The inextricable link between atherosclerosis and prototypical inflammatory diseases rheumatoid arthritis and systemic lupus erythematosus

The Biological Parallels Between Atherosclerosis and Cardiac Allograft Vasculopathy: Implications for Solid Organ Chronic Rejection

Atherosclerosis and solid organ chronic rejection are pervasive chronic disease states that account for significant morbidity and mortality in developed countries. Recently, a series of shared molecular pathways have emerged, revealing biological parallels from early stages of development up to the advanced forms of pathology. These shared mechanistic processes are inflammatory in nature, reflecting the importance of inflammation in both disorders. Vascular inflammation triggers endothelial dysfunction and disease initiation through aberrant vasomotor control and shared patterns of endothelial activation. Endothelial dysfunction leads to the recruitment of immune cells and the perpetuation of the inflammatory response. This drives lesion formation through the release of key cytokines such as IFN-y, TNF-alpha, and IL-2. Continued interplay between the adaptive and innate immune response (represented by T lymphocytes and macrophages, respectively) promotes lesion instability and thrombotic complications; hallmarks of advanced disease in both atherosclerosis and solid organ chronic rejection. The aim of this study is to identify areas of overlap between atherosclerosis and chronic rejection. We then discuss new approaches to improve current understanding of the pathophysiology of both disorders, and eventually design novel therapeutics.

Atherosclerosis and Inflammation: Insights from the Theory of General Pathological Processes

Recent advances have greatly improved our understanding of the molecular mechanisms behind atherosclerosis pathogenesis. However, there is still a need to systematize this data from a general pathology perspective, particularly with regard to atherogenesis patterns in the context of both canonical and non-classical inflammation types. In this review, we analyze various typical phenomena and outcomes of cellular pro-inflammatory stress in atherosclerosis, as well as the role of endothelial dysfunction in local and systemic manifestations of low-grade inflammation. We also present the features of immune mechanisms in the development of productive inflammation in stable and unstable plaques, along with their similarities and differences compared to canonical inflammation. There are numerous factors that act as inducers of the inflammatory process in atherosclerosis, including vascular endothelium aging, metabolic dysfunctions, autoimmune, and in some cases, infectious damage factors. Life-critical complications of atherosclerosis, such as cardiogenic shock and severe strokes, are associated with the development of acute systemic hyperinflammation. Additionally, critical atherosclerotic ischemia of the lower extremities induces paracoagulation and the development of chronic systemic inflammation. Conversely, sepsis, other critical conditions, and severe systemic chronic diseases contribute to atherogenesis. In summary, atherosclerosis can be characterized as an independent form of inflammation, sharing similarities but also having fundamental differences from low-grade inflammation and various variants of canonical inflammation (classic vasculitis).

Association of endometriosis with cardiovascular disease: Genetic aspects (Review)

Cardiovascular disease (CVD) comprises a broad spectrum of pathological conditions that affect the heart or blood vessels, including sequelae that arise from damaged vasculature in other organs of the body, such as the brain, kidneys or eyes. Atherosclerosis is a chronic inflammatory disease of the arterial intima and is the primary cause of coronary artery disease, peripheral vascular disease, heart attack, stroke and renal pathology. It represents a leading cause of mortality worldwide and the loss of human productivity that is marked by an altered immune response. Endometriosis is a heritable, heterogeneous, common gynecological condition influenced by multiple genetic, epigenetic and environmental factors, affecting up to 10% of the female population of childbearing age, causing pain and infertility; it is characterized by the ectopic growth of endometrial tissue outside the uterine cavity. Of note, epidemiological data obtained thus far have suggested a link between endometriosis and the risk of developing CVD. The similarities observed in specific molecular and cellular pathways of endometriosis and CVD may be partially explained by a shared genetic background. The present review presents and discusses the shared genetic factors which have been reported to be associated with the development of both disorders.

Myocardial Involvement in Systemic Autoimmune Rheumatic Diseases

Systemic autoimmune rheumatic diseases (SARDs) are defined by the potential to affect multiple organ systems, and cardiac involvement is a prevalent but often overlooked sequela. Myocardial involvement in SARDs is medicated by macrovascular disease, microvascular dysfunction, and myocarditis. Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, eosinophilic granulomatosis with polyangiitis, and sarcoidosis are associated with the greatest risk of myocardial damage and heart failure, though myocardial involvement is also seen in other SARDs or their treatments. Management of myocardial involvement should be disease-specific. Further research is required to elucidate targetable mechanisms of myocardial involvement in SARDs.

Identification of hub genes and transcription factors in patients with rheumatoid arthritis complicated with atherosclerosis

The aim of this study was to explore the overlapping key genes, pathway networks and transcription factors (TFs) related to the pathogenesis of rheumatoid arthritis (RA) and atherosclerosis. The gene expression profiles of RA and atherosclerosis were downloaded from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) between RA and atherosclerosis were identified. The biological roles of common DEGs were explored through enrichment analysis. Hub genes were identified using protein–protein interaction networks. TFs were predicted using Transcriptional Regulatory Relationships Unraveled by Sentence Based Text Mining (TRRUST) database. The hub genes and TFs were validated with other datasets. The networks between TFs and hub genes were constructed by CytoScape software. A total of 131 DEGs (all upregulated) were identified. Functional enrichment analyses indicated that DEGs were mostly enriched in leukocyte migration, neutrophil activation, and phagocytosis. CytoScape demonstrated 12 hub genes and one gene cluster module. Four of the 12 hub genes (CSF1R, CD86, PTPRC, and CD53) were validated by other datasets. TRRUST predicted two TFs, including Spi-1 proto-oncogene (SPI1) and RUNX family transcription factor 1(RUNX1). The expression of RUNX1 was validated with another dataset. Our study explored the common pathogenesis of RA and atherosclerosis. These results may guide future experimental research and clinical transformation.

Autoimmune Rheumatic Diseases and Premature Atherosclerotic Cardiovascular Disease: An Analysis From the VITAL Registry

BACKGROUND

Although the association between autoimmune rheumatic diseases and atherosclerotic cardiovascular disease is well-known, there is a lack of data regarding the role of such disorders in patients with premature and extremely premature atherosclerotic cardiovascular disease.

METHODS

The Veterans With Premature Atherosclerosis (VITAL) registry, including patients with premature (males <55 years, females <65 years) and extremely premature atherosclerotic cardiovascular disease (<40 years), was created from the 2014-2015 nationwide Veterans Affairs (VA) health care system database. We assessed age at the time of first cardiovascular event to compare patients with premature (n = 135,703) and those with extremely premature atherosclerotic cardiovascular disease (n = 7716) with age-matched patients without atherosclerotic cardiovascular disease (n_young = 1,153,535, n_{extremely young} = 441,836). We assessed whether systemic lupus erythematosus, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis were independently associated with premature and extremely premature atherosclerotic cardiovascular disease.

RESULTS

Patients with premature and extremely premature atherosclerotic cardiovascular disease had a higher prevalence of all rheumatic diseases as compared with age-matched patients without atherosclerotic cardiovascular disease. In fully adjusted models, systemic lupus erythematosus (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.56-1.83) and rheumatoid arthritis (OR: 1.72, 95% CI: 1.63-1.81) were associated with increased odds of premature atherosclerotic cardiovascular disease. Patients with systemic lupus erythematosus (OR: 3.06, 95% CI: 2.38-3.93) and rheumatoid arthritis (OR: 2.39, 95% CI: 1.85-3.08) also had a higher likelihood of extremely premature atherosclerotic cardiovascular disease.

CONCLUSION

Patients with systemic lupus erythematosus and rheumatoid arthritis carry higher odds of both premature and extremely premature atherosclerotic cardiovascular disease. Future studies are needed to understand the rheumatic disease-specific factors behind the development and progression of clinical atherosclerotic cardiovascular disease in these young patients.

