Increased risk of ischemic heart disease in young patients with newly diagnosed ankylosing spondylitis--a population-based longitudinal follow-up study

Association of ankylosing spondylitis with cardiovascular disease: a bidirectional two-sample mendelian randomization study

Backgrounds

Current observational investigations hint at a potential linkage between ankylosing spondylitis and cardiovascular wellness. However, the nature of this causality remains to be elucidated. Consequently, this study is designed to evaluate the causal interconnection between ankylosing spondylitis and cardiovascular-related conditions utilizing a bidirectional two-sample Mendelian Randomization (MR) methodology.

Methods

In this study, we conducted Mendelian randomization (MR) analyses using genome-wide association study (GWAS) data. The fixed-effects inverse variance weighted (IVW) model was used as the primary analysis method, and MR-Egger regression and the weighted median method were employed as supplementary approaches. Horizontal pleiotropy and heterogeneity were evaluated using various statistical tests, including MR-PRESSO global test, MR-Egger intercept, and Cochran's Q test.

Results

The MR result demonstrated an increased risk of heart failure in individuals with ankylosing spondylitis (OR: 1.0132, 95% CI = 1.0043-1.0221, p = 0.003). The MR analysis results did not demonstrate a causal relationship between ankylosing spondylitis and other cardiovascular diseases, such as atrial fibrillation, coronary artery disease, ischemic stroke, myocardial infarction, and valvular heart disease (all p > 0.05). No evidence of reverse causality was found between ankylosing spondylitis and mentioned cardiovascular diseases in reverse MR analyses. Sensitivity analysis verified the reliability of the results.

Conclusion

Our MR study indicates a relationship between ankylosing spondylitis and an increased risk of heart failure. Further research is needed to confirm these findings and elucidate the underlying mechanisms involved.

Pakistani Ankylosing Spondylitis Cohort with modifiable cardiovascular risk factors (PAS-CVD) study

Objective

To determine the frequency of modifiable cardiovascular risk factors in the Pakistani cohort with Ankylosing Spondylitis (AS).

Method

After IRB approval, a cross-sectional study was conducted among patients of AS, at the Department of Rheumatology Indus Medical College, Tando Mohammad Khan, from 15th March to 15th September, 2022. After obtaining demographic data, other parameters such as blood pressure (BP) and body mass index were recorded. In addition, a 5 ml blood sample was collected to assess their serum lipid profile, and fasting blood sugar levels. Using the laboratory data, the Framingham cardiovascular risk score was calculated for each patient and they were categorized into low, intermediate, or high-risk categories.

Results

Total 131 cases of ankylosing spondylitis: frequency of modifiable risk factors were: obesity (75.6%), high TG level (62.6%), high risk FRS score (40.5%), high LDL level (38.1%), low HDL (34.4%), hypertension (30.5%), diabetes mellitus (26.7%), high cholesterol level (17.6%), smoking (16%). In univariate analysis AS cases shows that increasing disease duration was associated with more risk of modifiable risk factors (p<0.05), on multivariate analysis, a positive association of age, diastolic blood pressure, smoking, diabetes mellitus, DMARDS, herbal medication-but not statistically significant (p>0.05).

Conclusion

In chronic AS there's higher prevalence of modifiable cardiovascular risk factors, earlier recognition and effective management helps in prevention of future cardiovascular events.

Impact of ankylosing spondylitis on stroke limited to specific subtypes: Evidence from Mendelian randomization study

Background

The relationship between Ankylosing Spondylitis (AS) and the risk of stroke is complex. Therefore, we utilized Two-Sample Mendelian randomization to examine the probable causal link between these two features.

Methods

The genetic instruments linked to AS were chosen from a summary-level genetic data set from the FinnGen consortium in people of European ancestry (1462 cases and 164,682 controls). Stroke and its subtypes were selected as outcomes, and the MEGASTROKE consortium population was used to identify the genetic associations of AS on stroke (40,585 cases and 406,111 controls), ischemic stroke (IS) (34,217 cases and 406,111 controls), and its subtypes including large artery stroke (LAS) (4373 cases and 146,392 controls), small vessel stroke (SVS) (5386 cases and 192,662 controls), and cardioembolic stroke (CES) (7193 cases and 204,570 controls). Intracerebral hemorrhage (ICH) (1687 cases and 201,146 controls) data set from the FinnGen consortium was also used. To obtain the casual estimates, the inverse variant weighted (IVW) method was mainly used. By examining the heterogeneity and pleiotropy of particular single nucleotide polymorphisms (SNPs), the robustness of the results was also examined.

