Atherosclerotic cardiovascular disease and dermatomyositis: an analysis of the Nationwide Inpatient Sample survey

Atherosclerotic cardiovascular disease following a diagnosis of idiopathic inflammatory myopathy: analysis from a retrospective cohort in the TriNetX registry

OBJECTIVE

Idiopathic inflammatory myopathies (IIM) confer an increased risk of morbidity from atherosclerotic cardiovascular disease (ASCVD). While ASCVD risk has been studied in other countries, these results may not be applicable to patients with dermatomyositis (DM) and polymyositis (PM) in the United States. This retrospective analysis of a cohort of patients identified by ICD code from TriNetX investigated the incidence of ASCVD after International Classification of Disease (ICD) codes of DM, PM, dermatopolymyositis (DPM) or juvenile dermatomyositis (JDM).

METHOD

Patients were identified by entry of two ICD codes separated by at least 6 months, according to their first diagnosis code; ASCVD was defined as first ICD code for myocardial infarction, ischemic stroke, transient ischemic attack, or peripheral arterial disease. Cox proportional hazards regression modeled time from first IIM ICD code to ASCVD event.

RESULTS

A total of 35,554 patients were identified with the mean age at first IIM code of 54 and 26.1% were male. The most common comorbidity for all groups except JDM was hyperlipidemia (39.9%) though 79.2% of patients were on no cholesterol lowering medication. ASCVD occurred in 30.4% of patients with PM, 24.3% of patients with DM and 0.9% of patients with JDM. Patients with PM had a median time to event of 9.7 years (95% Confidence interval (CI) 9.1, 10.7) and 14.3 years (95% CI 12.6, 14.8) for DM. This study demonstrates that ASCVD is a comorbidity occurring after a median of 12.5 years (95% CI 11.9, 13.6) in patients with IIM.

CONCLUSIONS

ASCVD appears to be a long-term complication for IIM patients occurring in nearly a quarter of US patients without prior ASCVD with at least two ICD codes for IIM, with a median time to event of 12.5 years. There appears to be a practice gap in the recognition and treatment of hyperlipidemia in these patients. Key Points • Hyperlipidemia was a common comorbidity identified in patients with IIM though most patients were not on cholesterol lowering medication. • Development of ASCVD appears to be a long-term complication for patients with IIM in the United States.

Identification of common mechanisms and biomarkers for dermatomyositis and atherosclerosis based on bioinformatics analysis

BACKGROUND

Dermatomyositis (DM) manifests as an autoimmune and inflammatory condition, clinically characterized by subacute progressive proximal muscle weakness, rashes or both along with extramuscular manifestations. Literature indicates that DM shares common risk factors with atherosclerosis (AS), and they often co-occur, yet the etiology and pathogenesis remain to be fully elucidated. This investigation aims to utilize bioinformatics methods to clarify the crucial genes and pathways that influence the pathophysiology of both DM and AS.

METHOD

Microarray datasets for DM (GSE128470, GSE1551, GSE143323) and AS (GSE100927, GSE28829, GSE43292) were retrieved from the Gene Expression Omnibus (GEO) database. The weighted gene co-expression network analysis (WGCNA) was used to reveal their co-expressed modules. Differentially expression genes (DEGs) were identified using the "limma" package in R software, and the functions of common DEGs were determined by functional enrichment analysis. A protein-protein interaction (PPI) network was established using the STRING database, with central genes evaluated by the cytoHubba plugin, and validated through external datasets. Immune infiltration analysis of the hub genes was conducted using the CIBERSORT method, along with Gene Set Enrichment Analysis (GSEA). Finally, the NetworkAnalyst platform was employed to examine the transcription factors (TFs) responsible for regulating pivotal crosstalk genes.

RESULTS

Utilizing WGCNA analysis, a total of 271 overlapping genes were pinpointed. Subsequent DEG analysis revealed 34 genes that are commonly found in both DM and AS, including 31 upregulated genes and 3 downregulated genes. The Degree Centrality algorithm was applied separately to the WGCNA and DEG collections to select the 15 genes with the highest connectivity, and crossing the two gene sets yielded 3 hub genes (PTPRC, TYROBP, CXCR4). Validation with external datasets showed their diagnostic value for DM and AS. Analysis of immune infiltration indicates that lymphocytes and macrophages are significantly associated with the pathogenesis of DM and AS. Moreover, GSEA analysis suggested that the shared genes are enriched in various receptor interactions and multiple cytokines and receptor signaling pathways. We coupled the 3 hub genes with their respective predicted genes, identifying a potential key TF, CBFB, which interacts with all 3 hub genes.

CONCLUSION

This research utilized comprehensive bioinformatics techniques to explore the shared pathogenesis of DM and AS. The three key genes, including PTPRC, TYROBP, and CXCR4, are related to the pathogenesis of DM and AS. The central genes and their correlations with immune cells may serve as potential diagnostic and therapeutic targets.

Assessment of cardiovascular risk factors in patients with idiopathic inflammatory myopathies: a systematic review

We performed a systematic review of cardiovascular risk factors in idiopathic inflammatory myopathies (IIMs) and their cardiovascular outcomes, including acute coronary syndrome and stroke. A qualitative systematic review was conducted from January 1956 to December 2022 according to the PRISMA protocol using three electronic databases: PubMed, Web of Science, and Scopus. The studies were analyzed based on the following eligibility criteria: at least one combination of the terms described in the search strategy appeared in the title, written in English, Portuguese, or Spanish, and addressed risk factors for cardiovascular diseases in IIMs. Brief reports, reviews, papers addressing juvenile IIMs, congress proceedings, monographs, and dissertations were excluded. Twenty articles were included. According to the literature, most patients with IIMs are middle-aged North American or Asian women, with dyslipidemia and hypertension. The prevalence of the cardiovascular risk factors was generally low in IIMs, but with a high incidence of acute myocardial infarction. Further theoretical and prospective studies are needed to define the actual impact of each variable (e.g., hypertension, diabetes, smoking, alcoholism, obesity, and dyslipidemia) on the cardiovascular risk of patients with IIMs.

Cardiovascular manifestations in idiopathic inflammatory myopathies

Cardiovascular involvement in idiopathic inflammatory myopathies (IIM) is an understudied area which is gaining increasing recognition in recent times. Recent advances in imaging modalities and biomarkers have allowed the detection of subclinical cardiovascular manifestations in IIM. However, despite the availability of these tools, the diagnostic challenges and underestimated prevalence of cardiovascular involvement in these patients remain significant. Notably, cardiovascular involvement remains one of the leading causes of mortality in patients with IIM. In this narrative literature review, we outline the prevalence and characteristics of cardiovascular involvement in IIM. Additionally, we explore investigational modalities for early detection of cardiovascular involvement, as well as newer approaches in screening to facilitate timely management. Key points • Cardiac involvement in IIM in majority cases is subclinical and a major cause of mortality. • Cardiac magnetic resonance imaging is sensitive for detection of subclinical cardiac involvement.

