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Yu F, Xie Y, Yang J. Analysis of hyperlipidemia risk factors among pilots based on physical examination data: A study using a multilevel propensity score models. Exp Ther Med 2024; 28:341. [PMID: 39006453 PMCID: PMC11240281 DOI: 10.3892/etm.2024.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/23/2024] [Indexed: 07/16/2024] Open
Abstract
Pilot tends to have a high prevalence of dyslipidemia. The present study aimed to identify key factors of pilot hyperlipidemia through thorough analysis of physical examination data, and to provide pilot-targeted health guidance to manage hyperlipidemia risks. The physical examination data of 1,253 pilot inpatients from January 2019 to June 2022, were evaluated and divided into two groups based on whether or not the pilot had hyperlipidemia. A total of three multivariate analysis models including logistic model, multilevel model and boosting propensity score were applied to find the risk factors of pilot hyperlipidemia. In the group of pilots with hyperlipidemia, four risk factors, including thrombin time, carbohydrate antigen 199, lymphocyte count and rheumatoid factor, were significantly different from pilots without hyperlipidemia, which might be positively associated with the incidence of hyperlipidemia. In future studies regarding pilots, whether hyperlipidemia is connected to abnormalities in thrombin time, carbohydrate antigen 199 and rheumatoid factor should be further explored. Based on the findings of the present study, pilot health management should be more refined and personalized, and attention should be paid to the risk factors of hyperlipidemia including diet and lifestyle.
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Affiliation(s)
- Feifei Yu
- Naval Medical Center, Naval Medical University (Second Military Medical University), Shanghai 200433, P.R. China
| | - Yi Xie
- Naval Medical Center, Naval Medical University (Second Military Medical University), Shanghai 200433, P.R. China
| | - Jishun Yang
- Naval Medical Center, Naval Medical University (Second Military Medical University), Shanghai 200433, P.R. China
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2
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Yuan S, Carter P, Mason AM, Yang F, Burgess S, Larsson SC. Genetic Liability to Rheumatoid Arthritis in Relation to Coronary Artery Disease and Stroke Risk. Arthritis Rheumatol 2022; 74:1638-1647. [PMID: 35583917 PMCID: PMC9804931 DOI: 10.1002/art.42239] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/30/2022] [Accepted: 05/12/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess the causality of the associations of rheumatoid arthritis (RA) with coronary artery disease (CAD) and stroke using the Mendelian randomization approach. METHODS Independent single-nucleotide polymorphisms strongly associated with RA (n = 70) were selected as instrumental variables from a genome-wide association meta-analysis including 14,361 RA patients and 43,923 controls of European ancestry. Summary-level data for CAD, all stroke, any ischemic stroke and its subtypes, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage were obtained from meta-analyses of genetic studies, international genetic consortia, the UK Biobank, and the FinnGen consortium. We obtained summary-level data for common cardiovascular risk factors and related inflammatory biomarkers to assess possible mechanisms. RESULTS Genetic liability to RA was associated with an increased risk of CAD and ICH. For a 1-unit increase in log odds of RA, the combined odds ratios were 1.02 (95% confidence interval [1.01, 1.03]; P = 0.003) for CAD and 1.05 (95% confidence interval [1.02, 1.08]; P = 0.001) for ICH. Genetic liability to RA was associated with increased levels of tumor necrosis factor and C-reactive protein (CRP). The association with CAD was attenuated after adjustment for genetically predicted CRP levels. There were no associations of genetic liability to RA with the other studied outcomes. CONCLUSION This study found that genetic liability to RA was associated with an increased risk of CAD and ICH and that the association with CAD might be mediated by CRP. The heightened cardiovascular risk should be actively monitored and managed in RA patients, and this may include dampening systemic inflammation.
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Affiliation(s)
| | | | | | - Fangkun Yang
- Ningbo First Hospital and Zhejiang UniversityNingboChina
| | | | - Susanna C. Larsson
- Karolinska Institutet, Stockholm, Sweden, and Uppsala UniversityUppsalaSweden
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3
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Gager GM, Eyileten C, Postula M, Gasecka A, Jarosz-Popek J, Gelbenegger G, Jilma B, Lang I, Siller-Matula J. Association Between the Expression of MicroRNA-125b and Survival in Patients With Acute Coronary Syndrome and Coronary Multivessel Disease. Front Cardiovasc Med 2022; 9:948006. [PMID: 35872885 PMCID: PMC9304571 DOI: 10.3389/fcvm.2022.948006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMicroRNAs (miRNA, miR) have an undeniable physiological and pathophysiological significance and act as promising novel biomarkers. The aim of the study was to investigate blood-derived miRNAs and their association with long-term all-cause mortality in patients with multivessel disease (MVD) suffering from acute coronary syndrome (ACS).Materials and MethodsThis study was an observational prospective study, which included 90 patients with MVD and ACS. Expression of miR-125a, miR-125b, and miR-223 was analysed by polymerase chain reaction (PCR). Patients were followed-up for a median of 7.5 years. All-cause mortality was considered as the primary endpoint. Adjusted Cox-regression analysis was performed for prediction of events.ResultsElevated expression of miR-125b (>4.6) at the time-point of ACS was associated with increased long-term all-cause mortality (adjusted [adj.] hazard ratio [HR] = 11.26, 95% confidence interval [95% CI]: 1.15–110.38; p = 0.038). The receiver operating characteristic (ROC) analysis showed a satisfactory c-statistics for miR-125b for the prediction of long-term all-cause mortality (area under the curve [AUC] = 0.76, 95% CI: 0.61–0.91; p = 0.034; the negative predictive value of 98%). Kaplan–Meier time to event analysis confirmed an early separation of the survival curves between patients with high vs low expression of miR-125b (p = 0.003). An increased expression of miR-125a and miR-223 was found in patients with non-ST-segment elevation ACS (NSTE-ACS) as compared to those with ST-segment elevation myocardial infarction (STEMI) (p = 0.043 and p = 0.049, respectively) with no difference in the expression of miR-125b between the type of ACS.ConclusionIn this hypothesis generating study, lower values of miR-125b were related to improved long-term survival in patients with ACS and MVD. Larger studies are needed to investigate whether miR-125b can be used as a suitable predictor for long-term all-cause mortality.
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Affiliation(s)
- Gloria M. Gager
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ceren Eyileten
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
- Genomics Core Facility, Center of New Technologies (CeNT), University of Warsaw, Warsaw, Poland
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Jarosz-Popek
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Jolanta Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Jolanta Siller-Matula,
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Port SC. Just go with the flow. J Nucl Cardiol 2022; 29:43-45. [PMID: 32607837 DOI: 10.1007/s12350-020-02244-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Steven C Port
- AdvocateAuroraHealth: Aurora Cardiovascular Services, Milwaukee, WI, USA.
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Thakur M, Evans B, Schindewolf M, Baumgartner I, Döring Y. Neutrophil Extracellular Traps Affecting Cardiovascular Health in Infectious and Inflammatory Diseases. Cells 2021; 10:1689. [PMID: 34359859 PMCID: PMC8305819 DOI: 10.3390/cells10071689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Neutrophil extracellular traps (NETs) are web-like structures of decondensed extracellular chromatin fibers and neutrophil granule proteins released by neutrophils. NETs participate in host immune defense by entrapping pathogens. They are pro-inflammatory in function, and they act as an initiator of vascular coagulopathies by providing a platform for the attachment of various coagulatory proteins. NETs are diverse in their ability to alter physiological and pathological processes including infection and inflammation. In this review, we will summarize recent findings on the role of NETs in bacterial/viral infections associated with vascular inflammation, thrombosis, atherosclerosis and autoimmune disorders. Understanding the complex role of NETs in bridging infection and chronic inflammation as well as discussing important questions related to their contribution to pathologies outlined above may pave the way for future research on therapeutic targeting of NETs applicable to specific infections and inflammatory disorders.
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Affiliation(s)
- Manovriti Thakur
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (M.T.); (B.E.); (M.S.); (I.B.)
| | - Bryce Evans
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (M.T.); (B.E.); (M.S.); (I.B.)
| | - Marc Schindewolf
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (M.T.); (B.E.); (M.S.); (I.B.)
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (M.T.); (B.E.); (M.S.); (I.B.)
| | - Yvonne Döring
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (M.T.); (B.E.); (M.S.); (I.B.)
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-University Munich (LMU), 80336 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
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Holmqvist M, Mantel Ä, Wållberg-Jonsson S, James S, Jernberg T, Askling J. Findings on Coronary Angiographies in Patients With Rheumatoid Arthritis and Ischemic Heart Disease: Are They Different From Patients Without Rheumatoid Arthritis? Arthritis Care Res (Hoboken) 2020; 73:658-665. [PMID: 33285616 DOI: 10.1002/acr.24214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/25/2020] [Accepted: 04/07/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) are at increased risk of coronary artery disease (CAD) and seem to develop more severe acute coronary syndromes (ACS) than the general population. Because few studies have investigated the CAD distribution in the context of acute or stable CAD in RA, the objective was to investigate whether this risk is due to a different distribution and severity of coronary stenoses (versus non-RA), resulting in clinical manifestation of CAD. METHODS We performed a population-based study using linkages of nationwide clinical, health, and demographics registers. We compared 1 cohort of patients with RA, and 1 matched cohort of patients without RA, undergoing a first coronary angiography from 2006 through 2015. Cardiovascular (CV) characteristics and the presence and distribution of clinically significant stenoses were compared (through odds ratios [ORs]), stratified by indication (stable CAD, ST-elevation myocardial infarction [STEMI], and non-ST-elevation ACS [NSTACS]), using logistic regression. RESULTS We identified 2,985 patients with RA and 10,290 patients without RA who underwent a first coronary angiography. A higher proportion of patients with RA (75% versus 69%) had STEMI and NSTACS as indication for angiography. We found no difference in the presence and distribution of clinically significant coronary stenoses in RA compared with the patients without RA, regardless of the CAD type (for having any significant stenosis in stable CAD OR 0.9, STEMI OR 0.8, and NSTACS OR 1.1), stratification by RA duration, sex, or burden of concomitant CV risk factors. CONCLUSION Although RA may accelerate the development of clinical CAD events, the underlying angiographic characteristics are similar to those in patients without RA.