Results

There was no evidence found to prove the correlation between genetically predicted AS and stroke (odds ratio [OR] 1.014; 95% confidence interval [CI] 0.999-1.031; P = 0.063), ICH (OR 1.030; 95% CI 0.995-1.067; P = 0.090), and IS (OR 1.013; 95% CI 0. 998-1.030; P = 0.090). In terms of the different subtypes of IS, there was strong evidence of positive causal inferences on CES (OR 1.051; 95% CI 1.022-1.081; P = 0.001), and suggestive evidence of positive causal inferences on LAS (OR 1.042; 95% CI 1.003-1.082; P = 0.033), while it was not significant for SVS (OR 1.010; 95% CI 0.975-1.047; P = 0.563).

Conclusion

This study suggests that the possible causative impact of genetically predicted AS on stroke may be restricted to the CES and LAS subtypes.

Therapeutic Utility and Adverse Effects of Biologic Disease-Modifying Anti-Rheumatic Drugs in Inflammatory Arthritis

Targeting specific pathologic pro-inflammatory cytokines or related molecules leads to excellent therapeutic effects in inflammatory arthritis, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. Most of these agents, known as biologic disease-modifying anti-rheumatic drugs (bDMARDs), are produced in live cell lines and are usually monoclonal antibodies. Several types of monoclonal antibodies target different pro-inflammatory cytokines, such as tumor necrosis factor-α, interleukin (IL)-17A, IL-6, and IL-23/12. Some bDMARDs, such as rituximab and abatacept, target specific cell-surface molecules to control the inflammatory response. The therapeutic effects of these bDMARDs differ in different forms of inflammatory arthritis and are associated with different adverse events. In this article, we summarize the therapeutic utility and adverse effects of bDMARDs and suggest future research directions for developing bDMARDs.

Burden of comorbidities and medication use in childbearing women with rheumatic diseases: a nationwide population-based study

BACKGROUND/AIMS

We aimed to estimate the prevalence of comorbidities and medication use in Korean women with rheumatic diseases (RDs) during their childbearing years.

METHODS

We included women aged 20 to 44 years with seropositive rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS) (n = 41,547) and age-matched women without seropositive RA, SLE, and AS (n = 208,941) from the National Health Insurance Service-National Health Information Database (2009 to 2016). The prevalence of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), and cancer and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids (CSs), and disease-modifying anti-rheumatic drugs (DMARDs) were estimated.

RESULTS

Women of childbearing age with RDs were more likely to have at least one of the measured comorbidities than the controls (odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9 to 3.1). The OR (95% CI) was 2.9 (2.8 to 3.0) for HTN, 2.8 (2.7 to 2.9) for HLD, 1.4 (1.4 to 1.5) for DM, and 1.3 (1.3 to 1.4) for cancer. The SLE group had the highest prevalence and odds of all four measured comorbidities. Almost all (97.9%) women of childbearing age with RDs were taking RD-related medications (NSAIDs, 81.6%; CSs, 77.8%; DMARDs, 87.3%). The RD group was 13.8 times more likely to take NSAIDs and 68.2 times more likely to take CSs than the controls. Use of NSAIDs was more prevalent in RA and AS than SLE, whereas use of CSs and DMARDs was more prevalent in RA and SLE than AS.

CONCLUSION

Korean women with RDs have a greater burden of comorbidities and medication use during their childbearing years than women without RDs of the same age.

Athrogenic indexes: Useful markers for predicting metabolic syndrome in axial spondyloarthritis

INTRODUCTION

Metabolic syndrome is a pathological entity associated with a high risk of cardiovascular disease. Data regarding the frequency of this syndrome, lipid profile, and atherogenic index of plasma in patients with radiographic axial spondyloarthritis are scarce. We aim to determine the prevalence of metabolic syndrome in patients with spondyloarthritis. We also aim to determine discriminative values of atherogenic indexes between patients with and without metabolic syndrome.