Incidence and prevalence, and medication use among adults living with dermatomyositis: an Alberta, Canada population-based cohort study

Dermatomyositis is a rare disease characterized by progressive muscle weakness and skin rashes. Estimates of incidence and prevalence are fundamental measures in epidemiology, but few studies have been conducted on dermatomyositis. To address this knowledge gap, we conducted a population-based study to determine the contemporary incidence (between 2013 and 2019) and prevalence (2019) of adults living with dermatomyositis using administrative health data in Alberta, Canada. We also described disease-related medication use, as there are very few approved medications for the treatment of dermatomyositis, and no Canadian therapeutic guidelines. The average age- and sex-standardized annual incidence of dermatomyositis was 2.8-3.0 cases per 100,000 adults, and prevalence was 28.6 cases per 100,000 adults, which is greater than reported in other cohorts. Dermatomyositis-related medication use decreased from 73% in the first year to 46% in the eighth year after diagnosis. Glucocorticoids were the most commonly used drug class, often taken concurrently with various immunomodulatory agents; this medication use aligns with empirically-based recommendations and the few therapeutic guidelines for dermatomyositis. Considering that Alberta may have one of the highest rates of dermatomyositis among adults, further research on the burden of disease is warranted for planning within the health care system.

Cost-effectiveness analysis of implementing polygenic risk score in a workplace cardiovascular disease prevention program

Background

Polygenic risk score for coronary artery disease (CAD-PRS) improves precision in assessing the risk of cardiovascular diseases and is cost-effective in preventing cardiovascular diseases in a health system and may be cost-effective in other settings and prevention programs such as workplace cardiovascular prevention programs. Workplaces provide a conducitve environment for cardiovascular prevention interventions, but the cost-effectiveness of CAD-PRS in a workplace setting remains unknown. This study examined the cost-effectiveness of integrating CAD-PRS in a workplace cardiovascular disease prevention program compared to the standard cardiovascular workplace program without CAD-PRS and no-workplace prevention program.

Methods

We developed a cohort simulation model to project health benefits (quality-adjusted life years gained) and costs over a period of 5 years in a cohort of employees with a mean age of 50 years. The model health states reflected the risk of disease (coronary artery disease and ischemic stroke) and statin prevention therapy side effects (diabetes, hemorrhagic stroke, and myopathy). We considered medical and lost productivity costs. Data were obtained from the literature, and the analysis was performed from a self-insured employer perspective with future costs and quality-adjusted life years discounted at 3% annually. Uncertainty in model parameter inputs was assessed using deterministic and probabilistic sensitivity analyses. Three programs were compared: (1) a workplace cardiovascular program that integrated CAD-PRS with the pooled cohort equation-a standard of care for assessing the risk of cardiovascular diseases (CardioriskSCORE); (2) a workplace cardiovascular prevention program without CAD-PRS (Standard-WHP); and (3) no-workplace health program (No-WHP). The main outcomes were total costs (US $2019), incremental costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratio.

Results

CardioriskSCORE lowered employer costs ($53 and $575) and improved employee quality-adjusted life years (0.001 and 0.005) per employee screened compared to Standard-WHP and No-WHP, respectively. The effectiveness of statin prevention therapy, employees' baseline cardiovascular risk, the proportion of employees that enrolled in the program, and statin adherence had the largest effect size on the incremental net monetary benefit. However, despite the variation in parameter input values, base case results remained robust.

Conclusion

Polygenic testing in a workplace cardiovascular prevention program improves employees' quality of life and simultaneously lowers health costs and productivity monetary loss for employers.

Cardiac involvement in polymyositis and dermatomyositis: diagnostic approaches

Polymyositis (PM) and dermatomyositis (DM) are rare idiopathic inflammatory myopathies (IIM). Myocardial involvement in patients with IIM is an unfavorable prognostic factor and one of the most common cause of mortality in this group of patients. The purpose of this review is to present current knowledge on cardiovascular manifestations observed in IIM. Data published in English until December 2021 were selected. Clinical symptoms suggesting cardiac involvement are non-specific and require a differential diagnosis in accordance with cardiological guidelines. Troponin I is specific to cardiac injury and should be preferred to other markers to evaluate the myocardium in IIM. Abnormalities in electrocardiography are common in IIM, especially non-specific changes of the ST-T segment. In standard echocardiography left ventricular diastolic dysfunction is reported frequently. New diagnostic technologies can reveal clinically silent myocardial abnormalities. However, the prognostic value of subclinical impairment of myocardial function require further studies.

A case of clinically amyopathic dermatomyositis in a Filipino woman

This is a case of a 59-year-old woman who presented with a 2-year history of heliotrope rash, Gottron's papules, shawl sign, V-neck sign, and muscle weakness. She was previously managed as a case of systemic lupus erythematosus and initially responded to unrecalled corticosteroids. She was admitted due to a 1-month progressively enlarging sacral mass, which eventually turned out to be an abscess. While the abscess was being treated, her autoimmune condition was worked up, and she was then managed as a case of clinically amyopathic dermatomyositis (CADM) with interstitial lung disease (ILD). She received corticosteroids and underwent the first cycle of cyclophosphamide infusion prior to discharge.

Integrating a Polygenic Risk Score for Coronary Artery Disease as a Risk-Enhancing Factor in the Pooled Cohort Equation: A Cost-Effectiveness Analysis Study

Background

Cardiovascular diseases are the leading cause of death in the United States, yet a significant proportion of adults at high risk remain undetected by standard screening practices. Polygenic risk score for coronary artery disease (CAD‐PRS) improves precision in determining the 10‐year risk of atherosclerotic cardiovascular disease but health benefits and health care costs associated with CAD‐PRS are unknown. We examined the cost‐effectiveness of including CAD‐PRS as a risk‐enhancing factor in the pooled cohort equation (PCE)—the standard of care for determining the risk of atherosclerotic cardiovascular disease—versus PCE alone.