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Affiliation(s)
| | | | | | | | - Tomas Jernberg
- Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Baumann AAW, Mishra A, Worthley MI, Nelson AJ, Psaltis PJ. Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine. Ther Adv Chronic Dis 2020; 11:2040622320938527. [PMID: 32655848 PMCID: PMC7331770 DOI: 10.1177/2040622320938527] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.
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Affiliation(s)
- Angus A. W. Baumann
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Aashka Mishra
- Flinders Medical School, Flinders University, Adelaide, South Australia, Australia
| | - Matthew I. Worthley
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, NC, USA
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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Wang H, Li X, Gong G. Cardiovascular outcomes in patients with co-existing coronary artery disease and rheumatoid arthritis: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19658. [PMID: 32243398 PMCID: PMC7440102 DOI: 10.1097/md.0000000000019658] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Through this analysis, we aimed to systematically compare the cardiovascular outcomes observed in patients with co-existing coronary artery disease (CAD) and rheumatoid arthritis (RA). METHODS Mendeley, Web of Science (WOS), MEDLINE, Cochrane central, EMBASE, Google scholar, and http://www.ClinicalTrials.gov were searched for English-based publications on CAD and RA. Selective cardiovascular outcomes were the endpoints in this analysis. The statistical software RevMan 5.3 was used for data assessment. Risk ratios (RR) with 95% confidence intervals (CI) were used to represent each subgroup analysis. RESULTS One thousand four hundred forty six (1446) participants had co-existing CAD and RA whereas 205,575 participants were in the control group (only CAD without RA). This current analysis showed that the risk of asymptomatic or stable angina was similar in CAD patients with versus without RA (RR: 0.98, 95% CI: 0.84 - 1.14; P = .78). However, all-cause mortality (RR: 1.47, 95% CI: 1.34 - 1.61; P = 0.00001), cardiac death (RR: 1.51, 95% CI: 1.05 - 2.17; P = .03) and congestive heart failure (RR: 1.41, 95% CI: 1.27 - 1.56; P = .00001) were significantly higher in CAD patients with RA. However, multi-vessel disease (RR: 2.03, 95% CI: 0.57 - 7.26; P = .28), positive stress test (RR: 1.69, 95% CI: 0.70 - 4.08; P = .24), and ischemic events (RR: 1.18, 95% CI: 0.81 - 1.71; P = .40) were similar in both groups. The risk for myocardial infarction, repeated revascularization, and the probability of patients undergoing percutaneous coronary intervention (PCI) (RR: 1.20, 95% CI: 0.75 - 1.93; P = .45) were also similar in CAD patients with versus without RA. When we considered outcomes only in those patients who underwent revascularization by PCI, all-cause mortality (RR: 1.43, 95% CI: 1.29 - 1.60; P = .00001) was still significantly higher in CAD patients with RA. CONCLUSIONS This analysis showed a significantly higher mortality risk in CAD patients with RA when compared to the control group. Congestive heart failure also significantly manifested more in CAD patients with co-existing RA. However, the risks all the other cardiovascular outcomes were similar in both groups. Nevertheless, due to the several limitations of this analysis, this hypothesis should be confirmed in forthcoming trials based on larger numbers of CAD patients with co-existing RA.
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Ogrič M, Poljšak KM, Lakota K, Žigon P, Praprotnik S, Semrl SS, Čučnik S. Neutralizing effects of anti-infliximab antibodies on synergistically-stimulated human coronary artery endothelial cells. Atherosclerosis 2019; 291:1-8. [PMID: 31629987 DOI: 10.1016/j.atherosclerosis.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 08/09/2019] [Accepted: 09/20/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Patients with rheumatic diseases have an increased risk of atherosclerosis with up-regulated serum amyloid A (SAA), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β), which were reported to activate human coronary artery endothelial cells (HCAEC). We aimed to investigate the effects of TNF-α inhibitor infliximab and anti-infliximab antibodies on the TNF-α/IL-1β/SAA activated HCAEC. METHODS HCAEC were incubated with TNF-α, IL-1β, SAA, infliximab, anti-infliximab antibodies and their combinations. The protein levels of pro- and anti-atherogenic analytes were measured in supernatants using ELISA and multiplex assays, while mRNA expression was determined by RT-PCR. Anti-infliximab antibodies were purified from sera samples by affinity chromatography. RESULTS IL-6, IL-8, GM-CSF and GRO-α were synergistically up-regulated in triple stimulation with TNF-α, IL-1β and SAA, while their levels in solely SAA- or TNF-α-stimulated HCAEC did not increase. IL-1Ra, IL-1α, VCAM-1, MCP-1, IL-10 and IL-17A were increased, but no synergistic responses were observed in triple stimulation. Infliximab was effective in lowering the synergistic effect of IL-6, IL-8, GM-CSF and GRO-α in triple stimulation, while anti-infliximab antibodies restored the levels. The changes were confirmed at the mRNA expression level for IL-6, IL-8 and GM-CSF. CONCLUSIONS Triple stimulation with TNF-α, IL-1β and SAA synergistically elevated IL-6, IL-8, GM-CSF and GRO-α release in supernatants of HCAEC, with infliximab substantially inhibiting their levels. An isolated, enriched fraction of polyclonal anti-infliximab antibodies was capable of neutralizing infliximab, in the presence of TNF-α/IL-1β/SAA. The long-term presence of anti-infliximab antibodies in the circulation of patients with chronic rheumatic diseases is potentially important for promoting the atherosclerotic process.
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Affiliation(s)
- Manca Ogrič
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia; University of Ljubljana, Faculty of Pharmacy, Chair of Clinical Biochemistry, Ljubljana, Slovenia
| | - Katjuša Mrak Poljšak
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
| | - Katja Lakota
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia; University of Primorska, FAMNIT, Koper, Slovenia
| | - Polona Žigon
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
| | - Sonja Praprotnik
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia
| | - Snezna Sodin Semrl
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia; University of Primorska, FAMNIT, Koper, Slovenia
| | - Saša Čučnik
- University Medical Centre Ljubljana, Department of Rheumatology, Ljubljana, Slovenia; University of Ljubljana, Faculty of Pharmacy, Chair of Clinical Biochemistry, Ljubljana, Slovenia.
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Naguib A, Elsawy N, Aboul-enein F, Hossam N. The relation between serum visfatin levels and cardiovascular involvement in rheumatoid arthritis. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2011.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Abir Naguib
- Department of Physical, Medicine Rheumatology and Rehabilitation Faculty of Medicine Alexandria UniversityEgypt
| | - Noha Elsawy
- Department of Physical, Medicine Rheumatology and Rehabilitation Faculty of Medicine Alexandria UniversityEgypt
| | - Fatma Aboul-enein
- Department of Cardiology and Angiology Faculty of Medicine Alexandria University Egypt
| | - Nermin Hossam
- Department of Clinical Pathology Faculty of Medicine Alexandria University Egypt
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Katsiari CG, Bogdanos DP, Sakkas LI. Inflammation and cardiovascular disease. World J Transl Med 2019; 8:1-8. [DOI: 10.5528/wjtm.v8.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular disease (CVD) has been associated with the so-called traditional risk factors, such as hypertension, hypercholesterolemia and cigarette smoking. Chronic inflammation, exemplified by elevated high sensitivity C-reactive protein, has been added to these risk factors for CVD as non-traditional risk factor. There are two aspects in this association. The first is whether inflammation plays a pathogenic role in traditional risk factors-mediated CVD or it is just an epiphenomenon. The second is whether chronic inflammation caused by an inflammatory disease has any impact on CVD. Accumulated data have shown that inflammation has a central and inciting role in the development of atherosclerosis leading to increased CVD risk. How inflammation contributes to CVD is a topic of continuous research where mechanisms involving both innate and adaptive immune pathways are involved. Endothelial dysfunction, oxidative stress in vascular endothelial cells, macrophage accumulation, formation of inflammasome, production of tumor necrosis factor (TNF)-a, IL-1 and IL-6 characterize the inflammatory process leading to atherogenesis. Recently clonal hematopoiesis of indeterminate potential represents a surprising and novel mechanism underlying atherogenesis. Data from chronic rheumatic inflammatory diseases exemplify the complexity of mechanisms leading to increased CVD, while they also provide evidence that anti-inflammatory biologic drugs, such as anti-TNF and anti-IL6 agents, could control atherogenesis and ameliorate CVD risk. Recent groundbreaking work using biologic anti-IL-1b therapy to treat men and women who have had a prior heart attack provides the best proof of the pathogenic contribution of inflammation in the development of CVD.