Premature Atherosclerotic Cardiovascular Disease: What Have We Learned Recently?

PURPOSE OF REVIEW

In contrast to patients with non-premature atherosclerotic cardiovascular disease (ASCVD), patients with premature ASCVD have not observed a similar decline in cardiovascular mortality and recurrent adverse events. We sought to review the underlying risk factors, potential gaps in medical management, associated outcomes, and tools for risk prognostication among patients with premature ASCVD.

RECENT FINDINGS

In addition to traditional cardiovascular risk factors (i.e., diabetes, familial hypercholesterolemia), non-traditional risk factors such as chronic inflammatory conditions, recreational drug use, genetics, and pregnancy-related complications play a key role in development and progression of premature ASCVD. Patients with premature ASCVD, and especially women, receive less optimal medical management as compared to their non-premature counterparts. There is an increasing prevalence of cardiovascular risk factors among young adults. Hence, this population remains at an elevated risk for premature ASCVD and subsequent adverse cardiovascular events. Future studies evaluating different risk assessment tools and focusing on young patients across all three major domains of ASCVD are needed.

High Expression Levels of the SOCS3 Gene Are Associated with Acute Myocardial Infarction

Aims: The present study was designed to evaluate whether the expression of the suppressor of cytokine signaling 3 (SOCS3) gene could serve as a biomarker to predict the risk of acute myocardial infarction (AMI). Basic Methods: Peripheral white blood cells were collected from 113 patients with AMI and 92 patients with stable coronary artery disease (SCAD). SOCS3 mRNA expression levels in peripheral blood cells were determined by a real-time quantitative polymerase chain reaction, and levels of the SOCS3 protein were determined by Western blotting. Results: The mRNA expression levels of the SOCS3 gene in AMI patients was 1.33-fold higher than that in the SCAD patients, and the level of the SOCS3 protein was 1.25-fold higher (p < 0.05 for both). Bivariate logistic regression analysis documented that elevated expression of the SOCS3 gene was an independent risk factor for AMI. A regression analysis demonstrated a lack of correlation between elevated expression levels of SOCS3 and the levels of fasting blood glucose high- and low-density lipoprotein, and cardiac troponin. Conclusions: Elevated expression of the SOCS3 gene results most likely from enhanced inflammatory responses and is an independent risk factor for AMI.

Phenotypic features of vascular calcification in chronic kidney disease

BACKGROUND

Patients with chronic kidney disease stage 5 (CKD5) are predisposed to vascular calcification (VC), but the combined effect of factors associated with VC was sparsely investigated. We applied the relaxed linear separability (RLS) feature selection model to identify features that concomitantly associate with VC in CKD5 patients.

METHODS

Epigastric arteries collected during surgery from living donor kidney transplant recipients were examined to score the histological extent of medial VC. Sixty-two phenotypic features in 152 patients were entered into RLS model to differentiate between no-minimal VC (n = 93; score 0-1) and moderate-extensive VC (n = 59; score 2-3). The subset of features associated with VC was selected on the basis of cross-validation procedure. The strength of association of the selected features with VC was expressed by the absolute value of 'RLS factor'.

RESULTS

Among 62 features, a subset of 17 features provided optimal prediction of VC with 89% of patients correctly classified into their groups. The 17 features included traditional risk factors (diabetes, age, cholesterol, BMI and male sex) and markers of bone metabolism, endothelial function, metabolites, serum antibodies and mitochondrial-derived peptide. Positive RLS factors range from 1.26 to 4.05 indicating features associated with increased risk of VC, and negative RLS factors range from -0.95 to -1.83 indicating features associated with reduced risk of VC.

CONCLUSION

The RLS model identified 17 features including novel biomarkers and traditional risk factors that together concomitantly associated with medial VC. These results may inform further investigations of factors promoting VC in CKD5 patients.

Approximate Mortality Risks between Hyperuricemia and Diabetes in the United States

Aim: This study aimed to compare mortality risks across uric acid (UA) levels between non-diabetes adults and participants with diabetes and to investigate the association between hyperuricemia and mortality risks in low-risk adults. Methods: We analyzed data from adults aged >18 years without coronary heart disease and chronic kidney disease (n = 29,226) from the National Health and Nutrition Examination Survey (1999–2010) and the associated mortality data (up to December 2011). We used the Cox proportional hazards models to examine the risk of all-cause and cause-specific (cardiovascular disease (CVD) and cancer) mortality at different UA levels between adults with and without diabetes. Results: Over a median follow-up of 6.6 years, 2069 participants died (495 from CVD and 520 from cancers). In non-diabetes adults at UA ≥ 5 mg/dL, all-cause and CVD mortality risks increased across higher UA levels (p-for-trend = 0.037 and 0.058, respectively). The lowest all-cause mortality risk in participants with diabetes was at the UA level of 5–7 mg/dL. We set the non-diabetes participants with UA levels of <7 mg/dL as a reference group. Without considering the effect of glycemic control, the all-cause mortality risk in non-diabetes participants with UA levels of ≥7 mg/dL was equivalent to risk among diabetes adults with UA levels of <7 mg/dL (hazard ratio = 1.44 vs. 1.57, p = 0.49). A similar result was shown in CVD mortality risk (hazard ratio = 1.80 vs. 2.06, p = 0.56). Conclusion: Hyperuricemia may be an indicator to manage multifaceted cardiovascular risk factors in low-risk adults without diabetes, but further studies and replication are warranted.

Expanded peripheral CD4+CD28null T cells and its association with atherosclerotic changes in patients with end stage renal disease on hemodialysis

End-stage renal disease (ESRD) patients, including those on hemodialysis, possess a high risk for cardiovascular diseases, as the first leading cause of death among them. Traditional risk factors do not utterly elucidate this. Throughout the last two decades, CD4⁺CD28^null T cells; an unusual subset of T lymphocytes, was detected high with excess cardiovascular (CV) mortality. We aimed to investigate the circulating CD4⁺CD28^null T cells frequency in ESRD patients on hemodialysis and to evaluate their relationship with atherosclerotic changes. High-resolution carotid ultrasonography was done to assess the common carotid artery intima media thickness in a number of ESRD patients, accordingly patients were selected and subdivided into two groups; 30 with atherosclerosis (mean [SD] age, 51.6 [6.3] years) and 30 without (mean [SD] age, 48.9 [5.5] years). Another 30 healthy individuals (mean [SD] age, 48.5 [6.8] years) were enrolled. Analysis of CD4⁺CD28^null T-cells frequency by flow-cytometry was performed in all studied subjects. CD4⁺CD28^null T cell percentage was significantly higher in ESRD patients, (mean [SD], 7.3 [2.7] %) compared to healthy individuals (mean [SD], 3.0 [0.8] %), (p < 0.001). Additionally, the expansion of these unusual T lymphocytes was significantly higher in ESRD patients with atherosclerotic changes (mean [SD], 9.47 [0.75] %) compared to those without atherosclerosis (mean [SD], 5.22 [2.14] %), (p < 0.001). In conclusion circulating CD4⁺CD28^null T lymphocyte population showed expansion in ESRD patients, and of interest in correlation to preclinical atherosclerotic changes.

Functional implications of single nucleotide polymorphisms rs662 and rs854860 on the antioxidative activity of paraoxonase1 (PON1) in patients with rheumatoid arthritis

BACKGROUND

Atherosclerosis leading to cardiovascular disease (CVD) is the main cause of mortality and morbidity in patients with rheumatoid arthritis (RA). Paraoxonase1 (PON1) is the best understood member of plasma paraoxonases with anti-atherogenic properties.