METHODS

We conducted a cross-sectional study including 51 patients meeting the ASAS 2009 criteria for radiographic axial spondyloarthritis. We measured the following parameters: triglyceride (TG), high-density lipoproteins (HDL_c), low-density lipoprotein cholesterol (LDL_c), and total cholesterol (TC). We calculated TC/HDL_c, TG/HDL_c, LDL_c/HDL_c ratios, and atherogenic index of plasma (LogTG/HDL_c).

RESULTS

Metabolic syndrome was noted in 33% of cases. Patients with active disease had a higher body mass index (26.89±5.88 versus 23.63±4.47kg/m², p=0.03), higher TG (1.41±0.64 versus 0.89±0.5mmol/L, p=0.05) and a lower HDL_c level (1±0.28 versus 1.31±0.22mmol/L, p=0.01). However, the LogTG/HDL_c and TG/HDL_c were higher in patients under TNFα inhibitors. The ability of the TG/HDL_c ratio and LogTG/HDL_c to distinguish patients with or without metabolic syndrome were good at cut-offs of 1.33 and 0.22, respectively (specificity: 91.2% and sensitivity 70.6% for both ratios).

CONCLUSION

Our study showed that metabolic syndrome is frequent in patients with axial spondyloarthritis. Atherogenic indexes can be used for predicting metabolic syndrome in these patients.

Cardiovascular Morbidity in Ankylosing Spondylitis: A Focus on Inflammatory Cardiac Disease

Ankylosing spondylitis (AS) is associated with an increase in cardiovascular (CV) morbidity when compared to the general population. The increased risk of CV involvement in AS is likely multifactorial including inflammation accelerating atherosclerosis and the cardiac inflammation itself in the form of aortitis and conduction anomalies. Establishing indisputable evidence linking AS and CV disease is challenging due to AS being relatively rare and it affects 1:1,000 and all studies analyzing the association between AS and CV disease involve a small sample size making long-term outcome measurements limited. The article reviews the literature studying the association between AS and CV disease as well as the impact of therapies for AS on the CV system (CVS).

Uveitis as a Risk Factor for Developing Acute Myocardial Infarction in Ankylosing Spondylitis: A National Population-Based Longitudinal Cohort Study

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease. Excess cardiovascular risks were well recognized in patients with AS and were attributed to prolonged systemic inflammation. Uveitis is one of the most common extra-articular symptoms of AS and is also considered an indicator of systemic inflammation. This study aimed to investigate whether uveitis was a risk factor for developing acute myocardial infarction (AMI) in patients with AS using the National Health Insurance Research Database (NHIRD).

Methods

Data were collected from the NHIRD over a fifteen-year period. Variables were analyzed using the Pearson chi-square test and Fisher’s exact test. Risk factors for the occurrence of AMI were examined by calculating hazard ratio. Kaplan-Meier analysis was performed to compare the cumulative incidence of AMI in the uveitis and non-uveitis cohorts.

Results

A total of 5905 patients with AS were enrolled, including 1181 patients with uveitis (20%) and 4724 patients without uveitis (80%). The Kaplan–Meier method with the log-rank test showed that the uveitis group had a significantly higher cumulative hazard for patients with AMI than the non-uveitis group (p < 0.001). The adjusted hazard ratio (aHR) of AMI was higher in the uveitis group than in the non-uveitis group (aHR = 1.653, p < 0.001). Stratified analysis revealed that patients with uveitis had an increased risk of developing AMI regardless of their sex (male/female aHR = 1.688/1.608, p < 0.001). Patients with uveitis in all age groups were independently associated with an increased risk of developing AMI compared to those without uveitis (20–39 years/40–59 years/≥ 60 years, aHR = 1.550, 1.579, 3.240, p < 0.001). Patients with uveitis had a higher probability of developing AMI regardless of comorbidities. Uveitis patients with comorbidities had a higher risk of developing AMI compared to uveitis patients without comorbidities.