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Affiliation(s)
- Christina G Katsiari
- Department of Rheumatology and Clinical Immunology, Division of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Division of Medicine, University of Thessaly, Larissa 41110, Greece
| | - Lazaros I Sakkas
- Department of Rheumatology and Clinical Immunology, Division of Medicine, University of Thessaly, Larissa 41110, Greece
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Shufelt C, Dutra E, Torbati T, Ramineni T. A clinical prescription for heart health in midlife women. Maturitas 2019; 119:46-53. [PMID: 30502750 PMCID: PMC6290356 DOI: 10.1016/j.maturitas.2018.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/08/2018] [Indexed: 12/01/2022]
Abstract
Cardiovascular disease is the leading cause of death in women throughout the United States and Europe. Despite efforts to raise awareness, the sex-specific risk factors are still poorly recognized in both regions, and many women do not identify cardiovascular disease as a primary threat. During midlife, the incidence of cardiovascular disease increases dramatically, and this unique time gives an opportunity to identify both traditional cardiovascular risk factors as well as emerging risk factors unique to women. This review will focus on the current guidelines for cardiovascular risk assessment in Europe and the United States, traditional and emerging cardiovascular risk factors, and preventive lifestyle recommendations for midlife women.
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Affiliation(s)
- Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Erika Dutra
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tina Torbati
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tina Ramineni
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Abd El-Monem SM, Ali AY, Hashaad NI, Bendary AM, Abd El-Aziz HA. Association of rheumatoid arthritis disease activity, severity with electrocardiographic findings, and carotid artery atherosclerosis. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_36_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Zeisbrich M, Yanes RE, Zhang H, Watanabe R, Li Y, Brosig L, Hong J, Wallis BB, Giacomini JC, Assimes TL, Goronzy JJ, Weyand CM. Hypermetabolic macrophages in rheumatoid arthritis and coronary artery disease due to glycogen synthase kinase 3b inactivation. Ann Rheum Dis 2018; 77:1053-1062. [PMID: 29431119 DOI: 10.1136/annrheumdis-2017-212647] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/13/2018] [Accepted: 01/16/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Accelerated atherosclerotic disease typically complicates rheumatoid arthritis (RA), leading to premature cardiovascular death. Inflammatory macrophages are key effector cells in both rheumatoid synovitis and the plaques of coronary artery disease (CAD). Whether both diseases share macrophage-dependent pathogenic mechanisms is unknown. METHODS Patients with RA or CAD (at least one myocardial infarction) and healthy age-matched controls were recruited into the study. Peripheral blood CD14+ monocytes were differentiated into macrophages. Metabolic profiles were assessed by Seahorse Analyzer, intracellular ATP concentrations were quantified and mitochondrial protein localisation was determined by confocal image analysis. RESULTS In macrophages from patients with RA or CAD, mitochondria consumed more oxygen, generated more ATP and built tight interorganelle connections with the endoplasmic reticulum, forming mitochondria-associated membranes (MAM). Calcium transfer through MAM sites sustained mitochondrial hyperactivity and was dependent on inactivation of glycogen synthase kinase 3b (GSK3b), a serine/threonine kinase functioning as a metabolic switch. In patient-derived macrophages, inactivated pGSK3b-Ser9 co-precipitated with the mitochondrial fraction. Immunostaining of atherosclerotic plaques and synovial lesions confirmed that most macrophages had inactivated GSK3b. MAM formation and GSK3b inactivation sustained production of the collagenase cathepsin K, a macrophage effector function closely correlated with clinical disease activity in RA and CAD. CONCLUSIONS Re-organisation of the macrophage metabolism in patients with RA and CAD drives unopposed oxygen consumption and ultimately, excessive production of tissue-destructive enzymes. The underlying molecular defect relates to the deactivation of GSK3b, which controls mitochondrial fuel influx and as such represents a potential therapeutic target for anti-inflammatory therapy.
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Affiliation(s)
- Markus Zeisbrich
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Rolando E Yanes
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Hui Zhang
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ryu Watanabe
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Yinyin Li
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Lukas Brosig
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Jison Hong
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Barbara B Wallis
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - John C Giacomini
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Themistocles L Assimes
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jörg J Goronzy
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Cornelia M Weyand
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
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15
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Geraldino-Pardilla L, Zartoshti A, Bag Ozbek A, Giles JT, Weinberg R, Kinkhabwala M, Bokhari S, Bathon JM. Arterial Inflammation Detected With 18 F-Fluorodeoxyglucose-Positron Emission Tomography in Rheumatoid Arthritis. Arthritis Rheumatol 2017; 70:30-39. [PMID: 28992382 DOI: 10.1002/art.40345] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/03/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In addition to traditional risk factors, excess cardiovascular disease (CVD) in rheumatoid arthritis (RA) is attributed to enhanced vascular and/or systemic inflammation. In several small studies using 18 F-fluorodeoxyglucose-positron emission tomography/computed tomography (18 F-FDG-PET/CT) to directly assess vascular inflammation, FDG uptake was higher in RA patients than in controls. Using a substantially larger sample of RA patients, we sought to identify RA disease characteristics independently associated with vascular FDG uptake. METHODS RA patients underwent cardiac FDG-PET/CT, with aortic inflammation assessed by quantification of FDG uptake in the ascending aorta, calculated as the mean and maximum (max) standardized uptake value (SUV) of the entire ascending aorta and of its most diseased segment (SUV MDS). Univariate and multivariable regression models were constructed to model the associations of patient characteristics with aortic FDG uptake. RESULTS Ninety-one RA patients were scanned. In multivariable models, in addition to the independent associations of hypertension and body mass index with increased aortic FDG uptake, the prevalence of rheumatoid nodules correlated with the SUV mean and SUV MDS mean measures, while anti-cyclic citrullinated peptide (anti-CCP) antibodies correlated inversely with these measures and with the SUV max and SUV MDS max (P < 0.05). A significant association of RA disease activity with aortic FDG uptake was observed but was restricted to anti-CCP seropositivity. CONCLUSION Traditional CV risk factors and RA disease characteristics (rheumatoid nodules and the Disease Activity Score in 28 joints using the C-reactive protein level in anti-CCP antibody-positive individuals) were independently associated with ascending aortic FDG uptake in RA patients without clinical CVD.
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Affiliation(s)
- Laura Geraldino-Pardilla
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Afshin Zartoshti
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Ayse Bag Ozbek
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Jon T Giles
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Richard Weinberg
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Mona Kinkhabwala
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Sabahat Bokhari
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | - Joan M Bathon
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
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16
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Mehta NN, Teague HL, Swindell WR, Baumer Y, Ward NL, Xing X, Baugous B, Johnston A, Joshi AA, Silverman J, Barnes DH, Wolterink L, Nair RP, Stuart PE, Playford M, Voorhees JJ, Sarkar MK, Elder JT, Gallagher K, Ganesh SK, Gudjonsson JE. IFN-γ and TNF-α synergism may provide a link between psoriasis and inflammatory atherogenesis. Sci Rep 2017; 7:13831. [PMID: 29062018 PMCID: PMC5653789 DOI: 10.1038/s41598-017-14365-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic inflammation is a critical component of atherogenesis, however, reliable human translational models aimed at characterizing these mechanisms are lacking. Psoriasis, a chronic inflammatory skin disease associated with increased susceptibility to atherosclerosis, provides a clinical human model that can be utilized to investigate the links between chronic inflammation and atherosclerosis development. We sought to investigate key biological processes in psoriasis skin and human vascular tissue to identify biological components that may promote atherosclerosis in chronic inflammatory conditions. Using a bioinformatics approach of human skin and vascular tissue, we determined IFN-γ and TNF-α are the dominant pro-inflammatory signals linking atherosclerosis and psoriasis. We then stimulated primary aortic endothelial cells and ex-vivo atherosclerotic tissue with IFN-γ and TNF-α and found they synergistically increased monocyte and T-cell chemoattractants, expression of adhesion molecules on the endothelial cell surface, and decreased endothelial barrier integrity in vitro, therefore increasing permeability. Our data provide strong evidence of synergism between IFN-γ and TNF- α in inflammatory atherogenesis and provide rationale for dual cytokine antagonism in future studies.