Methods and Results

We applied a Markov model on a cohort of 40‐year‐old individuals with borderline or intermediate 10‐year risk (5% to <20%) for atherosclerotic cardiovascular disease to identify those in the top quintile of the CAD‐PRS distribution who are at high risk and eligible for statin prevention therapy. Health outcomes examined included coronary artery disease (CAD; ie, myocardial infarction) and ischemic stroke. The model projected medical costs (2019 US$) of screening for CAD, statin prevention therapy, treatment, and monitoring patients living with CAD or ischemic stroke and quality‐adjusted life‐years for PCE+CAD‐PRS versus PCE alone. Deterministic and probabilistic sensitivity analyses and scenario analyses were performed to examine uncertainty in parameter inputs. PCE+CAD‐PRS was dominant compared with PCE alone in the 5‐ and 10‐year time horizons. We found that, respectively, PCE+CAD‐PRS had 0.003 and 0.011 higher mean quality‐adjusted life‐years and $40 and $181 lower mean costs per person screened, with 29 and 50 fewer events of CAD and ischemic stroke in a cohort of 10 000 individuals compared with PCE alone. The risk of developing CAD, the effectiveness of statin prevention therapy, and the cost of treating CAD had the largest impact on the cost per quality‐adjusted life‐year gained. However, this cost remained below the $50 000 willingness‐to‐pay threshold except when the annual risk of developing CAD was <0.006 in the 5‐year time horizon. Results from Monte Carlo simulation indicated that PCE+CAD‐PRS would be cost‐effective. with the probability of 94% and 99% at $50 000 willingness‐to‐pay threshold in the 5‐ and 10‐year time horizon, respectively.

Conclusions

Implementing CAD‐PRS as a risk‐enhancing factor in the PCE to determine the risk of atherosclerotic cardiovascular disease reduced the mean cost per individual, improved quality‐adjusted life‐years, and averted future events of CAD and ischemic stroke when compared with PCE alone.

Cardiovascular Risk in Myositis Patients Compared to the General Population: Preliminary Data From a Single-Center Cross-Sectional Study

Background

Idiopathic inflammatory myopathies (IIM) are associated with systemic inflammation, limited mobility, and glucocorticoid therapy, all of which can lead to metabolism disturbances, atherogenesis, and increased cardiovascular (CV) risk. The aim of this study was to assess the CV risk in IIM patients and healthy controls (HC), and its association with disease-specific features.

Methods

Thirty nine patients with IIM (32 females; mean age 56; mean disease duration 4.8 years; dermatomyositis: n = 16, polymyositis: n = 7, immune-mediated necrotizing myopathy: n = 8, anti-synthetase syndrome: n = 8) and 39 age-/sex-matched HC (32 females, mean age 56) without rheumatic diseases were included. In both groups, subjects with a history of CV disease (angina pectoris, myocardial infarction, cerebrovascular, and peripheral arterial vascular events) were excluded. Muscle involvement, disease activity, and tissue damage were evaluated (Manual Muscle Test-8, Myositis Intention to Treat Activity Index, Myositis Damage Index). Comorbidities and current treatment were recorded. All participants underwent examinations of carotid intima-media thickness (CIMT), pulse wave velocity (PWV), ankle-brachial index (ABI), and body composition (by densitometry and bioelectric impedance). The risk of fatal CV events was evaluated by the Systematic COronary Risk Evaluation (SCORE, charts for the European population) and its modifications.

Results

Compared to HC, there was no significant difference in IIM patients regarding blood pressure, ABI, PWV, CIMT, and the risk of fatal CV events by SCORE or SCORE2, or subclinical atherosclerosis (CIMT, carotid plaques, ABI, and PWV). The calculated CV risk scores by SCORE, SCORE2, and SCORE multiplied by the coefficient 1.5 (mSCORE) were reclassified according to the results of carotid plaque presence and CIMT; however, none of them was demonstrated to be significantly more accurate. Other significant predictors of CV risk in IIM patients included age, disease duration and activity, systemic inflammation, lipid profile, lean body mass, and blood pressure.

Conclusions

No significant differences in CV risk factors between our IIM patients and HC were observed. However, in IIM, CV risk was associated with age, disease duration, duration of glucocorticoid therapy, lipid profile, and body composition. None of the currently available scoring tools (SCORE, SCORE2, mSCORE) used in this study seems more accurate in estimating CV risk in IIM.

Coronary Heart Disease and Cardiovascular Risk Factors in Patients With Idiopathic Inflammatory Myopathies: A Systemic Review and Meta-Analysis

Objectives:

It is well-established that the association between atherosclerotic cardiovascular diseases (ASCVD) and connective tissue diseases (CTDs), but the relationship between coronary heart disease (CHD) and idiopathic inflammatory myopathies (IIMs) remains controversial yet. The aim of this meta-analysis is to systematically evaluate the risk of CHD in IIMs patients. In addition, we explore differences in traditional cardiovascular risk factors between IIMs patients and controls.

Methods:

We searched Pubmed, EMBASE and Cochrane databases to identify relevant observational studies published in English up to August 2021. Pooled relative risk (RR) and 95% confidence interval (CI) was calculated using the generic inverse variance method for the risk of CHD. A meta-proportion analysis was conducted to assess differences in cardiovascular risk factors between two groups.

Results:

A total of 15 studies met inclusion criteria: seven studies focused on CHD and nine studies focused on traditional cardiovascular risk factors. The results demonstrated that IIMs patients had a higher risk of CHD (RR = 2.19, 95% CI: 1.40–3.42). Hypertension (OR = 1.44, 95% CI: 1.28–1.61), diabetes mellitus (OR = 1.67, 95% CI: 1.55–1.81) and dyslipidemia (OR = 1.48, 95% CI: 1.19–1.84) were more prevalent in IIMs patients compared with controls. However, there was a significant heterogeneity among studies assessing the risk of CHD and hypertension. Subgroup analysis demonstrated that definition of CHD, country and sample size may be potential sources of heterogeneity.

Conclusions:

IIMs patients were at increased risk of CHD, and traditional cardiovascular risk factors appeared more prevalent in IIMs patients. This systemic review offers the proof that early appropriate interventions could reduce cardiovascular-associated morbidity and mortality in IIMs patients.

Underdiagnosis of cardiopulmonary involvement in patients with idiopathic inflammatory myopathies

Objectives

In the course of idiopathic inflammatory myopathies internal organs, including heart and lungs, can be involved. Cardiopulmonary complications significantly alter the course of the disease, leading to poorer prognosis. A lack of clear guidelines on the assessment of internal organ involvement in the course of myositis increases the risk of underdiagnosis. The aim of the study was to evaluate the incidence of clinical symptoms indicative of cardiovascular and pulmonary involvement in patients with myositis, and the impact of these ailments on daily living.

Material and methods

A self-designed online survey was distributed via online support groups and community forums for patients with idiopathic inflammatory myopathies. The questionnaire contained inquiries about demographical data, clinical symptoms, including symptoms indicative of cardiopulmonary involvement, as well as the standardised Health Assessment Questionnaire. Respondents were divided according to concomitant diseases into a subgroup diagnosed with cardiopulmonary diseases and a subgroup without such comorbidities. The prevalence of cardiopulmonary symptoms was compared between the subgroups. The impact of cardiopulmonary symptoms on the degree of disability and daily functioning was assessed.