PATIENTS AND METHODS

Spanish RA (n = 549) consecutively recruited from 1 single center and 477 ethnically matched healthy controls were included in a case-control study. The concentration of PON1 was evaluated by means of an enzyme-linked immunosorbent sssay (ELISA). An arylesterase/paraoxonase assay kit was used to evaluate PON1 activity. Sample genotyping was performed by using TaqMan assays-on-demand. All results were expressed as medians ± interquartile range. One-way ANOVA comparisons were done using a nonparametric Kruskall-Wallis test. P values under 0.05 were considered to be significant.

RESULTS

The concentration of PON1 in the RA group was higher than in control group (p = 0.0003), although the differences were not significant when PON1 activities were compared between both groups. No significant differences were found related to distributions of rs662 genotypes in RA patients compared to healthy controls. Among rs854860 polymorphisms, overall genotype was widely distributed between RA patients and controls. Overall PON1 concentration in plasma was not significantly different between individuals carrying any of rs662 (p = 0.8501) or rs854860 (p = 0.2741) polymorphisms. Although PON1 levels were not associated with any of the SNPs in the study, differences appear when enzyme activities are compared for each SNP separately. CVD in RA patients correlate with increased PON1 levels and lower PON1 activity.

CONCLUSIONS

Although protective role of PON1 against oxidative damage in vivo could be related to other activities, in our study arylesterase activity was useful to identify phenotypic differences with emphasis placed on two SNPs coding for nonconservative amino acid changes in the functional protein.

Evaluation on the effect of hydrogen sulfide on the NLRP3 signaling pathway and its involvement in the pathogenesis of atherosclerosis

BACKGROUND

As a common disease, the incidence of atherosclerosis (AS) in the world is high. Therefore, we aimed to evaluate the involvement of hydrogen sulfide (H ₂ S)/cystathionine γ-lyase (CSE) in the pathogenesis of AS as well as their possible signaling pathways.

METHODS

Enzyme-linked immunosorbent assay, real-time polymerase chain reaction, and Western blot analysis were used to detect the effect of CSE on the expression of inflammatory cytokines, ie, H ₂ S, thioredoxin-interacting protein (TXNIP), NLRP3, apoptosis-associated speck-like protein (ASC), caspase-1, and interleukin (IL)-1β. In addition, immunohistochemistry and Western blot analysis were performed to detect the levels of TXNIP, NLRP3, ASC, caspase-1, IL-1β, and IL-18 among different groups.

RESULT

Knockdown of CSE by the transfection of CSE small interfering RNA upregulated the levels of two inflammatory cytokines, ie, IL-1β and IL-18. In addition, the downregulation of CSE promoted the expression of TXNIP, NLRP3, ASC, caspase-1, and IL-1β in THP-1 cells. Meanwhile, treating the cells with sodium hydrosulfide (NaHS) inhibited the productions of IL-1β and IL-18. Furthermore, upregulation of H ₂ S synthesis by treating the cells with NaHS also reduced the protein levels of TXNIP, NLRP3, ASC, caspase-1, and IL-1β. Finally, the protein levels of TXNIP and NLRP3 in the AS group were much higher than those in the AS + H ₂ S group, which in turn was higher than the sham group. In addition, the AS group displayed the highest protein levels of TXNIP, NLRP3, ASC, caspase-1, IL-1β, and IL-18, while the levels of these proteins in the AS + H ₂ S group were higher than those in the sham group.

CONCLUSION

In summary, the present finding suggested a possible linkage between H ₂ S metabolism and AS through the H ₂ S/CSE-TXNIP-NLRP3-IL-18/IL-1β-nitric oxide (NO) signaling pathway.

B-cell activating factor and related genetic variants in lupus related atherosclerosis

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease with an increased atherosclerotic risk compared to healthy population, partially explained by traditional cardiovascular (CV) risk factors. Recent data suggest B-cell activating factor (BAFF) as an important contributor in the pathogenesis of both SLE and atherosclerosis. The aim of the current study is to explore whether serum BAFF levels along with variants of the BAFF gene increase lupus related atherosclerotic risk.

PATIENTS-METHODS

250 SLE patients underwent assessment of plaque formation and/or intimal media thickness (IMT) measurements in carotid and femoral arteries by ultrasound. Disease related features and CV traditional risk factors were also assessed. Serum BAFF levels were determined by commercially available ELISA and five single nucleotide polymorphisms (SNPs) of the BAFF gene (rs1224141, rs12583006, rs9514828, rs1041569 and the rs9514827) were evaluated by PCR-based assays in all patients and 200 healthy controls (HC) of similar age and sex distribution. SLE patients were further divided in high and low BAFF groups on the basis of the upper quartile level of the distribution (1358 pg/ml). Genotype and haplotype frequencies in SLE patients and HC were determined by SNPStats and SHEsis software.

RESULTS

High-BAFF SLE group displayed increased rates of both plaque formation and arterial wall thickening (defined as IMT>0.90 mm) compared to patients with low BAFF levels (58.1% vs 43.6%, p:0.048 and 38.6% vs 23.2%, p-value: 0.024, respectively). The association remained significant after disease related features were taken into account (ORs [95%CI]: 2.2 [1.0-5.1] and 2.5 [1.1-5.5] for plaque formation and arterial wall thickening, respectively). Moreover, the presence of the AA genotype of the rs12583006 BAFF gene variant increased susceptibility for both lupus and lupus related plaque formation (ORs [95%CI]: 2.8 [1.1-7.1], and 4.4 [1.3-15.4] in the codominant model, respectively). Finally, the haplotype TTTAT was found to be protective for plaque formation among SLE patients (OR 0.3 [0.1-0.9]. No associations between BAFF gene variants with arterial wall thickening were detected.

CONCLUSIONS

High BAFF serum levels in the upper 4th quartile as well as BAFF genetic variants seem to increase susceptibility for both lupus and lupus related subclinical atherosclerosis implying B-cell hyperactivity as a potential contributor in the pronounced lupus related atherosclerotic risk.

Inflammation: A Novel Therapeutic Target/Direction in Atherosclerosis

Over the past two decades, the viewpoint of atherosclerosis has been replaced gradually by a lipid-driven, chronic, low-grade inflammatory disease of the arterial wall. Current treatment of atherosclerosis is focused on limiting its risk factors, such as hyperlipidemia or hypertension. However, treatment targeting the inflammatory nature of atherosclerosis is still very limited and deserves further attention to fight atherosclerosis successfully. Here, we review the current development of inflammation and atherosclerosis to discuss novel insights and potential targets in atherosclerosis, and to address drug discovery based on anti-inflammatory strategy in atherosclerotic disease.

Atherosclerosis as autoimmune disease

No attention is usually focused on the possible involvement of immune mechanisms, particularly of autoimmunity, on the development and progress of atherosclerosis. The pioneering work occurring almost 50 years ago was overlooked, and the idea of atherosclerosis as an autoimmune disease only started gaining traction about 10 years ago. Our review discusses the recent findings and offers insights into the possibility that alterations of the immune system play a significant role in the development of atherosclerosis.

Atherosclerotic Heart Disease in Women With Autoimmune Rheumatologic Inflammatory Conditions

Women have a higher prevalence of several inflammatory rheumatologic conditions. These include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc) to name a few. These conditions are all associated with higher rates of cardiovascular (CV) morbidity and mortality, which is driven primarily by atherosclerotic heart disease. Traditional risk factors are important considerations in the assessment of CV risk in the rheumatologic patient; however, these factors do not appear to impart a similar weight of risk in women with inflammatory autoimmune rheumatologic conditions. In addition, even when controlling for traditional risk factors, patients with RA or SLE continue to have a higher risk of CV events, which has been linked to the burden of systemic inflammation. Currently, the CV risk scoring systems available for the general population underestimate the burden of the problem in these complex patients. The increased CV risk in patients with rheumatologic diseases has been reported in the literature for years but remains underrecognized by internists and cardiologists. Although these conditions themselves are relatively rare, the further study of inflammation and its treatment in CV disease will be beneficial to the general population.