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Affiliation(s)
- Nehal N Mehta
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Heather L Teague
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Yvonne Baumer
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nicole L Ward
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA
| | - Xianying Xing
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Brooke Baugous
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Andrew Johnston
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Aditya A Joshi
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joanna Silverman
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Drew H Barnes
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Liza Wolterink
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Rajan P Nair
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Philip E Stuart
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Martin Playford
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - John J Voorhees
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Mrinal K Sarkar
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - James T Elder
- Department of Dermatology, Univ. of Michigan, Ann Arbor, MI, USA
| | - Katherine Gallagher
- Department of Surgery, Division of Vascular Surgery, Univ. of Michigan, Ann Arbor, MI, USA
| | - Santhi K Ganesh
- Department of Internal Medicine, Division of Cardiovascular Medicine, and Department of Human Genetics, Univ. of Michigan, Ann Arbor, MI, USA
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17
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Halls S, Law RJ, Jones JG, Markland DA, Maddison PJ, Thom JM. Health Professionals' Perceptions of the Effects of Exercise on Joint Health in Rheumatoid Arthritis Patients. Musculoskeletal Care 2017; 15:196-209. [PMID: 27709770 DOI: 10.1002/msc.1157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Although exercise is an important factor in the management of rheumatoid arthritis (RA), research indicates that patients perceive that health professionals (HPs) are uncertain about the place of exercise in treatment and its relationship with joint damage. The present study investigated the perceptions of HPs regarding the effects of exercise on joint health in RA patients. METHODS A questionnaire investigating perceptions of exercise and joint health was distributed via professional networks and websites. Confirmatory factor analysis (CFA) was used to analyse questionnaire data and develop a focus group interview guide. Focus groups were conducted with multidisciplinary teams (MDTs) of rheumatology HPs and analysed using framework analysis. RESULTS A total of 137 rheumatology HPs (95 female; 27-65 years of age) completed questionnaires. CFA showed that a four-factor model provided a marginally acceptable fit. Analysis of four focus groups (n = 24; 19 female; 30-60 years of age) identified five themes relating to HPs' perceptions of exercise and joint health in RA patients: 'Exercise is beneficial', 'Concerns about damage to joints', 'Patients have barriers to exercise', 'HP knowledge differs' and 'Patients may think service delivery is vague'. CONCLUSIONS HPs were highly aware of the benefits and importance of exercise for RA patients. However, to remove the patient perception that HPs lack certainty and clarity regarding exercise it is important to ensure: (i) consistent promotion of exercise across the whole MDT; (ii) clear provision of information regarding rest, joint protection and exercise; (iii) HP education to ensure consistent, accurate knowledge, and understanding of the potential for conflicting advice when promoting exercise as part of an MDT. Copy © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Serena Halls
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
| | - Rebecca-Jane Law
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
- North Wales Centre for Primary Care Research, School of Healthcare Sciences, Bangor University, Bangor, UK
| | - Jeremy G Jones
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
- Department of Rheumatology, Betsi Cadwaladr University Health Board, UK
| | - David A Markland
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Peter J Maddison
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Jeanette M Thom
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
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18
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Unmet Needs in the Pathogenesis and Treatment of Cardiovascular Comorbidities in Chronic Inflammatory Diseases. Clin Rev Allergy Immunol 2017; 55:254-270. [PMID: 28741263 DOI: 10.1007/s12016-017-8624-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The developments that have taken place in recent decades in the diagnosis and therapy of a number of diseases have led to improvements in prognosis and life expectancy. As a consequence, there has been an increase in the number of patients affected by chronic diseases and who can face new pathologies during their lifetime. The prevalence of chronic heart failure, for example, is approximately 1-2% of the adult population in developed countries, rising to ≥10% among people >70 years of age; in 2015, more than 85 million people in Europe were living with some sort of cardiovascular disease (CVD) (Lubrano and Balzan World J Exp Med 5:21-32, 5; Takahashi et al. Circ J 72:867-72, 8; Kaptoge et al. Lancet 375:132-40, 9). Chronic disease can become, in turn, a major risk factor for other diseases. Furthermore, several new drugs have entered clinical practice whose adverse effects on multiple organs are still to be evaluated. All this necessarily involves a multidisciplinary vision of medicine, where the physician must view the patient as a whole and where collaboration between the various specialists plays a key role. An example of what has been said so far is the relationship between CVD and chronic inflammatory diseases (CIDs). Patients with chronic CVD may develop a CID within their lifetime, and, vice versa, a CID can be a risk factor for the development of CVD. Moreover, drugs used for the treatment of CIDs may have side effects involving the cardiovascular system and thus may be contraindicated. The purpose of this paper is to investigate the close relationship between these two groups of diseases and to provide recommendations on the diagnostic approach and treatments in light of the most recent scientific data available.
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19
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McClelland TJ, Penfold R, Kluzek S, Nagra NS. A large chronic pericardial effusion in an ultramarathon runner with anti-CCP positive rheumatoid arthritis. BMJ Case Rep 2017; 2017:bcr-2017-219350. [PMID: 28611162 DOI: 10.1136/bcr-2017-219350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pericardial effusions arise as an extra-articular manifestation of rheumatoid arthritis (RA). Pericardial effusions are often asymptomatic, particularly in the early phase, but patients are at risk of cardiac tamponade as the effusion progresses. We discuss the case of a 40-year-old male ultramarathon runner with RA who presented with mild pleuritic chest pain and exertional dyspnoea after a recent long-haul flight. Despite a relative tachycardia, his observations were otherwise unremarkable. His blood tests revealed a C-reactive protein (CRP) of 86 mg/L and an anti-cyclic citrullinated peptide (anti-CCP) titre of 360 units/mL. He was initially diagnosed with a pulmonary embolism; however, a large pericardial effusion was found incidentally on CT pulmonary angiogram with over 1500 mL subsequently drained. The patient's symptoms resolved and CRP normalised 2 weeks later. This unique case illustrates that physically fit patients may physiologically compensate for large pericardial effusions and that arthritic symptoms do not correlate with the severity of extra-articular features in RA.
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Affiliation(s)
| | - Rose Penfold
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
| | - Stefan Kluzek
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Botnar Research Centre (NDORMS), University of Oxford, Oxford, UK
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20
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Hatri A, Guermaz R, Laroche JP, Taharboucht S, Kessal F, Hamrour F, Zekri S, Mameri A, Brouri M. Accelerated Atherosclerosis in Takayasu Disease: Case-Control Study. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojim.2017.71002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Hemingway H, Vahtera J, Virtanen M, Pentti J, Kivimäki M. Outcome of stable angina in a working population: the burden of sickness absence. ACTA ACUST UNITED AC 2016; 14:373-9. [PMID: 17568235 DOI: 10.1097/01.hjr.0000230106.01396.a2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The decline in acute event rates among patients with stable angina emphasizes the need for outcome events that are commonly experienced, externally observed and sensitive to changing functional impairments. In the absence of previous studies, we sought to determine the burden of medically certified spells of sickness absence among individuals with angina and their relation to risk factors and co-morbidity. DESIGN AND METHODS A prospective study of 33 148 employees and 1 year experience of medically certified sickness absence in 341 physician-diagnosed angina patients (417 absence spells, total absence days 9733). RESULTS Among individuals with angina, sickness absence occurred at a rate of 125 spells per 100 person-years, with age and sex adjusted hazard ratios (compared with their colleagues with no chronic diseases) of 2.90 (95% confidence interval 2.51-3.36), greater than the effect of prolapsed intervertebral disc. Co-morbid diseases were stronger predictors of absence than behavioural risk factors or cardiovascular diseases, and explained 71% of the excess risk of absence in angina. CONCLUSION In a working population, angina has a significant impact on sick leave, largely because of co-morbid diseases. Angina intervention studies that include employed patients should measure, and seek to reverse, this prognostic burden.
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Affiliation(s)
- Harry Hemingway
- International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, London, UK.
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22
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Abstract
Atherosclerosis is a chronic inflammatory disease that is initiated by the retention and accumulation of cholesterol-containing lipoproteins, particularly low-density lipoprotein, in the artery wall. In the arterial intima, lipoprotein components that are generated through oxidative, lipolytic, and proteolytic activities lead to the formation of several danger-associated molecular patterns, which can activate innate immune cells as well as vascular cells. Moreover, self- and non-self-antigens, such as apolipoprotein B-100 and heat shock proteins, can contribute to vascular inflammation by triggering the response of T and B cells locally. This process can influence the initiation, progression, and stability of plaques. Substantial clinical and experimental data support that the modulation of adaptive immune system may be used for treating and preventing atherosclerosis. This may lead to the development of more selective and less harmful interventions, while keeping host defense mechanisms against infections and tumors intact. Approaches such as vaccination might become a realistic option for cardiovascular disease, especially if they can elicit regulatory T and B cells and the secretion of atheroprotective antibodies. Nevertheless, difficulties in translating certain experimental data into new clinical therapies remain a challenge. In this review, we discuss important studies on the function of T- and B-cell immunity in atherosclerosis and their manipulation to develop novel therapeutic strategies against cardiovascular disease.
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Affiliation(s)
- Daniel F J Ketelhuth
- From the Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Göran K Hansson
- From the Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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23
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Winchester R, Giles JT, Nativ S, Downer K, Zhang HZ, Bag-Ozbek A, Zartoshti A, Bokhari S, Bathon JM. Association of Elevations of Specific T Cell and Monocyte Subpopulations in Rheumatoid Arthritis With Subclinical Coronary Artery Atherosclerosis. Arthritis Rheumatol 2016; 68:92-102. [PMID: 26360530 DOI: 10.1002/art.39419] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 08/27/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Coronary artery disease (CAD) is the leading cause of excess deaths in rheumatoid arthritis (RA). However, identification of features denoting patients with a risk of developing CAD is lacking. The composition of circulating peripheral blood mononuclear cell (PBMC) subsets in RA patients differs markedly from that in healthy controls with regard to the extent of T cell activation, with clonal expansion and differentiation to effector memory status, and presence of inflammatory monocytes. In this study, we sought to evaluate whether elevations in these PBMC subpopulations in RA patients could denote those with an increased risk of subclinical CAD, as determined by the presence of coronary artery calcification (CAC). METHODS The study cohort comprised 72 patients with RA who underwent cardiac computed tomography to assess CAC. PBMC subsets were determined by multiparameter flow cytometry. Multivariable logistic regression was used to determine the associations between PBMC subpopulations and the presence of CAC. RESULTS Among the 72 patients with RA, 33% had CAC and exhibited significant increases in the levels of circulating CD4 T cell subsets denoting activation and differentiation to the effector memory phenotypes. Analogous increases in the levels of CD8 T cell subsets, as well as in the CD14(high)CD16+ intermediate monocyte subset, were also present in these patients, as compared to those without CAC. The increases in the CD4 and CD8 T cell subsets were highly intercorrelated, whereas the increases in CD14(high)CD16+ monocytes were independent of elevations in the CD4 T cell subsets. After adjustments for relevant confounders, the levels of CD4+CD56+CD57+ T cells and CD14(high)CD16+ monocytes remained associated with the presence of CAC. CONCLUSION These findings indicate that PBMC subsets are markers for the presence of CAC and suggest that mechanisms of atherogenesis in RA may operate in part through the elevations in these subsets, raising further questions about the mechanisms underlying the presence of such alterations in cell composition in patients with RA and the potential for shared etiologic pathways between RA and cardiovascular disease.