Results

In total, 370 patients were included in the study group. The most commonly symptoms included dyspnoea during exercise, palpitations and ankle oedema during daily activities. Cardiopulmonary symptoms were frequent in respondents diagnosed with cardiopulmonary diseases and in patients declaring no comorbidities of the heart and lungs. Intensity of chest pain, tolerance of physical activity, and fatigue were comparable in both of the study subgroups. The degree of disability was higher in respondents with concomitant cardiovascular and/or pulmonary comorbidities, but only dry cough and ankle oedema impacted the results.

Conclusions

Clinical symptoms indicative of heart and lung involvement occur frequently in patients with idiopathic inflammatory myopathies; however, cardiopulmonary complications seem to be relatively rarely detected. Active screening for cardiopulmonary involvement is recommended.

Arrhythmia prevalence among patients with polymyositis-dermatomyositis in the United States: An observational study

BACKGROUND

Systemic inflammation has been associated with atherosclerotic cardiovascular diseases (ASCVD) and arrhythmia occurrence in rheumatologic conditions such as rheumatoid arthritis. Polymyositis and dermatomyositis (PD) are rare rheumatologic conditions characterized by symmetrical proximal muscle weakness and, in the case of dermatomyositis, cutaneous eruption. Although there is literature associating PD with ASCVD, no population-level studies have analyzed arrhythmia risk in PD.

OBJECTIVE

The purpose of this study was to assess the prevalence of arrhythmia and its subtypes by age and sex in patients with PD and to determine associations between arrhythmia and PD.

METHODS

This retrospective cohort study included adults for whom hospitalizations had been recorded in the National Inpatient Sample database in the United States between 2016 and 2018. Patients with PD were matched (1:10) by age to patients without PD. Prevalence of arrhythmia was calculated in the 2 groups and compared by sex and age groups. Associations between PD and arrhythmia were determined after adjustment for common arrhythmia risk factors.

RESULTS

From 107,001,355 hospitalizations, 32,085 adults with PD were matched to 320,850 controls. Patients with PD aged <70 years had a higher prevalence of arrhythmia and higher adjusted odds of arrhythmia compared with controls. This increased risk was only seen for supraventricular arrhythmias. Adults with PD had increased odds of in-hospital mortality if they had an arrhythmia diagnosis (odds ratio 3.3; 95% confidence interval 2.5-4.5; P <.001).

CONCLUSION

We found a higher prevalence and odds of arrhythmias, particularly supraventricular arrhythmias, in young and middle-aged patients with PD compared with matched controls. Arrhythmias were associated with significant mortality among patients with PD.

Similar risk of cardiovascular events in idiopathic inflammatory myopathy and rheumatoid arthritis in the first 5 years after diagnosis

OBJECTIVES

To estimate the incidence of cardiovascular (CV) events in idiopathic inflammatory myopathy (IIM) compared to patients with rheumatoid arthritis (RA) and the general population. To explore the contribution of traditional CV risk factors to any difference observed.

METHODS

A retrospective matched population-based cohort study was conducted using UK Clinical Practice Research Datalink (CPRD) from 1987 to 2013. The incidence of CV events was calculated for each cohort over time and compared using Cox proportional hazards models. Multivariable analyses were used to adjust for traditional CV risk factors.

RESULTS

A total of 603 patients with IIM 4047 RA and 4061 healthy controls were included. The rate of CV events in IIM was significantly greater than healthy controls [hazard ratio (HR) 1.47 (95% confidence interval (CI) 1.18-1.83)] and remained significant after adjustment for CV risk factors [HR 1.38 (95% CI 1.11-1.72)]. Risk was similar between IIM and RA [HR 1.01 (95% CI 0.78-1.31)]. The rate of myocardial infarction [HR 1.61 (95% CI 1.27-2.04)] but not stroke [HR 0.92 (95% CI 0.59-1.44)] was significantly greater in IIM compared to healthy controls. After the first 5 years, the rate of CV events for RA remained significantly greater compared to the control group, but appeared to return to that of the healthy controls in the IIM group.

CONCLUSION

IIM is associated with an increased risk of CV events in the first 5 years after diagnosis similar to that of RA. Beyond 5 years, the risk appears to return to that of the general population in IIM but not RA. Key Points • The excess risk of cardiovascular events in IIM is similar to that found in RA. • The excess risk of cardiovascular events is greatest in the first 5 years after diagnosis.

Comparative Overall Comorbidity Burden Among Patients With Hidradenitis Suppurativa

Importance

The overall comorbidity burden among patients with hidradenitis suppurativa (HS) has not been systematically evaluated.

Objectives

To investigate the standardized overall comorbidity burden among patients with HS and to compare it with the comorbidity burden in patients with psoriasis and a control group.

Design, Setting, and Participants

A cross-sectional analysis was conducted of 5306 patients with HS, 14 037 patients with psoriasis, and 1 733 810 controls identified using electronic health records data from October 1, 2013, through October 1, 2018.

Main Outcome and Measure

The primary outcome was the mean Charlson Comorbidity Index (CCI) score.

Results

Each matched cohort had 3818 patients (2789 women and 1029 men; mean [SD] age, 45.7 [15.0]). Before matching, the overall mean (SD) CCI score was highest among the psoriasis cohort (2.33 [3.13]), followed by the HS cohort (1.80 [2.79]) and control cohort (1.26 [2.35]). In matched analyses, the overall mean (SD) CCI score was highest among the HS cohort (1.95 [2.96]), followed by the psoriasis cohort (1.47 [2.43]; P < .001) and control cohort (0.95 [1.99]; P < .001) patients. A total of 516 patients with HS (13.5%) had an overall mean CCI score of 5 or greater. Mean CCI score was highest for patients with HS across all sex, race, and age groups. The most common comorbidities among patients with HS were chronic pulmonary disease (1540 [40.3%]), diabetes with chronic complications (365 [9.6%]), diabetes without chronic complications (927 [24.3%]), and mild liver disease (455 [11.9%]). Patients with HS with a CCI score of 5 or greater had 4.97 (95% CI, 1.49-16.63) times the adjusted risk of 5-year mortality compared with patients with HS with a CCI score of zero.

Conclusions and Relevance

Patients with HS have a higher overall comorbidity burden compared with patients with psoriasis and a control group. A significant proportion of patients with HS have CCI scores of 5 or greater, which are associated with increased mortality. This degree of comorbidity burden may warrant multidisciplinary implementation of routine screening measures.