Assessment of cardiovascular risk profile based on measurement of tophus volume in patients with gout

Hyperuricemia and gout are associated with increased risk of cardiovascular disease and metabolic syndrome. The aim of this study was to evaluate the correlation of total tophus volumes, measured using dual-energy computed tomography, with cardiovascular risk and the presence of metabolic syndrome. Dual-energy computed tomography datasets from 91 patients with a diagnosis of gout were analyzed retrospectively. Patients who received urate lowering therapy were excluded to avoid the effect on tophus volume. The total volumes of tophaceous deposition were quantified using automated volume assessment software. The 10-year cardiovascular risk using the Framingham Risk Score and metabolic syndrome based on the Third Adult Treatment Panel criteria were estimated. Fifty-five and 36 patients with positive and negative dual-energy computed tomography results, respectively, were assessed. Patients with positive dual-energy computed tomography results showed significantly higher systolic blood pressure, diastolic blood pressure, fasting glucose, and higher prevalence of chronic kidney disease, compared with those with negative dual-energy computed tomography results. The total tophus volumes were significantly correlated with the Framingham Risk Score, and the number of metabolic syndrome components (r = 0.22 and p = 0.036 and r = 0.373 and p < 0.001, respectively). The total tophus volume was one of the independent prognostic factors for the Framingham Risk Score in a multivariate analysis. This study showed the correlation of total tophus volumes with cardiovascular risk and metabolic syndrome-related comorbidities. A high urate burden could affect unfavorable cardiovascular profiles.

Assessment of subclinical atherosclerosis in systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVES

To determine whether subclinical atherosclerosis is increased in patients with systemic lupus erythematosus (SLE) compared to healthy individuals, using carotid intima-media thickness (CIMT), carotid plaque (CP) presence or flow-mediated dilatation (FMD).

METHODS

A systematic literature search was performed using MedLine, Embase and Cochrane databases. Two reviewers independently screened the articles to identify studies that compared the rates of atherosclerosis in SLE patients versus healthy controls. The results were pooled in a meta-analysis. Factors influencing the CIMT, CP or FMD results were collected.

RESULTS

Of the 203 articles initially identified, 68 were selected for the meta-analysis. Compared to healthy controls, SLE patients had a significantly increased CIMT (mean difference [MD] of 0.08mm, 95% CI [0.06-0.09], P<0.05), more CP (odds ratio 2.01, 95% CI [1.63-2.47], P<0.05) and decreased FMD (MD -3.96%, 95% CI [-5.37 to -2.54)], P<0.05). There was marked heterogeneity among the studies. However, the results of the meta-analysis that included only the CIMT per new international recommendations also showed an increased CIMT in SLE patients, but the heterogeneity was low (MD 0.04mm, 95% CI [0.02-0.06], P<0.05; I²=23%).

CONCLUSION

SLE patients exhibit increased subclinical atherosclerosis compared to healthy controls. CIMT is a promising measure for cardiovascular risk evaluations because non-invasive, non-radiation-based, reproducible. Thus, CIMT can be proposed as an alternative to the reliable CP evaluation and to FMD, which is influenced by independent factors such as smoking. Future studies should focus on reducing the heterogeneity of these measures using standardized procedures.

Unmet Needs in the Pathogenesis and Treatment of Cardiovascular Comorbidities in Chronic Inflammatory Diseases

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.

Endothelial injury in rheumatoid arthritis: a crosstalk between dimethylarginines and systemic inflammation

Background

Symmetric (SDMA) and asymmetric (ADMA) dimethylarginines have emerged as novel biomarkers of cardiovascular disease (CVD) in several disease settings associated with atherosclerosis. Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterized by high CVD mortality and morbidity. ADMA and SDMA levels are abnormal in RA patients, but their correlation with assessments of endothelial function and structure remains unknown. We aimed to investigate whether SDMA and ADMA are associated with carotid intima media thickness (cIMT) and arterial stiffness as well as non-invasive assessments of in vivo micro- and macrovascular endothelial function in RA patients with high systemic inflammatory load.

Method

ADMA and SDMA levels were measured using immunoassays in 197 RA individuals. Twenty-six of these [23 (86.4%) females, median age 70, quartiles (60, 73)] were identified as having high inflammatory markers [erythrocyte sedimentation rate (ESR) >25 mm/hr and C-reactive protein (CRP) > 5 mg/L], and were compared to the remainder of the cohort. Patients underwent assessments of microvascular endothelium-dependent and endothelium-independent function [laser Doppler imaging with iontophoresis of acetylcholine (Ach) and sodium-nitroprusside (SNP) respectively], macrovascular endothelium-dependent and endothelium-independent function (flow-mediated dilatation and glyceryl-trinitrate-mediated dilation respectively), and vascular morphology [pulse wave analysis, and carotid intima media thickness (cIMT)].

Results

Significant interactions with inflammation were detected in the associations between ACh and both SDMA (p = 0.014) and ADMA:SDMA ratio (p = 0.027), as well as between SNP and SDMA (p = 0.042) and between arterial stiffness and ADMA:SDMA (p = 0.036), with the associations being stronger in the patients with high inflammatory markers in each case.

Conclusions

Besides their emerging role as markers of endothelial dysfunction SDMA and ADMA may promote endothelial injury in RA as mediators of the adverse effects of systemic inflammation on micro- and macrovasculature respectively in patients with active disease.

Prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis in Southern Brazil

OBJECTIVE

To estimate the prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis.

METHODS

A cross-sectional study using the American College of Rheumatology diagnostic criteria in order to select patients seen at primary or secondary health care units in Blumenau, Santa Catarina, Southern Brazil, in 2014. The presence of ischemic heart disease was defined as an acute myocardial infarction with percutaneous coronary intervention or coronary artery bypass graft surgery that has occurred after diagnosis. Fischer's exact test, Wald's linear trend test, and multivariate logistic regression analysis were used to test the associations.

RESULTS

Among 296 patients (83.1% female) with a mean age of 56.6 years and a mean rheumatoid arthritis duration of 11.3 years, 13 reported having acute myocardial infarction requiring a percutaneous or surgical reperfusion procedure, a prevalence of 4.4% (95% CI 2.0-6.7). Diabetes Mellitus (odds ratio [OR] 4.9 [95% CI 1.6-13.8]) and disease duration >10 years (OR 8.2 [95% CI 1.8-39.7]) were the only factors associated with an ischemic disease that remained in the final model, after the multivariate analysis.

CONCLUSION

The prevalence of acute myocardial infarction was similar to that observed in other studies. Among the traditional risk factors, Diabetes Mellitus, and among the factors related to rheumatoid arthritis, disease duration, were the variables associated with comorbidity.

Influence of coronary artery disease and subclinical atherosclerosis related polymorphisms on the risk of atherosclerosis in rheumatoid arthritis

A genetic component influences the development of atherosclerosis in the general population and also in rheumatoid arthritis (RA). However, genetic polymorphisms associated with atherosclerosis in the general population are not always involved in the development of cardiovascular disease (CVD) in RA. Accordingly, a study in North-American RA patients did not show the association reported in the general population of coronary artery disease with a series of relevant polymorphisms (TCF21, LPA, HHIPL1, RASD1-PEMT, MRPS6, CYP17A1-CNNM2-NT5C2, SMG6-SRR, PHACTR1, WDR12 and COL4A1-COL4A2). In the present study, we assessed the potential association of these polymorphisms with CVD in Southern European RA patients. We also assessed if polymorphisms implicated in the increased risk of subclinical atherosclerosis in non-rheumatic Caucasians (ZHX2, PINX1, SLC17A4, LRIG1 and LDLR) may influence the risk for CVD in RA. 2,609 Spanish patients were genotyped by TaqMan assays. Subclinical atherosclerosis was determined in 1,258 of them by carotid ultrasonography (assessment of carotid intima media thickness and presence/absence of carotid plaques). No statistically significant differences were found when each polymorphism was assessed according to the presence/absence of cardiovascular events and subclinical atherosclerosis, after adjustment for potential confounder factors. Our results do not show an association between these 15 polymorphisms and atherosclerosis in RA.