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Affiliation(s)
- Robert Winchester
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Jon T Giles
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Simona Nativ
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Kendall Downer
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Hui-Zhu Zhang
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Ayse Bag-Ozbek
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Afshin Zartoshti
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Sabahat Bokhari
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Joan M Bathon
- Columbia University College of Physicians and Surgeons, New York, New York
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Lai CH, Lai WW, Chiou MJ, Lin WC, Yang YJ, Li CY, Tsai LM. Outcomes of percutaneous coronary intervention in patients with rheumatoid arthritis and systemic lupus erythematosus: an 11-year nationwide cohort study. Ann Rheum Dis 2015; 75:1350-6. [DOI: 10.1136/annrheumdis-2015-207719] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/30/2015] [Indexed: 12/17/2022]
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25
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The story of CD4+ CD28- T cells revisited: solved or still ongoing? J Immunol Res 2015; 2015:348746. [PMID: 25834833 PMCID: PMC4365319 DOI: 10.1155/2015/348746] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/10/2015] [Accepted: 02/19/2015] [Indexed: 02/07/2023] Open
Abstract
CD4+CD28− T cells are a unique type of proinflammatory T cells characterised by blockade of costimulatory CD28 receptor expression at the transcriptional level, which is still reversible by IL-12. In healthy individuals older than 65 years, these cells may accumulate to up to 50% of total CD4+ T lymphocytes as in many immune-mediated diseases, immunodeficiency, and specific infectious diseases. Here we focus on CD4+CD28− T cells in chronic immune-mediated diseases, summarizing various phenotypic and functional characteristics, which vary depending on the underlying disease, disease activity, and concurrent treatment. CD4+CD28− T cells present as effector/memory cells with increased replicative history and oligoclonality but reduced apoptosis. As an alternative costimulatory signal instead of CD28, not only natural killer cell receptors and Toll-like receptors, but also CD47, CTLA-4, OX40, and 4-1BB have to be considered. The proinflammatory and cytotoxic capacities of these cells indicate an involvement in progression and maintenance of chronic immune-mediated disease. So far it has been shown that treatment with TNF-α blockers, abatacept, statins, and polyclonal antilymphocyte globulins (ATG) mediates reduction of the CD4+CD28− T cell level. The clinical relevance of targeting CD4+CD28− T cells as a therapeutic option has not been examined so far.
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26
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Effectiveness of methotrexate therapy with occasional corticosteroid in rheumatoid arthritis. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Arthritis Robustus: review of a case of an “abnormal” rheumatoid. SPRINGERPLUS 2014; 3:606. [PMID: 25392778 PMCID: PMC4203790 DOI: 10.1186/2193-1801-3-606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 11/23/2022]
Abstract
Introduction Incidental discovery or diagnosis of Rheumatoid Arthritis where the patient remains blissfully unaware of his affection is a rare occurrence. Case description We present the case of a telephone wireman in whom Rheumatoid Arthritis neither affected his activities of daily living nor caused any deformity to develop. It remained asymptomatic till its incidental discovery during his admission for treatment of myocardial infarction. Discussion and Evaluation This presentation of Rheumatoid Arthritis is termed ‘Arthritis Robustus’ and goes against the very tenets of the picture of Rheumatoid Arthritis we have in our minds. The name given to this entity stems from the fact that these patients are mostly physical labourers i.e. ‘Robust’. Conclusion Rheumatoid Arthritis can very rarely be asymptomatic. The rarity of the entity can be inferred from the paucity of published literature.
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Patel S, Sharma S, Devgarha S, Mathur RM. Complete coronary arterialization in patient of rheumatoid arthritis with fixed deformity of bilateral hips, knees, and kyphosis. Indian J Thorac Cardiovasc Surg 2014. [DOI: 10.1007/s12055-014-0338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Staniak HL, Bittencourt MS, de Souza Santos I, Sharovsky R, Sabbag C, Goulart AC, Lotufo PA, Benseñor IM. Association between psoriasis and coronary calcium score. Atherosclerosis 2014; 237:847-52. [PMID: 25463132 DOI: 10.1016/j.atherosclerosis.2014.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/17/2014] [Accepted: 11/03/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Emerging data suggests that chronic inflammatory disease, such as psoriasis, may be associated to coronary artery disease (CAD). OBJECTIVE Analyze the association between psoriasis and subclinical atherosclerosis using coronary calcium score (CAC). METHODS We investigated 221 participants with psoriasis and 718 age- and sex-matched controls without prior known CAD. All participants completed a questionnaire and underwent laboratory tests and a CAC exam. Logistic regression models adjusted for Framingham risk score (FRS) and C-reactive protein (hs-CRP) were built. CAC was included in the models as a binary variable with different cut off values. RESULTS Body-mass index, race, hypertension, HDL, LDL and hs-CRP were significantly associated with psoriasis presence and severity. Psoriasis severity was significantly associated with CAC (p = 0.04), particularly for very high CAC (>400) (p < 0.01). The OR for severe psoriasis and CAC >400 was 2.45 (95%CI: 1.26-4.75) in unadjusted models. In a model adjusted for the FRS, this association was no longer significant, but a trend was noted (p = 0.09). No significant changes in the association were noted after the inclusion of hs-CRP in the model. CONCLUSION Psoriasis is associated with higher CAC values, mainly in individuals with severe psoriasis. The current findings also suggest the potential involvement of other mechanisms beyond classical cardiovascular risk factors and inflammation in this association.
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Affiliation(s)
- Henrique L Staniak
- Division of Internal Medicine, Hospital Universitário, University of São Paulo, Brazil; Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Márcio Sommer Bittencourt
- Division of Internal Medicine, Hospital Universitário, University of São Paulo, Brazil; Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Itamar de Souza Santos
- Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Rodolfo Sharovsky
- Division of Internal Medicine, Hospital Universitário, University of São Paulo, Brazil; Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Cid Sabbag
- Postgraduate Student, University of São Paulo, Brazil
| | - Alessandra C Goulart
- Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Paulo A Lotufo
- Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil
| | - Isabela M Benseñor
- Center for Clinical and Epidemiologic Research, Hospital Universitário, University of São Paulo, Brazil.
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Conventional risk factors and cardiovascular outcomes of patients with inflammatory bowel disease with confirmed coronary artery disease. Inflamm Bowel Dis 2014; 20:1593-601. [PMID: 25105946 DOI: 10.1097/mib.0000000000000109] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Inflammation is increasingly being recognized as an important factor in the pathogenesis of atherosclerosis and outcome of percutaneous coronary intervention (PCI). The purpose of this study was to compare conventional risk factors and PCI outcomes in patients with inflammatory bowel disease (IBD) and non-IBD controls with angiographically proven coronary artery disease (CAD). METHODS We performed a historical cohort study of patients with IBD who were diagnosed with CAD by cardiac catheterization between January 2004 and June 2010. Four non-IBD controls with CAD were matched to each IBD case. Framingham risk score and corresponding 10-year coronary heart disease risk were calculated for all the patients. Outcomes were obtained using a prospectively maintained Institutional Interventional Catheterization Database. RESULTS One hundred thirty-one patients with IBD (54 Crohn's disease, 77 ulcerative colitis) with CAD and 524 matched non-IBD controls with CAD were included. Patients with IBD were younger (65.3 ± 10.0 versus 67.8 ± 11.0 yr, P = 0.016), had lower prevalence of active tobacco use (10.7% versus 18.7%, P = 0.03), and had lower body mass index (28.0 ± 5.1 versus 29.4 ± 6.4, P = 0.026) compared with controls. Patients with IBD had lower rates of severe left anterior descending artery disease (56% versus 73%, P < 0.0002) and multivessel CAD (71% versus 79%, P = 0.05). There was no difference in post-PCI major adverse cardiovascular outcomes (defined as all-cause death, myocardial infarction, cerebrovascular events, and target lesion revascularization). CONCLUSIONS Patients with IBD are diagnosed with CAD at a younger age as compared with non-IBD patients, are less likely to be active smokers and have lower body mass index. Post-PCI outcomes in patients with IBD with CAD are similar to non-IBD controls with CAD.