Outcome differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in postoperative ventricular arrhythmia, neurological complications, and in-hospital mortality

Objective: We study whether the carotid artery stenting (CAS) and carotid endarterectomy (CEA) differ from each other in postoperative ventricular arrhythmia, along with neurological complications (perioperative stroke and transient ischemic attack), in-hospital mortality, and estimated medical cost. Methods: This study used data of patients with carotid artery stenosis from the National Inpatient Sample (NIS) database (2011-2014) from the United States of America. Based on the procedure that patients received, individuals were categorized into groups of CAS and CEA. Multilevel analyses were conducted to examine the difference in the following outcomes: postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and medical costs between CAS and CEA. The patient age, gender, race, Charlson Comorbidity Index, primary payer, emergency department service record, bed size of hospital, region of the hospital, and location of the hospital were adjusted in each model. In addition, preexisting cardiovascular diseases (CVDs) were adjusted for when predicting postoperative ventricular arrhythmia; postoperative CVDs were adjusted for in the model of in-hospital mortality. Results: A total of 127,321 carotid artery stenosis hospitalizations were included in our analyses (n = 17,074 in CAS, n = 110,247 in CEA). Multivariate logistic regressions showed that compared with patients underwent CAS, those with CEA had a lower odds of postoperative ventricular arrhythmia (odds ratio [OR] = 0.81, 95% confidence interval [CI]: [0.66-0.98]), less neurological complications (OR = 0.55, 95% CI: [0.51-0.59] in general; OR = 0.63, 95% CI: [0.57-0.69] in ischemic stroke; OR = 0.26, 95% CI: [0.20-0.32] in hemorrhagic stroke; and OR = 0.58, 95% CI: [0.47-0.71] in transient ischemic attack), and in-hospital mortality (OR = 0.52, 95% CI: [0.42-0.64]). Generalized linear model indicated patients undergoing CEA had lower medical cost (β = -4329.99, 95% CI: [-4552.61, -4107.38]) than patients undergoing CAS. Conclusions: In short-term outcomes, CEA was associated with a lower risk of postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and lower cost as compared with CAS.

Incidence, survival, and risk of cardiovascular events in adult inflammatory myopathies in South Korea: a nationwide population-based study

OBJECTIVE

Epidemiological studies on inflammatory myopathies (IMs) show widely variable results, and studies on Asians are lacking. Despite emerging interest in the cardiovascular disease (CVD) risk associated with IMs, the prevalence of CVD in IM patients and its impact on mortality remain unclear. We conducted a nationwide, population-based study on the incidence, mortality, and associated major CVD events of IMs in the Republic of Korea over 11 years.

METHOD

Using the nationwide, population-based National Health Insurance claims database and the Rare Intractable Disease registration programme, we estimated incidence, mortality, and CVD occurrence. Survival was examined using the Kaplan-Meier method. Mortality rate in IMs with CVD was analysed by Cox proportional hazards regression.

RESULTS

There were 3014 incident cases, 640 of whom died during the study period. The mean annual incidence was 7.16/10⁶. Dermatomyositis (DM) and polymyositis (PM) had 5 year survival rates of 76.8% and 79.3%, respectively. Cardiovascular events occurred in 155 patients and 40.6% of IM patients with CVD died. Acute myocardial infarction in men had the highest risk of any CVD event in both DM [standardized incidence ratio (SIR) 4.2, 95% confidence interval (95% CI) 2.4-7.2] and PM (SIR 3.5, 95% CI 1.8-7.0). Haemorrhagic stroke had the highest hazard ratio (HR) in both DM (HR 2.31, 95% CI 1.13-4.70) and PM patients (HR 2.10, 95% CI 1.03-4.27) compared with the general population with CVD.

CONCLUSION

We found persistently low incidence, poor survival, and high major CVD incidence in IMs, and increased mortality in IMs with CVD.

Assessment of traditional and non-traditional risk factors for premature atherosclerosis in children with juvenile dermatomyositis and pediatric controls

BACKGROUND

Children with juvenile dermatomyositis (JDM), the most common inflammatory myopathy of childhood, may be at increased risk of premature atherosclerosis given a host of traditional and non-traditional risk factors. The primary aim of this study was to determine the underlying frequency of premature atherosclerosis in children with JDM compared to pediatric controls using flow-mediated dilation as a measure of endothelial function.

METHODS

Children and adolescents with and without JDM were evaluated for traditional atherosclerotic risk factors and assessment of endothelial function, using Endothelial Pulse Amplitude Testing (Endo-PAT).

RESULTS

In this study, 75% of pediatric controls were of Black or Hispanic descent (compared to 55% in the JDM group) and 70% were found to live in a household with a medium income less than $50,000/year (compared to 45% in the JDM group). Among traditional atherogenic risk factors, lipoprotein A appeared to be different between controls and JDM patients (66 nmol/L and 16.5 nmol/L, respectively). Using a reactive hyperemia index (RHI) < 1.67 as evidence of endothelial dysfunction, 75% of controls were defined as having endothelial dysfunction compared to 50% in JDM group. When controlled for lipoprotein A as an atherogenic confounder, JDM patients were found to have a 41% increase in RHI, thus indicating less endothelial dysfunction compared to controls.

CONCLUSIONS

In this study, we have shown that atherogenic risk factors are present in the pediatric population and may be associated with endothelial dysfunction, even at very young ages. Despite increasing concerns that children with rheumatologic disorders may be at increased risk of developing premature atherosclerosis, traditional and sociodemographic features may play a greater role in the ultimate development of cardiovascular disease.

Cardiovascular complications in patients with idiopathic inflammatory myopathies: does heart matter in idiopathic inflammatory myopathies?

This review presents a detailed study of original researches and previously published reviews concerning cardiovascular involvement in idiopathic inflammatory myopathies (IIM). We aimed to summarize the current knowledge on the cardiac involvement in IIM, evaluate its impact on mortality and indicate areas still awaiting to be investigated. We searched MEDLINE database (until January 2019) and the reference lists of articles. Selection criteria included only published data, available in English, both original researches and reviews. Articles related to cardiovascular involvement in IIM were selected and analysed. The references were also screened, and relevant articles were included. Cardiovascular involvement is frequent in IIM but typically remains subclinical. Among far less prevalent symptomatic forms, congestive heart failure is the most common. Myocardium and conduction system seems to be predominantly affected. High rate of left ventricular diastolic dysfunction was observed. Non-specific changes of ST-T segment were the most common abnormalities in electrocardiography. Patients with IIM were more frequently affected by atrial fibrillation as compared with other autoimmune diseases. Increased risk of myocardial infarction was observed; furthermore, patients often develop comorbidities that enhance cardiovascular risk. Since cardiovascular disorders remain one of the major causes of death and subclinical involvement is frequent, active screening is justified. Growing availability of the novel imaging techniques may facilitate diagnosis. Correlation between myocardial involvement and the type of autoantibodies and impact of different therapeutic options on the progression of cardiovascular lesions require further studies.