Endothelial progenitor cells: Are they displaying a function in autoimmune disorders?

Endothelial Progenitor Cells (EPCs) are bone marrow derived cells able to differentiate in mature endothelial cells (EC) contributing to the generation of new vessels, connecting to fibronectin, and forming colonies and/or colony forming units. Since circulating EPCs can be actively considered part of endothelial damage in several cardiovascular diseases and autoimmune disorders the possibility to have a measure for endothelium damage should be considered of interest to predict the patient out-come. At the same time the EPCs proliferative and regenerative role could be considered for therapeutic applications. Studies have been performed to elucidate the role of EPCs in Systemic Sclerosis and many review and articles published on this topic. In the present paper we aimed to review the role of EPCs in other autoimmune disorders.

LDLR and PCSK9 Are Associated with the Presence of Antiphospholipid Antibodies and the Development of Thrombosis in aPLA Carriers

Introduction

The identification of the genetic risk factors that could discriminate non- thrombotic from thrombotic antiphospholipid antibodies (aPLA) carriers will improve prognosis of these patients. Several human studies have shown the presence of aPLAs associated with atherosclerotic plaque, which is a known risk factor for thrombosis. Hence, in order to determine the implication of atherosclerosis in the risk of developing thrombosis in aPLA positive patients, we performed a genetic association study with 3 candidate genes, APOH, LDLR and PCSK9.

Material & Methods

For genetic association study we analyzed 190 aPLA carriers -100 with non-thrombotic events and 90 with thrombotic events- and 557 healthy controls. Analyses were performed by χ2 test and were corrected by false discovery rate. To evaluate the functional implication of the newly established susceptibility loci, we performed expression analyses in 86 aPLA carrier individuals (43 with thrombotic manifestations and 43 without it) and in 45 healthy controls.

Results

Our results revealed significant associations after correction in SNPs located in LDLR gene with aPLA carriers and thrombotic aPLA carriers, when compared with healthy controls. The most significant association in LDLR gene was found between SNP rs129083082 and aPLA carriers in recessive model (adjusted P-value = 2.55 x 10⁻³; OR = 2.18; 95%CI = 1.49–3.21). Furthermore, our work detected significant allelic association after correction between thrombotic aPLA carriers and healthy controls in SNP rs562556 located in PCSK9 gene (adjusted P-value = 1.03 x 10⁻²; OR = 1.60; 95%CI = 1.24–2.06). Expression level study showed significantly decreased expression level of LDLR gene in aPLA carriers (P-value <0.0001; 95%CI 0.16–2.10; SE 0.38–1.27) in comparison to the control group.

Discussion

Our work has identified LDLR gene as a new susceptibility gene associated with the development of thrombosis in aPLA carriers, describing for the first time the deregulation of LDLR expression in individuals with aPLAs. Besides, thrombotic aPLA carriers also showed significant association with PCSK9 gene, a regulator of LDLR plasma levels. These results highlight the importance of atherosclerotic processes in the development of thrombosis in patients with aPLA.

Multi-analyte profiling in human carotid atherosclerosis uncovers pro-inflammatory macrophage programming in plaques

Molecular characterisation of vulnerable atherosclerosis is necessary for targeting functional imaging and plaque-stabilising therapeutics. Inflammation has been linked to atherogenesis and the development of high-risk plaques. We set to quantify cytokine, chemokine and matrix metalloproteinase (MMP) protein production in cells derived from carotid plaques to map the inflammatory milieu responsible for instability. Carotid endarterectomies from carefully characterised symptomatic (n=35) and asymptomatic (n=32) patients were enzymatically dissociated producing mixed cell type atheroma cell suspensions which were cultured for 24 hours. Supernatants were interrogated for 45 analytes using the Luminex 100 platform. Twenty-nine of the 45 analytes were reproducibly detectable in the majority of donors. The in vitro production of a specific network of mediators was found to be significantly higher in symptomatic than asymptomatic plaques, including: tumour necrosis factor α, interleukin (IL) 1β, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF), CCL5, CCL20, CXCL9, matrix metalloproteinase (MMP)-3 and MMP-9. Ingenuity pathway analysis of differentially expressed analytes between symptomatic and asymptomatic patients identified a number of key biological pathways (p< 10(-25)). In conclusion, the carotid artery plaque culprit of ischaemic neurological symptoms is characterised by an inflammatory milieu favouring inflammatory cell recruitment and pro-inflammatory macrophage polarisation.

Atherosclerotic vascular disease in the autoimmune rheumatologic patient

Autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have a strong association with an increased risk of atherosclerotic cardiovascular diseases (ASCVD), particularly ischemic heart disease (IHD). A majority of the autoimmune conditions occur predominantly in women, and as women continue to experience a higher cardiovascular mortality compared to men, this potential added risk factor must be recognized. Inflammation and immune mechanisms have been shown to be an underlying mechanism for the development of atherosclerosis, thus sharing a common mechanism with rheumatologic conditions. There is an under recognition, in both patient and physician, of the increased cardiovascular (CV) risk within the autoimmune population, with present CV risk profile algorithms performing poorly in these patients. Traditional risk factors play a role in the development of IHD in the autoimmune patient, but their overall significance is unclear and does not fully explain the elevated CV risk. The role of inflammation and risk factors in autoimmune conditions, and their link to the elevated CV risk will be explored within this article.

Gout, not hyperuricemia alone, impairs left ventricular diastolic function

Introduction

Gout is a common metabolic disorder characterized by hyperuricemia and chronic inflammation. Previous studies show that hyperuricemia accelerates the occurrence and worsening of cardiovascular disease due to LV remodeling. However, it is still unclear whether hyperuricemia is the sole contributor to organic heart remodeling in patients with gout. In addition, there is a paucity of data regarding the association between LV diastolic function and gout. The objective of this study was to investigate the effects of gout on LV diastolic function.

Methods

A total of 173 patients were divided into tertiles based on the following serum uric acid (UA) levels: 1) serum UA ≤ 6.5 mg/dL (n = 54), 2) serum UA >6.5 to ≤8.5 mg/dL (n = 59), and 3) serum UA > 8.5 mg/dL (n = 60).Patients underwent a comprehensive Doppler-echocardiography examination to evaluate LV volume, systolic and diastolic function, and left atrial (LA) volume.

Results

LV diastolic parameters, including diastolic peak early transmitral flow velocity (E), late transmitral flow velocity (A), E/A, peak early diastolic mitral annular velocity (Em), late diastolic annular velocity (Am), Em/Am, E/Em, maximal LA volume index (LAVi) and prevalence of moderate to severe LV diastolic dysfunction were not significantly different between the three groups. Among the population being studied, 108 individuals received a gout diagnosis. Gout patients had greater LV end-systolic dimensions (27.08 ± 4.38 mm, p = 0.006), higher LV mass index (107.18 ± 29.51 g/m², p < 0.001), higher E/Em (10.07 ± 2.91, p = 0.008), and larger maximal LAVi (16.96 ± 7.39 mL/m², p < 0.001) than patients without gout. The prevalence of moderate to severe LV diastolic dysfunction was higher in patients with gout (23 %, p = 0.02).

Conclusions

Gout, not hyperuricemia alone, is associated with LV diastolic dysfunction and LA volume enlargement.