Conclusion

Uveitis is a significant risk factor for developing AMI in patients with AS. Physicians should be aware of the potential cardiovascular risk in AS patients with uveitis, especially simultaneously with other traditional risk factors of AMI. Further prospective studies are needed to elucidate the underlying mechanism between uveitis and AMI in patients with AS.

Factors associated with high cardiovascular risk in psoriatic arthritis and non-psoriatic spondyloarthritis

To identify the association between traditional cardiovascular risk factors, diseases related factors, body composition and adipokines with high cardiovascular risk (HCVR) in psoriatic arthritis and non-psoriatic spondyloarthritis. This was a cross-sectional study involving age and BMI matched adults with psoriatic arthritis (PsA) (n = 56) and non-psoriatic spondyloarthritis (nPsA-SpA) (n = 58). Body composition using whole-body dual energy X-ray absorptiometry, adipokines and disease characteristics along with cardiovascular risk scoring QRISK3 and carotid intimal medial thickness (CIMT) was collected. Individuals with a QRISK3 ≥ 10% or CIMT of ≥ 75 percentile of the general population were categorised as HCVR. Predictors of HCVR were determined by logistic regression. HCVR was detected in 39 (34.2%) of the patients. After adjusting for all the factors, sarcopenia (aOR-15.83; 95% CI 1.16-215.48; p = 0.038) and presence of any traditional CV comorbidity (aOR: 18.97; 95% CI 1.63-221.29; p = 0.019) were associated with HCVR. nPsA-SpA had a 97% lesser chance of having HCVR as compared to PsA. The ROC curve analysis for the multiple logistic regression model which estimated the AUC as 0.787 (95% CI 0.701-0.874) and a P value < 0.001. Adipokine levels correlated well with body composition, but not with HCVR. PsA has a higher CV risk and the mechanisms for the same are poorly understood. Sarcopenia is an important determinant of HCVR and may be due to ectopic adipose tissue deposition in skeletal muscles. Focused physical therapy to prevent sarcopenia, optimum treatment of traditional CV risk factors and adequate disease control may help in preventing atherosclerosis in SpA.

Acute myocardial infarction in a young man with ankylosing spondylitis: A case report

BACKGROUND

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease that mainly affects the spine and sacroiliac joints. To the best of our knowledge, AS with acute myocardial infarction (AMI) has rarely been reported. Here, we report an unusual case of AS with AMI in a young patient.

CASE SUMMARY

A 37-year-old man was admitted to the Department of Rheumatology and Immunology of our hospital on March 14, 2020, for low back pain. Further evaluation with clinical examinations, laboratory tests, and imaging resulted in a diagnosis of AS. Treatment with a non-steroidal anti-inflammatory drug and a tumor necrosis factor inhibitor partially improved his symptoms. However, his back pain persisted. After 6 wk of treatment, he was admitted to the emergency room of another hospital in this city for sudden-onset severe chest pain consistent with a diagnosis of AMI. Angiography revealed severe narrowing of the coronary arteries. Surgical placement of two coronary stents completely relieved his back pain.

CONCLUSION

AS can cause cardiovascular diseases, including AMI. It is important to consider the cardiovascular risks in the management of AS.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Cardiovascular Risk Prediction in Ankylosing Spondylitis: From Traditional Scores to Machine Learning Assessment

Introduction

The performance of seven cardiovascular (CV) risk algorithms is evaluated in a multicentric cohort of ankylosing spondylitis (AS) patients. Performance and calibration of traditional CV predictors have been compared with the novel paradigm of machine learning (ML).

Methods

A retrospective analysis of prospectively collected data from an AS cohort has been performed. The primary outcome was the first CV event. The discriminatory ability of the algorithms was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), which is like the concordance-statistic (c-statistic). Three ML techniques were considered to calculate the CV risk: support vector machine (SVM), random forest (RF), and k-nearest neighbor (KNN).