Pregnancy in myositis and scleroderma

Myositis and scleroderma are both rare autoimmune diseases with female predominance and often occur before and during reproductive years. The rarity of diseases explains the low frequency of concurrent disease and pregnancy. Like other autoimmune diseases, myositis and scleroderma may be more active during pregnancy as well. To date, many patients with myositis and scleroderma can have favorable pregnancy outcomes with careful management. This chapter provides a current overview of pregnancy outcomes in myositis and scleroderma. A major theme that appears to have emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and thus, personalized management is necessary depending on the disease state and comorbidities.

The failure of non-invasive prenatal testing due to maternal dermatomyositis

We experienced a case of a pregnant woman who failed to obtain a result from NIPT, due to the high level of total cell-free DNA. A subsequent ultrasound examination discovered that the fetus had severe intrauterine growth restriction, so the woman decided to abort the baby. At the same time, the woman developed slight swelling and tenderness of the proximal interphalangeal and meta-carpophalangeal joints. At first, these symptoms were not noticed, but, when the pregnant woman was admitted to the hospital, her laboratory tests were seriously abnormal, such as serum lactate dehydrogenase (640U/L), creatine phosphor kinase (4525U/L), kinase isoenzyme MB (170U/L), and a hydroxybutyrate dehydrogenase (398U/L). The patient had no other symptoms at this time. Misoprostol and subsequent forceps curettage were used for the induced abortion, a 167-g female fetus was aborted. Fetal skin tissue was taken for chromosomal microarray analysis (CMA) and placenta (biopsied in four places and tested as two composite samples) were taken for postnatal karyotyping to exclude a confined placental mosaicism, chromosomal microarray analysis of the fetal skin tissue revealed that the karyotype was 46, XX, karyotyping of placenta (100 cells) gave results of 46, XX, no abnormalities were detected. Ten days after induction, the patient had developed progressive symmetric muscle weakness in the proximal extremities. Physical examination revealed Gottron's sign and erythema. A manual muscle test showed weakness of the muscles (4/5) of her proximal extremities. Electromyography showed myogenic impairment. After excluding the possibility of neoplasia, the patient was diagnosed with dermatomyositis.

Acute Coronary Syndrome in Idiopathic Inflammatory Myopathies: A Population-based Study

Objective.

Evidence suggests an increased risk of cardiovascular (CV) diseases, including acute coronary syndrome (ACS), in idiopathic inflammatory myopathies (IIM). The aim of this study was to investigate the risk of ACS in an incident IIM cohort compared to the general Swedish population.

Methods.

A cohort of 655 individuals with incident IIM and 6813 general population comparators were identified from national registries. IIM subjects were diagnosed from 2002 to 2011. Followup started at IIM diagnosis and corresponding date in the general population. ACS, CV comorbidities, and CV risk factors were defined using International Classification of Diseases codes. Incidence rates including 95% CI were calculated. Cox proportional hazards models were used to compare the risk of ACS in patients with IIM and the general population. The competing risk of death was accounted for using competing risk regression models.

Results.

The incidence rate of ACS in IIM was higher than in the general population, particularly within the first year of diagnosis and in older individuals. The overall ACS incidence rate in IIM was 15.6 (95% CI 11.7–20.4) per 1000 person-years, with an HR of 2.4 (95% CI 1.8–3.2) compared with the general population. When accounting for the competing risk of death, the risk of ACS in IIM remained increased with a cumulative incidence of 7% at 5 years compared to 3.3% in the general population.

Conclusion.

IIM individuals are at higher risk of ACS, particularly within the first year after diagnosis.

The Effect of Statin Use on Mortality in Systemic Autoimmune Rheumatic Diseases

OBJECTIVE

Systemic autoimmune rheumatic diseases (SARD) are associated with an increased risk of premature cardiovascular disease (CVD) and all-cause mortality. We examined the potential survival benefit of statin use among patients with SARD in a general population setting.

METHODS

We conducted an incident user cohort study using a UK general population database. Our population included patients with a SARD as determined by Read code diagnoses of systemic lupus erythematosus, systemic sclerosis, Sjögren syndrome, dermatomyositis, polymyositis, mixed connective tissue disease, Behçet disease, or antineutrophil cytoplasmic antibodies-associated vasculitis between January 1, 2000, and December 31, 2014. We compared propensity score-matched cohorts of statin initiators and noninitiators within 1-year cohort accrual blocks to account for potential confounders, including disease duration, body mass index, lifestyle factors, comorbidities, and medication use.

RESULTS

Of 2305 statin initiators, 298 died during the followup period (mean 5.1 yrs), whereas among 2305 propensity score-matched noninitiators, 338 died during the followup period (mean 4.8 yrs). This corresponded to mortality rates of 25.4/1000 and 30.3/1000 person-years, respectively. Statin initiation was associated with reduced all-cause mortality (HR 0.84, 95% CI 0.72-0.98). When we compared the unmatched cohorts, the statin initiators (n = 2863) showed increased mortality (HR 1.85, 95% CI 1.58-2.16) compared with noninitiators (n = 2863 randomly selected within 1-year cohort accrual blocks) because of confounding by indication.

CONCLUSION

In this general population-based study, statin initiation was shown to reduce overall mortality in patients with SARD after adjusting for relevant determinates of CVD risk.

Cardiovascular and cerebrovascular comorbidities of juvenile dermatomyositis in US children: an analysis of the National Inpatient Sample

Objective

JDM is associated with multiple potential risk factors for cardiovascular disease, including reduced heart rate variability, systolic/diastolic cardiac dysfunction, abnormal brachial artery reactivity and metabolic syndrome. However, little is known about cardiovascular risk in JDM. We sought to examine the association between JDM and cardiovascular risk factors and disease in US children.

Methods

Data from the 2002-12 National Inpatient Sample was analysed, including ∼20% of all US hospitalizations (n = 14 535 620 paediatric hospitalizations).

Results

JDM was significantly associated with 12 of 13 comorbidities, including hypertension [survey logistic regression; crude odds ratio (95% CI): 22.25 (15.51, 31.92)], obesity [5.87 (3.44, 10.02)], uncomplicated diabetes [7.95 (4.21, 15.00)], lipid abnormalities [5.84 (2.77, 12.31)], particularly lipodystrophy [151.08 (38.24, 596.86)], peripheral and visceral atherosclerosis [10.09 (3.70, 27.56)], late effects of cerebrovascular disease [15.49 (2.37, 101.43)], personal history of transient ischaemic attack and cerebral infarction [10.82 (2.46, 47.65)], pulmonary circulatory disorder [12.23 (2.59, 57.73)], arrhythmia [3.93 (2.80, 5.52)], bradycardia [4.22 (2.65, 6.74)] and hypotension [2.62 (1.27, 5.39)].