HU-444, a Novel, Potent Anti-Inflammatory, Nonpsychotropic Cannabinoid

Cannabidiol (CBD) is a component of cannabis, which does not cause the typical marijuana-type effects, but has a high potential for use in several therapeutic areas. In contrast to Δ(9)-tetrahydrocannabinol (Δ(9)-THC), it binds very weakly to the CB1 and CB2 cannabinoid receptors. It has potent activity in both in vitro and in vivo anti-inflammatory assays. Thus, it lowers the formation of tumor necrosis factor (TNF)-α, a proinflammatory cytokine, and was found to be an oral antiarthritic therapeutic in murine collagen-induced arthritis in vivo. However, in acidic media, it can cyclize to the psychoactive Δ(9)-THC. We report the synthesis of a novel CBD derivative, HU-444, which cannot be converted by acid cyclization into a Δ(9)-THC-like compound. In vitro HU-444 had anti-inflammatory activity (decrease of reactive oxygen intermediates and inhibition of TNF-α production by macrophages); in vivo it led to suppression of production of TNF-α and amelioration of liver damage as well as lowering of mouse collagen-induced arthritis. HU-444 did not cause Δ(9)-THC-like effects in mice. We believe that HU-444 represents a potential novel drug for rheumatoid arthritis and other inflammatory diseases.

Subclinical atherosclerosis and impaired bone health in patients with primary Sjogren's syndrome: prevalence, clinical and laboratory associations

Introduction

To determine the prevalence and clinical/laboratory associations of subclinical atherosclerosis and impaired bone health in primary Sjogren’s syndrome (SS).

Methods

64 consecutive patients with primary SS, 77 with rheumatoid arthritis (RA) and 60 healthy controls (HC) οf similar age and sex distribution were enrolled. Demographics, clinical/laboratory features, classical risk factors for atherosclerosis and osteoporosis (OP) were recorded. Intima-medial thickness scores (IMT) and carotid/femoral (C/F) plaque formation, as well as bone mineral density (BMD) and fractures were evaluated. Determinants of IMT/BMD levels and the presence of plaque were assessed by univariate and multivariate models. Serum levels of the Wnt signaling mediators Dickkopf-related protein 1(DKK1) and sclerostin were determined in primary SS patients and HC.

Results

Increased arterial wall thickening (IMT > 0.90 mm) and impaired bone health (defined as OP or osteopenia), were detected in approximately two-thirds of primary SS and RA patients, with a mean IMT value being significantly increased compared to HC. The presence of primary SS emerged as an independent risk factor for arterial wall thickening when traditional risk factors for cardiovascular disease (CVD) including age, sex, hypertension, smoking (pack/years), LDL and HDL levels were taken into account in a multivariate model [adjusted OR 95% (CI): 2.8 (1.04-7.54)]. In primary SS, age was revealed as independent predictor of increased IMT scores; age and lymphopenia as well as increased urine pH as independent determinants of C/F plaque formation and OP/osteopenia, respectively. An independent association of OP/osteopenia with plaque formation was observed when independent predictors for both variables were considered, with low DKK1 levels being associated with both plaque formation and lower BMD levels.

Conclusions

Comorbidities such as subclinical atherosclerosis and impaired bone health occur frequently in primary SS, in association with disease related features and traditional risk factors. Wnt signaling mediators are potentially involved in the pathogenesis of both entities.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0613-6) contains supplementary material, which is available to authorized users.

Accelerated vascular disease in systemic lupus erythematosus: role of macrophage

Atherosclerosis is a chronic inflammatory condition that is considered a major cause of death worldwide. Striking phenomena of atherosclerosis associated with systemic lupus erythematosus (SLE) is its high incidence in young patients. Macrophages are heterogeneous cells that differentiate from hematopoietic progenitors and reside in different tissues to preserve tissue integrity. Macrophages scavenge modified lipids and play a major role in the development of atherosclerosis. When activated, macrophages secret inflammatory cytokines. This activation triggers apoptosis of cells in the vicinity of macrophages. As such, macrophages play a significant role in tissue remodeling including atherosclerotic plaque formation and rupture. In spite of studies carried on identifying the role of macrophages in atherosclerosis, this role has not been studied thoroughly in SLE-associated atherosclerosis. In this review, we address factors released by macrophages as well as extrinsic factors that may control macrophage behavior and their effect on accelerated development of atherosclerosis in SLE.

Evaluation of early cardiac dysfunction in patients with systemic lupus erythematosus with or without anticardiolipin antibodies

The aim of this study was to use transthoracic Doppler echocardiographic (TTE) imaging methods to identify cardiac dysfunction, an indicator of subclinical atherosclerosis in asymptomatic systemic lupus erythematosus (SLE) patients in terms of cardiac effects. This study involved 80 patients: a study group ( n = 50) and control group ( n = 30). They were categorized into four subgroups: anticardiolipin antibodies (aCL) (+) ( n = 14) and aCL (−) ( n = 36); systemic lupus erythematosus disease activity index (SLEDAI) ≥ 6 ( n = 15) and SLEDAI < 6 ( n = 35); disease period ≥ 5 years ( n = 21) and disease period < 5 years ( n = 29); major organ involvement (+) ( n = 19), major organ involvement (−) ( n = 31). The ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E′) for the study group was found to be higher than the control ( p < 0.01). Systolic septal motion velocity (Ssm) was lower in the study group compared with the control ( p < 0.01). Left atrium (LA) dimension was greater in the study group than the control ( p < 0.01). Ssm was found to be lower in the aCL (+) patients compared with the control and aCL (−) groups ( p < 0.01, p < 0.05, respectively). LA dimension was greater in the aCL (+) and (−) groups compared with the control, ( p < 0.01, p < 0.05, respectively) and aCL groups compared with each other ( p < 0.05). The E/E′ ratio for the aCL (+) and (−) groups was found to be greater than the control ( p < 0.05). In the study, both the Ssm and the late diastolic septal velocity (sA′) was found to be lower in the SLEDAI ≥6 group compared with SLEDAI<6 group, ( p < 0.001, p < 0.05, respectively). LA dimension was statistically greater in the SLEDAI ≥6 group compared with the SLEDAI <6 group ( p < 0.001). E′ and early diastolic septal velocity (sE′) were statistically lower in the disease period >5 years group compared with the disease period <5 years group ( p < 0.01, p < 0.05, respectively). Carrying out regular scans with TTE image of SLE patients is important in order to identify early cardiac involvement during monitoring and treatment. Identifying early cardiac involvement in SLE may lead to a reduction in mortality and morbidity rates.

An important role for A20-binding inhibitor of nuclear factor-kB-1 (ABIN1) in inflammation-mediated endothelial dysfunction: an in vivo study in ABIN1 (D485N) mice

Introduction

The link between cardiovascular disease (CVD) and patients with chronic inflammation is not clearly understood. We examined a knock-in mouse expressing a poly-ubiquitin-binding-defective mutant of the protein ABIN1 (ABIN1(D485N)), which develops a systemic lupus erythematosus-like autoimmune disease because of the hyperactivation of IκB kinases (IκKs) and mitogen-activated protein kinases (MAPKs). These mice were used to determine the potential role of these signaling pathways in inflammation-mediated CVD development.

Methods

Laser Doppler imaging in combination with the iontophoresis of vasoactive chemicals were used to assess endothelium-dependent vasodilatation in vivo in ABIN1 (D485N)) mutant defective (n = 29) and wild-type (WT) control (n = 26) mice. Measurements were made at baseline, and animals were subdivided to receive either chow or a proatherogenic diet for 4 weeks, after which, follow-up assessments were made. Paired and unpaired t tests, and ANOVA with post hoc Bonferroni correction were used for statistical significance at P <0.05.