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Ischemic heart disease in systemic inflammatory diseases. An appraisal. Int J Cardiol 2013; 170:286-90. [PMID: 24331863 DOI: 10.1016/j.ijcard.2013.11.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 11/17/2013] [Indexed: 02/07/2023]
Abstract
Systemic inflammatory diseases are inflammatory syndromes that are associated with increased cardiovascular morbidity and mortality. The link between inflammatory and cardiovascular diseases can be attributed to coexistence of classical risk factors and of inflammatory mechanisms activated in systemic inflammatory diseases and involving the immune system. Yet, clinical implications of these findings are not entirely clear and deeper knowledge and awareness of cardiac involvement in inflammatory diseases are necessary. The aims of this review are to summarize cardiac involvement in systemic inflammatory diseases and to identify areas where evidence is currently lacking that deserve further investigation in the future.
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Betjes MGH, Weimar W, Litjens NHR. Circulating CD4(+)CD28null T Cells May Increase the Risk of an Atherosclerotic Vascular Event Shortly after Kidney Transplantation. J Transplant 2013; 2013:841430. [PMID: 24288592 PMCID: PMC3830856 DOI: 10.1155/2013/841430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/29/2013] [Indexed: 12/14/2022] Open
Abstract
Proinflammatory CD4(+) T cells without the costimulatory molecule CD28 (CD4(+)CD28null T cells) are expanded in patients with end-stage renal disease (ESRD) and associated with atherosclerotic vascular events (AVE). In a prospective study, the number of circulating CD4(+)CD28null T cells was established in 295 ESRD patients prior to receiving a kidney allograft. Within the first year after transplantation, an AVE occurred in 20 patients. Univariate analysis showed that besides a history of cardiovascular disease (CVDpos, HR 8.1, P < 0.001), age (HR 1.04, P = 0.02), dyslipidaemia (HR 8.8, P = 0.004), and the % of CD4(+)CD28null T cells (HR 1.04 per % increase, 95% CI 1.00-1.09, P = 0.01) were significantly associated with the occurrence of a posttransplantation AVE. In a multivariate analysis, only CVDpos remained a significant risk factor with a significant and positive interaction between the terms CVDpos and the % of CD4(+)CD28null T cells (HR 1.05, 95% CI 1.03-1.11, P < 0.001). Within the CVDpos group, the incidence of an AVE was 13% in the lowest tertile compared to 25% in the highest tertile of % of CD4(+)CD28null T cells. In conclusion, the presence of circulating CD4(+)CD28null T cells is associated with an increased risk for a cardiovascular event shortly after kidney transplantation.
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Affiliation(s)
- Michiel G. H. Betjes
- Erasmus Medical Center, Department of Internal Medicine, Division of Nephrology & Transplantation, D414, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Willem Weimar
- Erasmus Medical Center, Department of Internal Medicine, Division of Nephrology & Transplantation, D414, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Nicolle H. R. Litjens
- Erasmus Medical Center, Department of Internal Medicine, Division of Nephrology & Transplantation, D414, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Karpouzas GA, Malpeso J, Choi TY, Li D, Munoz S, Budoff MJ. Prevalence, extent and composition of coronary plaque in patients with rheumatoid arthritis without symptoms or prior diagnosis of coronary artery disease. Ann Rheum Dis 2013; 73:1797-804. [DOI: 10.1136/annrheumdis-2013-203617] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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CD4⁺CD28⁻ lymphocytes and cerebral ischaemic stroke. Part II: CD4⁺CD28⁻ lymphocytes and carotid artery atherosclerotic plaque characteristics. Neurol Neurochir Pol 2013; 47:208-13. [PMID: 23821417 DOI: 10.5114/ninp.2013.35574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE CD4⁺CD28⁻ lymphocytes can directly contribute to the instability of atherosclerotic plaque. This paper attempts to answer the question of the potential influence of the CD4⁺CD28⁻ lymphocyte population on the ultrasound image of atherosclerotic plaque in the common carotid artery (CCA) wall. MATERIAL AND METHODS The study involved a group of 109 patients, aged 45 to 65 years, including 42 patients with first ever ischaemic stroke, experiencing symptoms resulting from disturbances of the anterior area of cerebral circulation, arterial hypertension and/or type 2 diabetes mellitus (group 1). Group 2 consisted of 34 patients with mentioned risk factors, without ischaemic stroke. The control group comprised 33 heal-thy individuals. The percentage of CD4⁺CD28⁻ lymphocytes was assessed with flow cytometry. RESULTS A significant difference in the incidence of heterogeneous plaques was noted between groups 1 and 3 (p = 0.0023) as well as between group 2 and 3 (p = 0.0005), whereas groups 1 and 2 did not differ from each other. The proportion of CD4⁺CD28⁻ lymphocytes was similar in groups 1 and 2 (p = 0.97), but it differed between groups 1 and 3 (p < 0.0001) and between groups 2 and 3 (p < 0.001). A correlation was found between the proportion of CD4⁺CD28⁻ lymphocytes in the blood and the number of CCA atherosclerotic plaques (Rs = 0.191, p = 0.046). The proportion of CD4⁺CD28⁻ lymphocytes in peripheral blood did not correlate with the ultrasound types of atherosclerotic plaques. No correlation between the proportion of CD4⁺CD28 ⁻lymphocytes and the area of atherosclerotic plaques was found. CONCLUSIONS The correlation between the proportion of CD4⁺CD28⁻ lymphocytes and the number of atherosclerotic plaques within the CCA suggests that the cells are involved in the mechanism of carotid plaque formation. There is no proof of the involvement of the above-mentioned cells in the mechanism of plaque destabilization in those arteries.
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Sharma A, Gopalakrishnan D, Kumar R, Vijayvergiya R, Dogra S. Metabolic syndrome in psoriatic arthritis patients: a cross-sectional study. Int J Rheum Dis 2013; 16:667-73. [PMID: 24382278 DOI: 10.1111/1756-185x.12134] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The major objective of our study was to assess the prevalence of metabolic syndrome in Indian patients with psoriatic arthritis. METHOD This was a one-time survey involving no follow-up. The study was performed among outpatients attending the speciality clinics of an institutional tertiary referral centre. A consecutive sample of 100 patients diagnosed as having psoriatic arthritis in our clinics was included in the study. Height, weight, body mass index, blood pressure and waist circumference of patients were measured at the enrolment visit. Venous samples were taken after 8 h of overnight fasting for the estimation of serum cholesterol, triglycerides and plasma glucose levels. The primary study outcome was the prevalence of metabolic syndrome in the study population. RESULTS Fifty-eight and 59 patients had metabolic syndrome according to the Adult Treatment Panel III criteria and the consensus definition of metabolic syndrome for adult Asian patients, respectively. Patients with metabolic syndrome were older (P < 0.001), with longer duration of psoriasis (P = 0.017), and higher Bath Ankylosing Spondylitis Activity Index (P = 0.016) than those without metabolic syndrome. CONCLUSIONS Metabolic syndrome is common in Asian Indian patients with psoriatic arthritis, especially in those with long-standing psoriasis and active joint disease.
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Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Arnab B, Biswadip G, Arindam P, Shyamash M, Anirban G, Rajan P. Anti-CCP antibody in patients with established rheumatoid arthritis: Does it predict adverse cardiovascular profile? J Cardiovasc Dis Res 2013; 4:102-6. [PMID: 24027365 DOI: 10.1016/j.jcdr.2012.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 09/17/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is an independent risk factor for adverse cardiovascular (CV) events that accounts for a significant proportion of mortality among these patients. Anti-CCP antibodies are associated with higher frequency of extra-articular manifestations and poorer outcomes in RA. AIMS To determine the role of anti-cyclic citrullinated peptide (CCP) antibody as an independent risk factor for developing CV complications as documented by carotid intima medial thickness and abnormal echocardiography in established RA patients. MATERIALS AND METHODS Eighty patients of RA having disease duration of at least 3 years participated in this hospital-based, cross-sectional, and observational study. Forty patients were anti-CCP antibody positive. Patients of established RA having known CV risk factors, known heart disease, or family history of premature ischemic heart disease were excluded. RESULTS Anti-CCP positive group had early morning stiffness, tender and swollen joint count, and c-reactive protein (CRP) level significantly higher than those in anti-CCP negative group. Average intima-medial thicknesses of common carotid arteries were also significantly higher among anti-CCP positive group (P = 0.029) and were positively correlated with patients' age and disease duration. Lower left ventricular ejection fraction and left ventricular diastolic dysfunction were more commonly dispersed among the anti-CCP positive patients with P values of 0.01 and 0.034, respectively. Mild pericardial thickening was documented among 12.5% patients of anti-CCP positive group, while none of the anti-CCP negative patients had similar findings in echocardiography. CONCLUSION This study stressed on the important role of anti-CCP antibody in myocardial dysfunction due to inflammation in RA patients. Both atherosclerotic vascular involvement and cardiac abnormalities including pericardial, myocardial, and endocardial involvements were higher among anti-CCP positive RA patients. Hence, patients with high titer of anti-CCP antibody associated with prolonged disease duration and increased disease activity should be evaluated for CV morbidity more meticulously.
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Affiliation(s)
- Banerjee Arnab
- Department of Medicine, Medical College and Hospital, Kolkata 700 073, West Bengal, India
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Iafolla M. Rheumatoid arthritis and atypical cardiovascular disease: inflammation changing the clinical presentation. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2013; 59:505-509. [PMID: 23673587 PMCID: PMC3653654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Marco Iafolla
- Internal Medicine, University of Alberta, Edmonton, Canada.