Conclusions

There are significantly higher odds of cardiovascular and cerebrovascular comorbidities among inpatients with JDM, with adolescents, girls and racial/ethnic minorities being at highest risk.

Aminoquinoline antimalarial therapy in dermatomyositis-are we missing opportunities with respect to comorbidities and modulation of extracutaneous disease activity?

It is now widely accepted that long-term aminoquinoline antimalarial therapy with hydroxychloroquine (HCQ) can mitigate one of the most important comorbidities of systemic lupus erythematosus (LE)-atherosclerotic cardiovascular disease (ASCVD). Increasing evidence suggests that idiopathic inflammatory myopathy (IIM) patients have a risk for ASCVD comorbidity that is similar to that of systemic LE. I would like to explore the primary hypothesis that long-term HCQ therapy could provide those with IIM, especially dermatomyositis (DM) patients, an ASCVD comorbidity benefit similar to that of systemic LE. In addition, while HCQ is known to have clinical benefits for the cutaneous manifestations of DM, I would also like to explore the secondary hypothesis that HCQ might have steroid-sparing effects on one or more of the systemic manifestations of DM.

Hospitalization mortality and associated risk factors in patients with polymyositis and dermatomyositis: A retrospective case-control study

BACKGROUND

Polymyositis and dermatomyositis (PM/DM) are systemic autoimmune diseases with multiple organ involvements that manifest as muscular and cutaneous disorders, interstitial lung disease (ILD) and malignancies. However, information concerning the outcomes and associated factors for PM/DM patients who are hospitalized is limited.

METHODS

We retrospectively reviewed the medical charts of PM/DM patients admitted to a Chinese tertiary referral hospital (Peking Union Medical College Hospital, PUMCH) from 2008 to 2014. The deceased group included 63 patients who had "deceased discharge" status or were confirmed to have died within two weeks of hospital discharge. The demographic data, clinical manifestations, and direct causes of death were analyzed retrospectively. Medical records for 126 age- and sex-matched PM/DM patients were selected as controls from 982 inpatients successively admitted to the same center during the same period. In addition to the comparison of clinical manifestations between the two groups, binary logistic regression was conducted to explore the risk factors related to PM/DM mortality.

RESULTS

Over the past 6 years at PUMCH, the in-hospital mortality rate of PM/DM patients was 4.58%. The male gender and the elder patients had a high risk of death (P = 0.031 and P = 0.001 respectively). The three most frequent causes of death for PM/DM patients were pulmonary infection (35%), ILD exacerbation (21%) or both conditions (25%). Pulmonary infection (P<0.001, OR = 5.63, 95% CI, 2.37-13.36), pneumomediastinum (P = 0.041, OR = 11.02, 95%CI, 1.10-110.54), Gottron's papules (P = 0.010, OR = 3.24, 95%CI, 1.32-7.97), and elevated erythrocyte sedimentation rate (ESR) (P = 0.005, OR = 9.9, 95%CI 2.0-49.0) were independent risk factors for in-hospital mortality of PM/DM patients.

CONCLUSION

PM/DM patients continue to display high in-hospital mortality. Pulmonary infection is the strongest predictor of poor prognosis in PM/DM patients, followed by pneumomediastinum, Gottron's papules, and elevated ESR.

Pregnancy outcomes in adult patients with dermatomyositis and polymyositis

OBJECTIVE

The idiopathic inflammatory myopathies dermatomyositis (DM) and polymyositis (PM) are autoimmune diseases that can affect females of childbearing potential. We assessed pregnancy outcomes in DM and PM patients compared with the general obstetric population.

METHODS

The Nationwide Inpatient Sample (NIS) (1993-2007) was used to identify delivery-associated hospitalizations in women with DM or PM (DM/PM, n = 853). Controls were from the general obstetric population delivery-associated hospitalizations matched to each case by year of delivery. Pregnancy outcomes included hospital length of stay (LOS), hypertensive disorders (HTN), premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), and cesarean delivery. Multivariate regression analyses were performed using maternal age, race/ethnicity, and diabetes mellitus as covariates.

RESULTS

On multivariate analysis, patients with DM/PM had longer LOS compared to controls (p < 0.001). DM/PM was associated with an increased risk of hypertensive disorders compared to controls (OR = 2.90, 95% CI: 2.00-4.22). There were no differences in rates of PROM, IUGR, or cesarean section in patients with DM/PM compared with controls. Independent of a DM/PM diagnosis, African-American race, older age, and diagnosis of diabetes increased the hospital LOS (p < 0.001). African-American race and diabetes increased the risk of hypertensive disorders (OR = 1.38, 95% CI: 1.19-1.60; OR = 2.94, 95% CI: 2.04-4.23, respectively) compared to controls.

CONCLUSION

These data suggest that patients with inflammatory myopathies are at increased risk of hypertensive disorders of pregnancy and longer length of hospitalization. Vigilant monitoring of blood pressure is advisable in pregnant patients with DM or PM.

Is it cardiac involvement mimicking acute myocardial infarction in idiopathic inflammatory myopathy?

Idiopathic inflammatory myopathy (IIM) comprises a group of rare systemic diseases characterized by progressive weakness of the symmetrical proximal limb muscles, elevated muscle enzymes, inflammation or necrosis on muscle biopsy. IIM may impair the function of multiple organs, particularly the heart. However, it rarely manifests as acute myocardial infarction (AMI) at initial presentation. The present study described the case of a 39-year-old woman with AMI, whose muscle biopsy on the left arm conformed to polymyositis. Coronary arteriography showed irregularities in the left descending and right coronary artery (25% diameter reduction in middle segment). It was concluded that AMI was the chief manifestation of IIM at initial presentation. Furthermore, to the best of our knowledge, the present study was the first to provide a systematic literature review to assess AMI in IIM patients and discuss the possible causes of AMI.