Results

Endothelium-dependent vasodilatation to acetylcholine was attenuated at 4 weeks in ABIN1(D485N)-chow-fed mice compared with age-matched WT-chow-fed mice (P <0.05). The magnitude of attenuation was similar to that observed in WT-cholesterol-fed animals (versus WT-chow, P <0.01). ABIN1(D485N)-cholesterol-fed mice had the poorest endothelium-dependent responses compared with other groups (P <0.001). ABIN1(D485N)-chow-fed mice had increased plasma interleukin-6 (IL-6) levels (versus WT-chow, P <0.001), and this was further elevated in ABIN1(D485N)-cholesterol-fed mice (versus ABIN1(D485N)-chow; P <0.05). IL-1α was significantly greater in all groups compared with WT-chow (P <0.01). ABIN1(D485N) mice showed significant cardiac hypertrophy (P <0.05).

Conclusions

The ABIN(D485N) mice display endothelial dysfunction and cardiac hypertrophy, which is possibly mediated through IL-6 and, to a lesser degree, IL-1α. These results suggest that the ABIN1-mediated hyperactivation of IKKs and MAPKs might mediate chronic inflammation and CVD development.

Cardiorheumatology: cardiac involvement in systemic rheumatic disease

Autoimmune rheumatic diseases can affect the cardiac vasculature, valves, myocardium, pericardium, and conduction system, leading to a plethora of cardiovascular manifestations that can remain clinically silent or lead to substantial cardiovascular morbidity and mortality. Although the high risk of cardiovascular pathology in patients with autoimmune inflammatory rheumatological diseases is not owing to atherosclerosis alone, this particular condition contributes substantially to cardiovascular morbidity and mortality-the degree of coronary atherosclerosis observed in patients with rheumatic diseases can be as accelerated, diffuse, and extensive as in patients with diabetes mellitus. The high risk of atherosclerosis is not solely attributable to traditional cardiovascular risk factors: dysfunctional immune responses, a hallmark of patients with rheumatic disorders, are thought to cause chronic tissue-destructive inflammation. Prompt recognition of cardiovascular abnormalities is needed for timely and appropriate management, and aggressive control of traditional risk factors remains imperative in patients with rheumatic diseases. Moreover, therapies directed towards inflammatory process are crucial to reduce cardiovascular disease morbidity and mortality. In this Review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders, their underlying pathophysiology, and available management strategies, with particular emphasis on the vascular aspects of the emerging field of 'cardiorheumatology'.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

Atherosclerosis and cardiovascular disease in systemic lupus erythematosus: effects of in vivo statin treatment

OBJECTIVE

Statins may have beneficial vascular effects in systemic lupus erythematosus (SLE) beyond their cholesterol-lowering action, although the mechanisms involved are not completely understood. We investigated potential mechanisms involved in the efficacy of fluvastatin in preventing atherothrombosis in SLE.

METHODS

Eighty-five patients with SLE and 62 healthy donors were included in the study. Selected patients (n=27) received 20 mg/day fluvastatin for 1 month. Blood samples were obtained before the start and at the end of treatment. Monocytes from five patients were treated in vitro with fluvastatin.

RESULTS

Increased prothrombotic and inflammatory variables were found in patients with SLE. SLE monocytes displayed altered mitochondrial membrane potential and increased oxidative stress. Correlation and association analyses demonstrated a complex interplay among autoimmunity, oxidative stress, inflammation and increased risk of atherothrombosis in SLE. Fluvastatin treatment of patients for 1 month reduced the SLE Disease Activity Index and lipid levels, oxidative status and vascular inflammation. Array studies on monocytes demonstrated differential expression in 799 genes after fluvastatin treatment. Novel target genes and pathways modulated by fluvastatin were uncovered, including gene networks involved in cholesterol and lipid metabolism, inflammation, oxidative stress and mitochondrial activity. Electron microscopy analysis showed increased density volume of mitochondria in monocytes from fluvastatin-treated patients, who also displayed higher expression of genes involved in mitochondrial biogenesis. In vitro treatment of SLE monocytes confirmed the results obtained in the in vivo study.

CONCLUSIONS

Our overall data suggest that fluvastatin improves the impairment of a redox-sensitive pathway involved in processes that collectively orchestrate the pathophysiology of atherothrombosis in SLE.

Gene profiling reveals specific molecular pathways in the pathogenesis of atherosclerosis and cardiovascular disease in antiphospholipid syndrome, systemic lupus erythematosus and antiphospholipid syndrome with lupus

Objective

To identify shared and differential molecular pathways involved in the pathogenesis of atherosclerosis (AT) and cardiovascular disease (CVD) in systemic lupus erythematosus (SLE), primary antiphospholipid syndrome (APS) and APS associated with SLE (APS plus SLE).

Methods

129 patients (42 APS, 31 APS plus SLE and 56 SLE) and 61 healthy donors were included. Microarray expression profiling was performed in monocytes. RT-PCR of selected genes and western blot were used to validate microarray data. Clinical and inflammatory parameters were also analysed.

Results

Compared with controls, 555, 1224 and 518 genes were differentially expressed in monocytes from SLE, APS plus SLE and APS patients, respectively. Approximately 25–30% of differentially expressed genes were related to AT and CVD. Each disease displayed a specific AT/CVD/Inflammation-related gene signature. Compared with SLE, APS showed alterations in mitochondria biogenesis and function and oxidative stress. Besides the interferon signature, found in APS plus SLE and SLE patients, various genes mediating atherosclerotic/inflammatory signalling were also differentially expressed in APS plus SLE. IgG-anticardiolipin (aCL) titres independently predicted both atherosclerotic and thrombosis in APS plus SLE. Moreover, a significant correlation of IgG-aCL titres with mRNA levels of certain inflammatory molecules in monocytes was further noticed. In vitro treatment of monocytes with IgG-aCL promoted an increase in the expression of the genes most significantly changed in APS plus SLE versus healthy donors.

Conclusions

Gene expression profiling allows the segregation of APS, APS plus SLE and SLE, with specific signatures explaining the pro-atherosclerotic and pro-thrombotic alterations in these highly related autoimmune diseases.

IFNα serum levels are associated with endothelial progenitor cells imbalance and disease features in rheumatoid arthritis patients

Introduction

IFNα has been largely implicated in the ethiopathogenesis of autoimmune diseases but only recently it has been linked to endothelial damage and accelerated atherosclerosis in autoimmunity. In addition, proinflammatory conditions are supposed to be implicated in the cardiovascular status of these patients. Since a role for IFNα in endothelial damage and impaired Endothelial Progenitor Cell (EPC) number and function has been reported in other diseases, we aimed to evaluate the potential associations of IFNα serum levels on EPC populations and cytokine profiles in Rheumatoid Arthritis (RA) patients.

Methods

pre-EPC, EPC and mature EPC (mEPC) populations were quantified by flow cytometry analyzing their differential CD34, CD133 and VEGFR2 expression in blood samples from 120 RA patients, 52 healthy controls (HC), and 83 systemic lupus erythematosus (SLE) patients as disease control. Cytokine serum levels were measured by immunoassays and clinical and immunological data, including cardiovascular (CV) events and CV risk factors, were retrospectively obtained by reviewing clinical records.

Results

Long-standing, but not recent onset RA patients displayed a significant depletion of all endothelial progenitor populations, unless high IFNα levels were present. In fact, the IFN^high RA patient group (n = 40, 33%), showed increased EPC levels, comparable to SLE patients. In addition, high IFNα serum levels were associated with higher disease activity (DAS28), presence of autoantibodies, higher levels of IL-1β, IL-6, IL-10 and MIP-1α, lower amounts of TGF-β, and increased mEPC/EPC ratio, thus suggesting higher rates of endothelial damage and an endothelial repair failure. Finally, the relationship between high IFNα levels and occurrence of CV events observed in RA patients seems to support this hypothesis.

