitochondrial abnormalities are associated with fiber atrophy in the skeletal muscle of rats with collagen-induced arthritis

Rheumatoid arthritis (RA) has a negative impact on muscle mass, and reduces patient's mobility and autonomy. Furthermore, RA is associated with metabolic comorbidities, notably in lipid homeostasis by unknown mechanisms. To understand the links between the loss in muscle mass and the metabolic abnormalities, arthritis was induced in male Sprague Dawley rats (n = 11) using the collagen-induced arthritis model. Rats immunized with bovine type II collagen were compared to a control group of animals (n = 11) injected with acetic acid and complete Freund's adjuvant. The clinical severity of the ensuing arthritis was evaluated weekly by a semi-quantitative score. Skeletal muscles from the hind limb were used for the histological analysis and exploration of mitochondrial activity, lipid accumulation, metabolism and regenerative capacities. A significant atrophy in tibialis anterior muscle fibers was observed in the arthritic rats despite a non-significant decrease in the weight of the muscles. Despite moderate inflammation, accumulation of triglycerides (P < 0.05), reduced mitochondrial DNA copy number (P < 0.05) and non-significant dysfunction in mitochondrial cytochrome c oxidase activity were found in the gastrocnemius muscle. Concomitantly, our results suggested an activation of the muscle specific E3 ubiquitin ligases MuRF-1 and MAFbx. Finally, the adipose tissue from the arthritic rats exhibited decreased PPARγ mRNA suggesting reduced adipogenic capacities. In conclusion, the reduced adipose tissue adipogenic capacity and skeletal muscle mitochondrial capacity are probably involved in the activation of protein catabolism, inhibition of myogenesis, accumulation of lipids and fiber atrophy in the skeletal muscle during RA.

Relationship of rheumatoid arthritis and coronary artery disease in the Korean population: a nationwide cross-sectional study

BACKGROUND

Rheumatoid arthritis (RA) is known to be associated with coronary artery diseases (CAD). Previous studies of the association between RA and CAD were reported mainly in non-Asian groups. We aimed to examine the prevalence of RA and the relationship between RA and CAD in South Korea.

METHODS

We conducted a nationwide cross-sectional study by using the Korea National Health and Nutrition Examination Survey, which collected data for four years between 2008 and 2012. A total of 25,828 eligible participants were included. To balance the distribution of baseline characteristics, we used propensity score-matching. A multivariable logistic regression model was employed and we calculated the odds ratios (ORs) and 95% confidence intervals (CI) for the odds of the participants with RA on CAD prevalence.

RESULTS

The prevalence of RA in Korea from 2008 to 2012 was 0.6% and RA was predominant among elderly women. The prevalence of CAD in patients with RA was significantly higher than in general population. After propensity score-matching to balance the confounding factors, RA was significantly associated with CAD (OR 2.97, 95% CI 1.15-7.68, P = 0.02).

CONCLUSIONS

The prevalence of RA in South Korea was comparable to the worldwide data, and the presence of CAD in RA patients was more than two-fold.

Alterations of HDL particle phospholipid composition and role of inflammation in rheumatoid arthritis

The increased cardiovascular risk in RA (rheumatoid arthritis) cannot be explained by common quantitative circulating lipid parameters. The objective of the study was to characterize the modifications in HDL phosphosphingolipidome in patients with RA to identify qualitative modifications which could better predict the risk for CVD. Nineteen patients with RA were compared to control subjects paired for age, sex, BMI, and criteria of metabolic syndrome. The characterization of total HDL phosphosphingolipidome was performed by LC-MS/MS. RA was associated with an increased HDL content of lysophosphatidylcholine and a decreased content of PC (phosphatidylcholine), respectively, positively and negatively associated with cardiovascular risk. A discriminant molecular signature composed of 18 lipids was obtained in the HDL from RA patients. The detailed analysis of phospholipid species showed that molecules carrying omega-3 FA (fatty acids), notably docosahexaenoic acid (C22:6 n-3), were depleted in HDL isolated from RA patients. By contrast, two PE (phosphatidylethanolamine) species carrying arachidonic acid (C20:4 n-6) were increased in HDL from RA patients. Furthermore, disease activity and severity indexes were associated with altered HDL content of 4 PE and 2 PC species. In conclusion, the composition of HDL phosphosphingolipidome is altered during RA. Identification of a lipidomic signature could therefore represent a promising biomarker for CVD risk. Although a causal link remains to be demonstrated, pharmacological and nutritional interventions targeting the normalization of the FA composition of altered phospholipids could help to fight against RA-related inflammation and CVD risk.

Vascular brain-derived neurotrophic factor pathway in rats with adjuvant-induced arthritis: Effect of anti-rheumatic drugs

BACKGROUND AND AIMS

In rheumatoid arthritis, the control of both disease activity and standard cardiovascular (CV) risk factors is expected to attenuate the increased CV risk. Evidence that brain-derived neurotrophic factor (BDNF) plays a role in vascular biology led us to investigate the vascular BDNF pathway in arthritis rats as well as the interaction between endothelial nitric oxide (NO) and BDNF production.

METHODS

The aortic BDNF pathway was studied in rats with adjuvant-induced arthritis, (AIA) using Western blot and immunohistochemical analysis. Control of arthritis score was achieved by administration (for 3 weeks) of an equipotent dosage of etanercept, prednisolone, methotrexate, celecoxib or diclofenac. Aortas were exposed to an NO donor or an NO synthase inhibitor and vasoreactivity experiments were performed using LM22A-4 as a TrkB agonist.

RESULTS

Vascular BDNF and full length tropomyosin-related kinase B receptor (TrkB-FL) were higher in AIA than in control rats. These changes coincided with decreased endothelial immunoreactivity in BDNF and pTrkB^tyr816 and were disconnected from arthritis score. Among anti-rheumatic drugs, only prednisolone and methotrexate prevented AIA-induced vascular BDNF loss. The effect of AIA on aortic BDNF levels was reversed by an NO donor and reproduced by an NOS inhibitor. Finally, LM22A-4 induced both NO-dependent vasodilation and phosphorylation of endothelial NO synthase at serine 1177.

CONCLUSIONS

Our study identified changes in the BDNF/TrkB pathway as a disease activity-independent component of AIA-associated changes in endothelial phenotype. It provides new perspectives in the understanding and management of the high CV risk reported in rheumatoid arthritis.