Results

Of 133 AS patients enrolled, 18 had a CV event. c-statistic scores of 0.71, 0.61, 0.66, 0.68, 0.66, 0.72, and 0.67 were found, respectively, for SCORE, CUORE, FRS, QRISK2, QRISK3, RRS, and ASSIGN. AUC values for the ML algorithms were: 0.70 for SVM, 0.73 for RF, and 0.64 for KNN. Feature analysis showed that C-reactive protein (CRP) has the highest importance, while SBP and hypertension treatment have lower importance.

Conclusions

All of the evaluated CV risk algorithms exhibit a poor discriminative ability, except for RRS and SCORE, which showed a fair performance. For the first time, we demonstrated that AS patients do not show the traditional ones used by CV scores and that the most important variable is CRP. The present study contributes to a deeper understanding of CV risk in AS, allowing the development of innovative CV risk patient-specific models.

Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis

The cardiovascular burden in inflammatory rheumatic diseases is well recognized. Recently, this burden has been highlighted in ankylosing spondylitis (also known as radiographic axial spondyloarthritis) and psoriatic arthritis. We review the cardiovascular morbidity and mortality in these diseases, as well as the prevalence and incidence of traditional cardiovascular risk factors. We examine the contribution of anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and TNF inhibitors on the cardiovascular risk profile. Finally, we examine the available recommendations for the management of cardiovascular comorbidity, as they apply to the spondyloarthritis population.

The Prevalence of Renal Impairment in Patients with Spondyloarthritis: Results from the International ASAS-COMOSPA Study

OBJECTIVE

To assess the prevalence and association of renal dysfunction in patients with spondyloarthritis (SpA).

METHODS

The ASAS-COMOSPA (Assessment of Spondyloarthritis international Society-COMOrbidities in SPondyloArthritis) was an international study (22 participating countries from 4 continents) investigating comorbidities in SpA. Renal function was assessed based on estimated glomerular filtration rate (eGFR) calculated using the Modification of Diet in Renal Disease equation. SpA characteristics and risk factors for renal impairment were collected. Nonsteroidal antiinflammatory drug (NSAID) use was assessed based on current intake (last 3 mos).

RESULTS

Of the 3984 patients recruited, 2098 (52.6%) were analyzed after excluding outliers and patients with no available eGFR measurement [male sex: 63.5%; age: 45.3 yrs; disease duration: 8.6 years; HLA-B27+: 73.1%; Bath Ankylosing Spondylitis Activity Index (BASDAI): 3.6/10]. Overall, 153 patients (5.2%, mean age: 53.6 yrs) exhibited an eGFR < 60 ml/min/1.73 m2. In univariate analysis, renal impairment was associated with age (p < 0.001), HLA-B27 positivity (p = 0.003), several cardiovascular (CV) risk factors (history of hypertension, p < 0.001; systolic blood pressure, p = 0.009; diabetes, p = 0.005; and Framingham risk score, p < 0.001), disease activity scores [BASDAI, p = 0.001; Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP), p < 0.001], functional variables (Bath Ankylosing Spondylitis Functional Index, p < 0.001), inflammatory biomarkers (erythrocyte and CRP, both p < 0.001), and NSAID intake since onset of disease (percentage of days, p = 0.008). However, there was no association with disease duration, disease severity, or ASAS-NSAID score. In multivariate analysis, age (45-59 yrs: OR 1.9, > 60 yrs: OR 6.2), HLA-B27 positivity (OR 0.51), and CRP (OR 1.3) remained significantly associated with eGFR < 60 ml/min/1.73 m2.

CONCLUSION

Renal impairment was associated with age, HLA-B27 positivity, and inflammation, though not with CV risk factors, disease severity, or NSAID intake in patients with SpA.

Association of ischemic stroke with ankylosing spondylitis: a nationwide longitudinal cohort study

BACKGROUND

The purpose of this nationwide age- and sex-matched longitudinal follow-up study was to investigate the risk of developing ischemic stroke in ankylosing spondylitis (AS).

METHODS

The data in this study, spanning from January 1, 2010 to December 31, 2014, was obtained from a database maintained by the Korean National Health Insurance Service. A total of 12,988 patients with a diagnosis of AS were enrolled. The control group consisted of 64,940 age-sex-stratified matching subjects without AS. The 6year ischemic stroke incidence rate for each group was calculated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to estimate the hazard ratio of ischemic stroke.