Conclusions

IFNα serum marker could be used to identify a group of RA patients with increased disease activity, EPC imbalance, enhanced proinflammatory profile and higher cardiovascular risk, probably due, at least in part, to an impaired endothelial repair.

Cardiovascular disease in latin american patients with systemic lupus erythematosus: a cross-sectional study and a systematic review

Objective. This study was performed to determine the prevalence of and associated risk factors for cardiovascular disease (CVD) in Latin American (LA) patients with systemic lupus erythematosus (SLE). Methods. First, a cross-sectional analytical study was conducted in 310 Colombian patients with SLE in whom CVD was assessed. Associated factors were examined by multivariate regression analyses. Second, a systematic review of the literature on CVD in SLE in LA was performed. Results. There were 133 (36.5%) Colombian SLE patients with CVD. Dyslipidemia, smoking, coffee consumption, and pleural effusion were positively associated with CVD. An independent effect of coffee consumption and cigarette on CVD was found regardless of gender and duration of disease. In the systematic review, 60 articles fulfilling the eligibility criteria were included. A wide range of CVD prevalence was found (4%-79.5%). Several studies reported ancestry, genetic factors, and polyautoimmunity as novel risk factors for such a condition. Conclusions. A high rate of CVD is observed in LA patients with SLE. Awareness of the observed risk factors should encourage preventive population strategies for CVD in patients with SLE aimed at facilitating the suppression of cigarette smoking and coffee consumption as well as at the tight control of dyslipidemia and other modifiable risk factors.

Effect of therapeutic inhibition of TNF on circulating endothelial progenitor cells in patients with rheumatoid arthritis

Endothelial dysfunction has been detected in RA patients and seems to be reversed by control of inflammation. Low circulating endothelial progenitor cells (EPCs) have been described in many conditions associated with increased cardiovascular risk, including RA. The aim of this study was to investigate the effect of inhibition of TNF on EPCs in RA patients. Seventeen patients with moderate-severe RA and 12 sex and age-matched controls were evaluated. Endothelial biomarkers were tested at baseline and after 3 months. EPCs were identified from peripheral blood mononuclear cells by cytofluorimetry using anti-CD34 and anti-vascular endothelial growth factor-receptor 2. Asymmetric dimethylarginine (ADMA) was tested by ELISA and flow-mediated dilatation (FMD) by ultrasonography. Circulating EPCs were significantly lower in RA patients than in controls (P = 0.001). After 3 months EPCs increased significantly (P = 0.0006) while ADMA levels significantly decreased (P = 0.001). An inverse correlation between mean increase in EPCs number and mean decrease of DAS28 after treatment was observed (r = −0.56, P = 0.04). EPCs inversely correlated with ADMA (r = −0.41, P = 0.022). No improvement of FMD was detected. Short-term treatment with anti-TNF was able to increase circulating EPCs concurrently with a proportional decrease of disease activity suggesting that therapeutic intervention aimed at suppressing the inflammatory process might positively affect the endothelial function.

Dyslipidemia and changes in lipid profiles associated with rheumatoid arthritis and initiation of anti-tumor necrosis factor therapy

OBJECTIVE

To investigate the frequency of lipid testing in clinical practice and to explore the relationship between rheumatoid arthritis (RA), dyslipidemia, and other cardiovascular (CV) risk factors with RA treatment.

METHODS

Patients in this retrospective database study were ages ≥18 years and had ≥2 physician diagnoses for RA or osteoarthritis (OA; comparator group) between March 2004 and March 2008. Outcomes of interest included the percentage of RA and OA patients receiving lipid tests, lipid profiles (total cholesterol, low-density lipoprotein [LDL] cholesterol, and high-density lipoprotein [HDL] cholesterol) of RA versus OA patients, and lipid profiles of RA patients before and after initiation with a tumor necrosis factor (TNF) inhibitor. We used multivariable regression to control potential confounders between the cohorts.

RESULTS

Over a median ≥2-year followup, fewer RA patients than OA patients had ≥1 lipid test (62.0% [95% confidence interval (95% CI) 61.5-62.5] versus 69.8% [95% CI 69.5-70.1]). Mean total cholesterol and LDL cholesterol were each 4 mg/dl lower in the RA cohort (P < 0.0001); HDL cholesterol was similar between the cohorts. Across the RA cohort, 25.2% of patients had suboptimal LDL cholesterol levels (≥130 mg/dl). Among RA patients not receiving lipid-lowering therapy who initiated TNF inhibitor therapy (n = 96), mean total cholesterol and LDL cholesterol increased by 5.4 and 4.0 mg/dl, respectively.

CONCLUSION

Patients with RA were less likely to be tested for hyperlipidemia and had more favorable lipid profiles than patients with OA. TNF inhibitor therapy modestly increased all lipid parameters. Additional studies are needed to determine the effect of traditional CV risk factors and inflammation and the impact of biologic agents on CV outcomes in RA patients.

Cardiovascular disease in rheumatoid arthritis: a systematic literature review in latin america

Background. Cardiovascular disease (CVD) is the major predictor of poor prognosis in rheumatoid arthritis (RA) patients. There is an increasing interest to identify "nontraditional" risk factors for this condition. Latin Americans (LA) are considered as a minority subpopulation and ethnically different due to admixture characteristics. To date, there are no systematic reviews of the literature published in LA and the Caribbean about CVD in RA patients. Methods. The systematic literature review was done by two blinded reviewers who independently assessed studies for eligibility. The search was completed through PubMed, LILACS, SciELO, and Virtual Health Library scientific databases. Results. The search retrieved 10,083 potential studies. A total of 16 articles concerning cardiovascular risk factors and measurement of any cardiovascular outcome in LA were included. The prevalence of CVD in LA patients with RA was 35.3%. Non-traditional risk factors associated to CVD in this population were HLA-DRB1 shared epitope alleles, rheumatoid factor, markers of chronic inflammation, long duration of RA, steroids, familial autoimmunity, and thrombogenic factors. Conclusions. There is limited data about CVD and RA in LA. We propose to evaluate cardiovascular risk factors comprehensively in the Latin RA patient and to generate specific public health policies in order to diminish morbi-mortality rates.

Analysis of the interferon gamma (rs2430561, +874T/A) functional gene variant in relation to the presence of cardiovascular events in rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased cardiovascular (CV) morbidity and mortality. Since interferon-gamma (IFN-γ) has a direct effect on inflammation, in this study we assessed the potential association of the IFNG functional gene variant rs2430561 with CV disease in patients with RA.

METHODS

One thousand six hundred and thirty-five patients fulfilling the 1987 American College of Rheumatology classification criteria for RA were genotyped for the IFNG (rs2430561, +874T/A) gene polymorphism using TaqMan genotyping assay. Patients were stratified according to the presence of CV events or not. Logistic regression models to explain the presence of CV disease according to the IFNG rs2430561 allele distribution were performed. The potential influence of this variant in the development of subclinical atherosclerosis was also analyzed in a subgroup of patients with no history of CV events to determine carotid artery intima-media thickness (IMT) (n = 286) and presence of carotid plaques. Levels of the cytokine were determined in a subgroup of patients by ELISA.

RESULTS

Adjusted logistic regression model disclosed that presence of the minor allele A was not associated with increased risk of suffering CV events in RA patients. Besides, differences did not achieve statistical significance regarding carotid IMT and presence of carotid plaques in RA patients carrying IFNG rs2430561 variant allele. Levels of IFN-γ were higher in patients who had suffered CV events compared to patients who did not.

CONCLUSION

Our results do not support a role of IFNG rs2430561 (+874T/A) functional gene variant in the development of CV disease in RA patients.