Cardiac involvement in adult and juvenile idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM) include the main subgroups polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM) and juvenile DM (JDM). The mentioned subgroups are characterised by inflammation of skeletal muscles leading to muscle weakness and other organs can also be affected as well. Even though clinically significant heart involvement is uncommon, heart disease is one of the major causes of death in IIM. Recent studies show an increased prevalence of traditional cardiovascular risk factors in JDM and DM/PM, which need attention. The risk of developing atherosclerotic coronary artery disease is increased twofold to fourfold in DM/PM. New and improved diagnostic methods have in recent studies in PM/DM and JDM demonstrated a high prevalence of subclinical cardiac involvement, especially diastolic dysfunction. Interactions between proinflammatory cytokines and traditional risk factors might contribute to the pathogenesis of cardiac dysfunction. Heart involvement could also be related to myocarditis and/or myocardial fibrosis, leading to arrhythmias and congestive heart failure, demonstrated both in adult and juvenile IIM. Also, reduced heart rate variability (a known risk factor for cardiac morbidity and mortality) has been shown in long-standing JDM. Until more information is available, patients with IIM should follow the same recommendations for cardiovascular risk stratification and prevention as for the corresponding general population, but be aware that statins might worsen muscle symptoms mimicking myositis relapse. On the basis of recent studies, we recommend a low threshold for cardiac workup and follow-up in patients with IIM.

The Prevalence of Atherosclerosis in Those with Inflammatory Connective Tissue Disease by Race, Age, and Traditional Risk Factors

Systemic inflammation promotes cardiovascular disease. Inflammatory connective tissue diseases (CTD) like lupus and rheumatoid arthritis associate with cardiovascular risk, but it is unknown whether particular groups of patients have enhanced propensity for atherosclerotic cardiovascular disease (ASCVD) associated with their CTD. Analysis of aggregate health record data at a large U.S. academic center identified CTD and ASCVD status for 287,467 African American and white adults. ASCVD prevalence in those with CTD was 29.7% for African Americans and 14.7% for white patients with prevalence ratios, compared to those without CTD, of 3.1 and 1.8, respectively. When different types of CTD were analyzed individually (rheumatoid arthritis; lupus; scleroderma; Sjögren Syndrome; dermatomyositis/polymyositis; unspecified/mixed CTD; other inflammatory arthropathy), increased ASCVD rates were found in nearly all subsets, always with higher prevalence ratios in African Americans. The prevalence ratio of ASCVD was particularly high in young African Americans. Furthermore, individuals lacking traditional cardiovascular risk factors had more ASCVD if they had CTD (prevalence ratio 2.9). Multivariate analysis confirmed a positive interaction between CTD and African-American race and a negative interaction between CTD and age. The factors driving the observed disproportionate CTD-associated ASCVD in African Americans, young adults, and those without traditional risk factors warrant further study.

Risk of myocardial infarction and ischaemic stroke in adults with polymyositis and dermatomyositis: a general population-based study

OBJECTIVE

Limited data are available on the risk of cardiovascular disease in DM and PM. The purpose of this study was to estimate the risk of incident myocardial infarction (MI) and ischaemic stroke in adults with incident PM/DM at the general population level.

METHODS

We assembled a retrospective cohort of all adults with incident PM/DM in British Columbia, and we matched up to 10 adults randomly selected from the general population. We estimated the incidence rates (IRs) per 1000 person-years for MI and stroke. We calculated hazard ratios (HRs), adjusting for potential confounders.

RESULTS

Among 774 new cases of inflammatory myopathies, 424 had PM (59% female, mean age 60 years) and 350 had DM (65% female, mean age 56 years). IRs for MI and stroke in PM were 22.52 and 10.15 events per 1000 person-years, respectively, vs 5.50 and 5.58 events in the comparison cohort, respectively. Fully adjusted HRs (95% CI) were 3.89 (95% CI: 2.28, 6.65) for MI and 1.76 (95% CI: 0.91, 3.40) for stroke. The age-, sex- and entry time-matched HRs for MI and stroke were highest in the first year after PM diagnosis (6.51, [95% CI: 3.15, 13.47] and 3.48 [95% CI: 1.26, 9.62], respectively). Similar trends were seen for DM.

CONCLUSION

Our study demonstrates that PM and DM are both associated with an increased risk of MI but not ischaemic stroke. Our findings support increased vigilance in cardiovascular prevention, surveillance and risk modification in adults with PM and DM.

A population-based study of infection-related hospital mortality in patients with dermatomyositis/polymyositis

OBJECTIVE

Dermatomyositis (DM) and polymyositis (PM) are debilitating inflammatory myopathies associated with significant mortality. We evaluated the relative contribution of infection to hospital mortality in a large population-based study of individuals with PM/DM.

METHODS

Data derive from the 2007 to 2011 Healthcare Cost and Utilization Project National Inpatient Samples and include all hospital discharges that met a validated administrative definition of PM/DM. The primary outcome was hospital mortality. Variables for infections and comorbidities were generated from discharge diagnoses using validated administrative definitions. Logistic regression was used to investigate the relationship between infection and mortality in individuals with PM/DM, adjusting for sociodemographics, utilization variables, and comorbidities. Relative risks (RRs) were calculated to compare the overall prevalence of specific infections and associated mortality in PM/DM hospitalizations with those seen in the general hospitalized population.

RESULTS

A total of 15,407 hospitalizations with PM/DM met inclusion criteria for this study and inpatient mortality was 4.5% (700 deaths). In adjusted logistic regression analyses, infection (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.9-4.0) was the strongest predictor of hospital mortality among individuals with PM/DM. Bacterial infection (OR 3.5, 95% CI 3.0-4.1), comprised primarily of pneumonia and bacteremia, and opportunistic fungal infections (OR 2.5, 95% CI 1.5-4.0) were independently associated with hospital mortality. The overall burden of infection in hospitalizations with PM/DM was significantly increased in comparison with the general hospitalized population (RR 1.5, 95% CI 1.4-1.6).

CONCLUSION

Among hospitalized individuals with PM/DM, infection is the leading cause of mortality. Strategies to mitigate infection risk in both the clinic and hospital settings should be evaluated to improve disease outcomes.

Increased subsequent risk of acute coronary syndrome for patients with dermatomyositis/polymyositis: a nationwide population-based retrospective cohort study

OBJECTIVES

The aim of this study was to explore the possible association between dermatomyositis/polymyositis (DM/PM) and subsequent acute coronary syndrome (ACS) risk.

METHOD

We used data from the National Health Insurance (NHI) system of Taiwan to address the research topic. The exposure cohort contained 2029 patients with new diagnoses of DM/PM. Each patient was randomly frequency-matched according to sex and age with four participants from the general population who did not have a history of ACS at the index date (control group). Cox proportional hazard regression analyses were conducted to estimate the relationship between DM/PM and subsequent ACS risk.

RESULTS

Among patients with DM/PM, the overall risk for developing subsequent ACS was significantly higher than that of the control group [adjusted hazard ratio (aHR) 1.98, 95% confidence interval (CI) 1.17-3.35]. Further analysis indicated a higher risk in patients who were male, older, or diagnosed with comorbidities.

CONCLUSIONS

The findings from this population-based retrospective cohort study suggest that DM/PM is associated with an increased subsequent ACS risk.