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Singh HV, Shrivastava AK, Raizada A, Singh SK, Pandey A, Singh N, Yadav D, Sharma H. Atherogenic lipid profile and high sensitive C-reactive protein in patients with rheumatoid arthritis. Clin Biochem 2013; 46:1007-1012. [PMID: 23578742 DOI: 10.1016/j.clinbiochem.2013.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/06/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the lipid profile and high sensitive C-reactive protein (hs-CRP) levels in rheumatoid arthritis (RA) patients, and compare them with healthy controls, and also compare the different patterns of these parameters during active RA between male and female patients. DESIGN AND METHODS We studied 60 RA patients and 65 controls matched by age and sex. All cases were selected from the Rheumatology Department of a tertiary care hospital, Delhi, India and fulfilled the 1987 American College of Rheumatology revised criteria for RA. RESULTS We found that male RA patients had significantly higher levels of hs-CRP (p<0.001), low density lipoprotein cholesterol (LDL-C)/high density lipoprotein cholesterol (HDL-C) (p<0.001), total cholesterol (TC)/HDL-C (p<0.05), and lower level of HDL-C (p<0.01), than male controls. The mean levels of HDL-C and TC were high (p<0.05), and LDL-C, LDL-C/HDL-C (p<0.01), and hs-CRP (p<0.001) were low in healthy females as compared to female RA patients. Between RA patients, females had significantly high level of HDL-C (p<0.001), and low levels of TC/HDL-C and LDL-C/HDL-C (p<0.001) as compared to RA males. Mean levels of TC and HDL-C were higher in healthy females (p<0.05) and triglyceride (TG) was lower (p<0.05) than in healthy males. CONCLUSIONS Results demonstrate that the RA patients have high levels of inflammatory marker hs-CRP and altered lipid profile, and these are affected by the gender of the RA patients. Lipid levels should be monitored and managed in patients with RA to minimize the long-term risk of cardiovascular disease.
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Affiliation(s)
- Harsh Vardhan Singh
- Biochemist, Department of Pathology, Hindu Rao Hospital, Delhi 110007, India
| | - Amit Kumar Shrivastava
- Department of Biochemistry, Sudha Rustagi College of Dental Sciences & Research, Faridabad 121001, India.
| | - Arun Raizada
- Department of Pathology and Laboratory Medicine, Medanta-The Medicity, Gurgaon 122001, India
| | | | - Aparna Pandey
- Department of Biochemistry, Narsinhbhai Patel Dental College and Hospital, Visnagar 384315, India
| | - Neelima Singh
- Department of Biochemistry, G. R. Medical College, Gwalior 474009, India
| | - Devendra Yadav
- Department of Pathology and Laboratory Medicine, Medanta-The Medicity, Gurgaon 122001, India
| | - Hemant Sharma
- Department of Rheumatology, Hindu Rao Hospital, Delhi 110007, India
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Lan MY, Chang YY, Chen WH, Tseng YL, Lin HS, Lai SL, Liu JS. Association between MIF gene polymorphisms and carotid artery atherosclerosis. Biochem Biophys Res Commun 2013; 435:319-22. [PMID: 23537651 DOI: 10.1016/j.bbrc.2013.02.129] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/23/2013] [Indexed: 01/08/2023]
Abstract
Atherosclerosis is a chronic inflammatory disorder. Macrophage migration inhibitory factor (MIF) is a potent cytokine that plays an important role in the regulation of immune responses. Polymorphisms including five- to eight-repeat CATT variants ((CATT)(5-8)) and G-173C in the promoter region of the MIF gene are associated with altered levels of MIF gene transcription. The purpose of the study is to investigate the relationship between promoter polymorphisms of the MIF gene and the severity of carotid artery atherosclerosis (CAA). The severity of CAA was assessed in 593 individuals with a history of ischemic stroke by using sonographic examination, and the MIF promoter polymorphisms of these individuals were genotyped. The carriage of (CATT)7 (compared to genotypes composed of (CATT)5, (CATT)6, or both), carriage of C allele (compared to GG), and carriage of the haplotype (CATT)7-C (compared to genotypes composed of (CATT)5-G, (CATT)6-G, or both) were significantly associated with an increase in the severity of CAA. We conclude that polymorphisms in the MIF gene promoter are associated with CAA severity in ischemic stroke patients. These genetic variants may serve as markers for individual susceptibility to CAA.
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Affiliation(s)
- Min-Yu Lan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosong, Kaohsiung 833, Taiwan
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Szabo SM, Levy AR, Rao SR, Kirbach SE, Lacaille D, Cifaldi M, Maksymowych WP. Increased risk of cardiovascular and cerebrovascular diseases in individuals with ankylosing spondylitis: a population-based study. ACTA ACUST UNITED AC 2013; 63:3294-304. [PMID: 21834064 DOI: 10.1002/art.30581] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To estimate the excess risk of cardiovascular and cerebrovascular diseases among individuals with ankylosing spondylitis (AS) in Quebec compared with the general population of Quebec. METHODS A retrospective cohort study was conducted using population-based administrative data from Quebec. The cohort included all adult individuals with at least 1 AS diagnosis on physician billing or hospital discharge records between 1996 and 2006. A comparison cohort was generated using a 1% random sample of individuals without AS. Cardiovascular and cerebrovascular diseases, and associated hospitalizations, were classified into 1 of 6 subcategories: congestive heart failure, valvular (aortic or nonaortic) heart disease, ischemic heart disease, cerebrovascular disease, or "other" cardiovascular disease. The age- and sex-stratified prevalence estimates, and standardized prevalence ratios, of cardiovascular or cerebrovascular disease in patients with AS, compared to that in the general population, were calculated. RESULTS The AS cohort included 8,616 individuals diagnosed over the period 1996-2006. The prevalence of cardiovascular and cerebrovascular diseases increased with increasing age for all cardiovascular disease subgroups, and was similar for individuals of both sexes. Age- and sex-stratified prevalence ratios were highest in younger individuals with AS. The age- and sex-standardized prevalence ratios comparing the risk among those with AS to the risk in the general population were as follows: for aortic valvular heart disease 1.58 (95% confidence interval [95% CI] 1.31-1.91), for nonaortic valvular heart disease 1.58 (95% CI 1.43-1.74), for ischemic heart disease 1.37 (95% CI 1.31-1.44), for congestive heart failure 1.34 (95% CI 1.26-1.42), for "other" cardiovascular disease 1.36 (95% CI 1.29-1.44), for cerebrovascular disease 1.25 (95% CI 1.15-1.35), and for any hospitalization for a cardiovascular or cerebrovascular disease 1.31 (95% CI 1.22-1.41). CONCLUSION Compared with the general population, patients with AS are at increased risk for many types of cardiovascular and cerebrovascular diseases, and are more likely to be hospitalized for these diseases. The excess risk is greatest in younger patients with AS.
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Profumo E, Buttari B, Saso L, Capoano R, Salvati B, Riganò R. T lymphocyte autoreactivity in inflammatory mechanisms regulating atherosclerosis. ScientificWorldJournal 2012; 2012:157534. [PMID: 23304078 PMCID: PMC3529860 DOI: 10.1100/2012/157534] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 11/22/2012] [Indexed: 02/06/2023] Open
Abstract
Atherosclerosis has been clearly demonstrated to be a chronic inflammatory disease of the arterial wall. Both cells of the innate and the acquired immune system, particularly monocytes and T lymphocytes, are implicated in the atherogenic process, producing different cytokines with pro- and anti-inflammatory effects. The majority of pathogenic T cells involved in atherosclerosis are of the Th1 profile, that has been correlated positively with coronary artery disease. Many studies conducted to evaluate the molecular factors responsible for the activation of T cells have demonstrated that the main antigenic targets in atherosclerosis are modified endogenous structures. These self-molecules activate autoimmune reactions mainly characterized by the production of Th1 cytokines, thus sustaining the inflammatory mechanisms involved in endothelial dysfunction and plaque development. In this paper we will summarize the different T-cell subsets involved in atherosclerosis and the best characterized autoantigens involved in cardiovascular inflammation.
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Affiliation(s)
- Elisabetta Profumo
- Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità, viale Regina Elena 299, 00161 Rome, Italy
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Gandhi S, Narula N, Marshall JK, Farkouh M. Are patients with inflammatory bowel disease at increased risk of coronary artery disease? Am J Med 2012; 125:956-62. [PMID: 22840916 DOI: 10.1016/j.amjmed.2012.03.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/07/2012] [Accepted: 03/07/2012] [Indexed: 02/06/2023]
Abstract
The inflammatory state of atherosclerosis has been established as those with chronic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus, who are at increased risk of coronary artery disease. A systematic search was conducted to retrieve high-quality, peer-reviewed studies of inflammatory bowel disease and coronary artery disease. Recent literature supports an association between inflammatory bowel disease and coronary artery disease. While hypertension increases the risk of coronary artery disease in inflammatory bowel disease patients, other typical risk factors have not been confirmed, and markers of inflammation may predict coronary artery disease risk in this population. Common cardiovascular drugs such as statins and angiotensin-converting enzyme inhibitors may have dual potential for controlling inflammatory bowel disease and preventing or treating coronary artery disease. Large, prospective, longitudinal studies can help to determine the true prevalence of coronary artery disease in this population and confirm risk factors. In the absence of such evidence, physicians should be cognizant of increased coronary artery disease risk in inflammatory bowel disease patients without traditional risk factors and consider primary preventive strategies.