RESULTS

During the follow-up period, 73 patients (0.56%) in the AS group and 250 patients (0.38%) in the control group developed ischemic stroke (p = 0.0041). The hazard ratio of ischemic stroke in the AS group was 1.46 (95% confidence interval [95% CI], 1.13-1.90) after adjusting for age and sex. The adjusted hazard ratio of ischemic stroke in the AS group was 1.35 (95% CI, 1.04-1.75) after controlling for demographics and comorbid medical disorders. According to subgroup analysis, in female and diabetes and non-hypertension and dyslipidemia subgroups, ischemic stroke incidence rates were significantly higher in AS patients than those in control group.

CONCLUSION

Our nationwide longitudinal study suggests an increased risk of ischemic stroke in AS patients.

The effect of inspiratory muscle training on respiratory variables in a patient with ankylosing spondylitis: A case report

Ankylosing Spondylitis (AS) presents with both musculoskeletal and cardiorespiratory pathophysiological manifestations. Inspiratory muscle training (IMT) may be a useful intervention to address deficits in respiratory and functional status.

CASE DESCRIPTION

A 25-year-old male with AS initially sought treatment for low back and right hip pain, but 7 weeks of IMT was also provided due to abnormal respiratory performance.

OUTCOMES

At baseline, the patient presented with a resting respiratory rate (RR) of 14.5 breaths/minute, tidal volume (TV) of 0.76 L, minute ventilation (VE) of 10.87 L/min, and end tidal CO2 (PetCO2) of 30.56 mmHg. Baseline exercise test results revealed a VO2max of 44 ml/kg/min and VE to CO2 output (VE/VCO2) slope of 30. Baseline MIP, SMIP, and MEP were 54 cm H2O, 507 PTU, and 87 cm H2O, respectively, and increased to 176 cm H2O, 807 PTU, and 151 cm H2O, respectively, after IMT. The VO2max increased to 51 ml/kg/min with decreases in the VE/VCO2 slope (29), resting RR (12 breaths/minute), resting TV (0.52 L), and resting VE (6.83 L/min) after IMT. Improvements during postural challenges were also observed.

DISCUSSION

This case demonstrates the clinical utility of respiratory gas analysis and respiratory performance measures to identify functional deficits and manage a patient with AS. The improvements in respiratory performance at rest, during postural challenges, and during maximal exercise after a relatively short period of IMT highlights the role IMT may have to improve functional status in patients with AS. Further investigation of IMT in patients with AS is warranted.

Recommendations for the Management of Comorbidity in Patients With Axial Spondyloarthritis in Clinical Practice

OBJECTIVES

To identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective.

METHODS

A multidisciplinary group was selected (10 rheumatologists-six of them experts in AxSpA-, 2 general practitioners, an internist, a cardiologist, a gastroenterologist and a psychologist). In a first discussion meeting, the scope and users were established and a list of comorbidities was voted based on frequency and impact. The panelists had to defend the inclusion of each comorbidity/item in the document with consistent arguments. Four panelists and two methodologists developed systematic reviews on controversial topics. In a second meeting, the results of the reviews and the arguments concerning the items to be included were presented. After the meeting, the final document was drafted.

RESULTS

The final document includes two checklists, one for health professionals and another for patients; they incorporate cardiovascular risk, renal comorbidities, gastrointestinal risk, lifestyle, risk of infections and vaccinations, pulmonary involvement, concomitant medication, psycho-affective disorders, osteoporosis, and risk of fracture. In addition, the document reflects the arguments favoring the inclusion of each item and how to record the items for subsequent collection. The panel considered it also appropriate to likewise establish «practices to avoid» applicable to comorbidity in AxSpA.

CONCLUSIONS

Two checklists and a list of situations to avoid were generated to facilitate the management of comorbidities in AxSpA. In a future step, their utility and acceptance will be tested by a broad group of users that includes doctors, patients and nurses.