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Affiliation(s)
- Sumeet Gandhi
- Department of Medicine, University of Toronto, Ontario, Canada
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Szwebel TA, Le Jeunne C. Risques cardiovasculaires d’une corticothérapie. Presse Med 2012; 41:384-92. [DOI: 10.1016/j.lpm.2012.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 01/04/2012] [Accepted: 01/09/2012] [Indexed: 11/15/2022] Open
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Apoptotic effects of antilymphocyte globulins on human pro-inflammatory CD4+CD28- T-cells. PLoS One 2012; 7:e33939. [PMID: 22479483 PMCID: PMC3316508 DOI: 10.1371/journal.pone.0033939] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 02/23/2012] [Indexed: 12/22/2022] Open
Abstract
Background Pro-inflammatory, cytotoxic CD4+CD28− T-cells with known defects in apoptosis have been investigated as markers of premature immuno-senescence in various immune-mediated diseases. In this study we evaluated the influence of polyclonal antilymphocyte globulins (ATG-Fresenius, ATG-F) on CD4+CD28− T-cells in vivo and in vitro. Principal Findings Surface and intracellular three colour fluorescence activated cell sorting analyses of peripheral blood mononuclear cells from 16 consecutive transplant recipients and short-term cell lines were performed. In vivo, peripheral levels of CD3+CD4+CD28− T-cells decreased from 3.7±7.1% before to 0±0% six hours after ATG-F application (P = 0.043) in 5 ATG-F treated but not in 11 control patients (2.9±2.9% vs. 3.9±3.0%). In vitro, ATG-F induced apoptosis even in CD4+CD28− T-cells, which was 4.3-times higher than in CD4+CD28+ T-cells. ATG-F evoked apoptosis was partially reversed by the broad-spectrum caspase inhibitor benzyloxycarbonyl (Cbz)-Val-Ala-Asp(OMe)-fluoromethylketone (zVAD-fmk) and prednisolon-21-hydrogensuccinate. ATG-F triggered CD25 expression and production of pro-inflammatory cytokines, and induced down-regulation of the type 1 chemokine receptors CXCR-3, CCR-5, CX3CR-1 and the central memory adhesion molecule CD62L predominately in CD4+CD28− T-cells. Conclusion In summary, in vivo depletion of peripheral CD3+CD4+CD28− T-cells by ATG-F in transplant recipients was paralleled in vitro by ATG-F induced apoptosis. CD25 expression and chemokine receptor down-regulation in CD4+CD28− T-cells only partly explain the underlying mechanism.
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Abstract
Cardiovascular disease represents a major source of extra-articular comorbidity in patients with rheumatoid arthritis (RA). A combination of traditional cardiovascular risk factors and RA-related factors accounts for the excess risk in RA. Among RA-related factors, chronic systemic inflammation has been implicated in the pathogenesis and progression of atherosclerosis. A growing body of evidence--mainly derived from observational databases and registries--suggests that specific RA therapies, including methotrexate and anti-TNF biologic agents, can reduce the risk of future cardiovascular events in patients with RA. The cardiovascular profile of other biologic therapies for the treatment of RA has not been adequately studied, including of investigational drugs that improve systemic inflammation but alter traditional cardiovascular risk factors. In the absence of large clinical trials adequately powered to detect differences in cardiovascular events between biologic drugs in RA, deriving firm conclusions on cardiovascular safety is challenging. Nevertheless, observational research using large registries has emerged as a promising approach to study the cardiovascular risk of emerging RA biologic therapies.
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Ketelhuth DFJ, Hansson GK. Cellular immunity, low-density lipoprotein and atherosclerosis: break of tolerance in the artery wall. Thromb Haemost 2011; 106:779-86. [PMID: 21979058 DOI: 10.1160/th11-05-0321] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 09/06/2011] [Indexed: 01/11/2023]
Abstract
Atherosclerosis is a chronic inflammatory disease. Atherosclerotic plaques contain abundant immune cells that can dictate and effect inflammatory responses. Among them, T cells are present during all stages of the disease suggesting that they are essential in the initiation as well as the progression of plaque. Experimental as well as clinical research has demonstrated different T cell subsets, i.e. CD4+ Th1, Th2, Th17, and Treg as well as CD8+ and NKT cells in the plaque. Moreover, candidate antigens inducing T cell responses have been identified. Knowledge about the pathological role of these cells in atherogenesis may lead to development of new therapies. This review provides an overview of the research field of cellular immunity in atherosclerosis. It emphasises the events and findings involving antigen specific T cells, in particular low-density lipoprotein-specific T cells.
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Affiliation(s)
- D F J Ketelhuth
- Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
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Daïen CI, Fesler P. [Rheumatoid arthritis: a cardiovascular disease?]. Ann Cardiol Angeiol (Paris) 2011; 61:111-7. [PMID: 21885031 DOI: 10.1016/j.ancard.2011.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 07/24/2011] [Indexed: 11/20/2022]
Abstract
Mortality in rheumatoid arthritis (RA) is doubled when compared to the general population. This excess in mortality can be explained in half of cases by cardiovascular (CV) events. The risk of myocardial infarction is increased by about 60% in RA. Mortality secondary to cerebrovascular stroke is increased by 50% even if the incidence of stroke is not increased. Indeed, the risk of fatal CV events is increased in RA when compared to the general population. The increased CV risk cannot be explained only by traditional CV risk factors, even if smoking and changes in lipid profile may be implied. It is mainly related to the chronic inflammatory condition that causes many metabolic disturbances. Other parameters such as treatments used in RA also play a role. Thus, it is essential for proper management of RA patients to be aware of this risk and to treat any modifiable CV risk factors.
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Affiliation(s)
- C I Daïen
- Service d'immuno-rhumatologie, CHU Lapeyronie, Montpellier, France
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Nagaraju K, Lundberg IE. Polymyositis and dermatomyositis: pathophysiology. Rheum Dis Clin North Am 2011; 37:159-71, v. [PMID: 21444017 DOI: 10.1016/j.rdc.2011.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Recent advances have increased the understanding of the pathogenesis of polymyositis and dermatomyositis. Clearly, the pathogenesis is complex, and adaptive (eg, autoimmune) and innate and nonimmune pathways play a role in the disease mechanisms, but the relative contribution may vary between patients and in different phases of the disease. Phenotyping patients using autoantibody profiling has resulted in information on molecular pathways that may be relevant in certain subsets of patients with polymyositis or dermatomyositis, but combining the autoantibody profiles with molecular signatures of innate and nonimmune mechanisms would enhance our ability to classify, diagnose, and treat these disorders more effectively.
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Affiliation(s)
- Kanneboyina Nagaraju
- Research Center for Genetic Medicine, Children's National Medical Center and Department of Integrative Systems Biology, The George Washington University Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA
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Marder W, Khalatbari S, Myles JD, Hench R, Yalavarthi S, Lustig S, Brook R, Kaplan MJ. Interleukin 17 as a novel predictor of vascular function in rheumatoid arthritis. Ann Rheum Dis 2011; 70:1550-5. [PMID: 21727237 DOI: 10.1136/ard.2010.148031] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is associated with enhanced cardiovascular (CV) risk and subclinical vascular disease. The proinflammatory milieu has been linked to premature atherosclerosis and endothelial dysfunction in RA. While interleukin 17 (IL-17) is considered pathogenic in RA, its role in determining vascular dysfunction in this disease has not been systematically assessed. OBJECTIVES To analyse candidate variables that might determine endothelial function in various vascular territories in a cohort of patients with RA receiving treatment with biological agents, with minimal traditional CV risk factors and low disease activity score. METHODS Patients with RA (n=50) receiving stable treatment with biological agents underwent measurement of conduit artery endothelial function by brachial artery flow-mediated dilatation; arterial compliance by pulse wave velocity (PWV) assessment; and endothelium-dependent microvascular testing with Endo-Pat2000 device to assess the reactive hyperaemia index (RHI). IL-17 was quantified by ELISA and disease activity was assessed by 28-joint count Disease Activity Score. RESULTS IL-17 was the main determinant of lower RHI in univariate and multivariate analysis. Traditional and non-traditional CV risk variables determined PWV, with a significant positive association with IL-17 in univariate and multivariate analysis. In contrast, conduit endothelial function was mainly determined by rheumatoid factor titres in univariate and multivariate analysis. Anti-cyclic citrullinated peptide titres, specific disease-modifying antirheumatic drugs or biological agents and disease activity did not determine vascular function. CONCLUSION In patients with RA treated with biological agents, IL-17 is a main predictor of microvascular function and arterial compliance. This study suggests that IL-17 may play a significant role in development of endothelial dysfunction and cardiovascular disease in RA.
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Affiliation(s)
- Wendy Marder
- University of Michigan Medical School, Ann Arbor, Michigan 48109, USA
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A comparative analysis of serological parameters and oxidative stress in osteoarthritis and rheumatoid arthritis. Rheumatol Int 2011; 32:2377-82. [DOI: 10.1007/s00296-011-1964-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 05/22/2011] [Indexed: 12/31/2022]
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