Prevalence of psoriatic arthritis and costs generated by treatment of psoriatic arthritis patients in the public health system - the case of Poland

Objective

The objective of the study was to analyse the prevalence of psoriatic arthritis (PsA) in Poland and to assess the costs generated by treatment of PsA patients in the system of public healthcare.

Material and methods

The analysis was based on the database of the public payer, the National Health Fund (NFZ). PsA was defined by the diagnostic ICD-10 codes M07 (Enteropathic arthropathies) and L40.5 (Psoriatic arthropathies). The estimate of the costs was based on the reports submitted to the NFZ by health service providers. The prevalence rates were calculated using the NFZ data and the population estimates from the Central Statistical Office of Poland (GUS).

Results

In 2015, the prevalence of PsA (ICD-10: L40.5 and M07) in Poland was 3.2 per 10 000 population (3.7 in women and 2.6 in men). In 2015, nearly 7.3 thousand patients with the diagnosis of M07 and 6.3 thousand patients with the diagnosis of L40.5 received healthcare benefits. Women accounted for 60.6% of those patients. Nearly three fourths of PsA patients were aged 40 to 69 years with the median age of 54 years (56 years in women and 50 years in men). Between 2008 and 2015 the NFZ expenditure on the treatment of PsA increased from 6.6 million Polish zloty (PLN) (1.9 million EUR) to PLN 50.8 million (12.1 million EUR). In the same period, the number of PsA patients increased from 3.4 thousand to 11.9 thousand. In 2015, the mean cost of treatment per PsA patient was PLN 3.8 thousand.

Conclusions

The PsA prevalence rates estimated by the authors from the NFZ database are clearly lower than those derived from studies in other European countries, which may suggest that the actual number of PsA patients in Poland may be underestimated. Still the number of patients treated for PsA increased nearly 3.5-fold during 2008–2015, when the cost of PsA treatment rose more than 7 times.

Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations

Patients with inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, have higher rates of cardiovascular mortality. While the increased cardiovascular risk is only explained to some extent, a lot of research is currently conducted to improve our understanding of its pathogenesis, risk stratification, and optimal cardiovascular risk management. This review sought to report epidemiological data pertaining to the cardiovascular disease burden in patients with inflammatory arthritis, underlying mechanisms accounting for excessive cardiovascular risk, along with recommendations regarding risk assessment and management in this patient population.

Differences in cardiovascular manifestations between ankylosing spondylitis patients with and without kyphosis

The objective of this study is to evaluate the differences in cardiovascular manifestations between ankylosing spondylitis (AS) patients with and without kyphosis. A retrospective review of consecutive AS patients treated at our hospital between June 2013 and June 2015 was performed. There were 122 patients who met all of the inclusion and exclusion criteria. Among these patients, there were 57 (ASK group) patients with global kyphosis (GK) > 40° and 65 (AS group) patients with GK < 40°. General information, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), electrocardiography, and echocardiography were record. ESR and CRP levels in the ASK group were significantly higher than the AS group (P < 0.05). Fifteen patients in ASK group but 3 patients in AS group suffered from a left ventricular high voltage (P < 0.05). Heart rate in ASK group was 83.91 ± 13.68 beats/min, and it was 73.88 ± 13.04 beats/min in AS group (P < 0.05). The E/A ratio was 1.13 ± 0.38 in ASK group and 1.32 ± 0.49 in AS group (P < 0.05). The mitral E-wave deceleration time and isovolumetric relaxation time were, respectively, 236.25 ± 34.26 ms and 101.86 ± 17.57 ms in ASK group, which were shorter in AS group (P < 0.05). This study showed that AS patients with kyphosis had a statistically increased incidence of cardiovascular complications including a more rapid heart rate, left ventricular high voltage, and left ventricular diastolic dysfunction.

Is ankylosing spondylitis a risk factor for cardiovascular disease, and how do these risks compare with those in rheumatoid arthritis?

Aims

To assess and compare the incidence of cardiovascular (CV) events, by CV phenotype, between patients with ankylosing spondylitis (AS), rheumatoid arthritis (RA) and the general population.

Methods

Using linkages of national and population-based registers, we identified one cohort of prevalent patients with AS (n=5358), one with RA (n=37 245) and one with matched general population subjects (n=25 006). These cohorts were identified in 2006 through 2011 and were followed in 31 December 2012, for first ever occurrence of acute coronary syndromes (ACS), deep venous thromboembolism, pulmonary embolism and stroke, respectively. For each outcome, we calculated incidence rates standardised to the age and sex distribution of the AS cohort, as well as relative risks using Cox proportional hazards models.

Results

Based on 69 ACS events during 20 251 person-years of follow-up of the patients with AS, and 966 events during 127 014 person-years in the RA cohort, the age/sex-adjusted relative risks for ACS compared with the general population was 1.3 (95% CI 1.0 to 1.7) for AS and 1.7 (1.4 to 2.0) for RA. For thromboembolic events, the corresponding risks were 1.4 (1.1 to 1.9) in AS and 1.8 (1.5 to 2.1) in RA. Finally, for stroke, the relative risks were 1.5 (1.1 to 2.0) in AS and 1.5 (1.2 to 1.8) in RA, compared with the general population.

Conclusions

Prevalent patients with AS are at a 30%–50% increased risk of incident CV events. When compared with patients with RA, this level of increase was similar for stroke, but only half as high for ACS and thrombotic events.

Midlife Ankylosing Spondylitis Increases the Risk of Cardiovascular Diseases in Males 5 Years Later: A National Population-Based Study

There are limited studies describing the association between ankylosing spondylitis (AS) and cardiovascular disease (CVD) in patients over 40 years old. We aimed to focus on the incident AS patients in those aged 40 years or older and to investigate whether events of CVD occurred more than the general population.We conducted a nationwide cohort study between 2000 and 2005 using the Taiwan National Health Insurance Research Database. The risk of newly diagnosed CVD was compared between incident AS patients and matched age- and sex-matched subjects without AS. Events of CVDs were classified into 1 of 5 subcategories: hypertensive heart disease, coronary heart disease, congestive heart failure, cerebrovascular disease, or "other" CVD according to the ICD-9-CM codes. Cumulative incidences and hazard ratios (HRs) were calculated after adjusting for demographic and comorbid medical disorders. Multivariate analyses were performed using Cox proportional hazards model.We compared 537 AS and 2685 non-AS patients and found that the cumulative incidence rate of CVD during follow-up period was higher in the AS cohort than the non-AS cohort. The crude HR of CVD for the AS group was 1.24 [95% confidence interval (95% CI), 1.05-1.46; P = 0.01] and the adjusted HR was 1.20 with 95% CI 1.02 to 1.42 (P = 0.03). When stratified by age, AS cohort at age 60 to 69 years exhibited a significantly higher HR for all CVD than the general population cohort (adjusted HR 1.48, 95% CI 1.06-2.08, P < 0.05). When stratified by gender, male AS group had a significantly higher HR for all CVD than the general population cohort with the adjusted HR 1.28 (95% CI 1.01-1.63, P < 0.05). There was no statistically significant difference for females.Patients with AS, especially age 60 to 69 years male patients, had a higher risk of CVDs than non-AS controls.

Changes in cardiac function after pedicle subtraction osteotomy in patients with a kyphosis due to ankylosing spondylitis

Cardiac disease in patients with ankylosing spondylitis (AS) has previously been studied but not in patients with a kyphosis or in those who have undergone an operation to correct it.

The aim of this study was to measure the post-operative changes in cardiac function of patients with an AS kyphosis after pedicle subtraction osteotomy (PSO).

The original cohort consisted of 39 patients (33 men, six women). Of these, four patients (two men, two women) were lost to follow-up leaving 35 patients (31 men, four women) to study. The mean age of the remaining patients was 37.4 years (22.3 to 47.8) and their mean duration of AS was 17.0 years (4.6 to 26.4). Echocardiographic measurements, resting heart rate (RHR), physical function score (PFS), and full-length standing spinal radiographs were obtained before surgery and at the two-year follow-up.

The mean pre-operative RHR was 80.2 bpm (60.6 to 112.3) which dropped to a mean of 73.7 bpm (60.7 to 90.6) at the two-year follow-up (p = 0.0000). Of 15 patients with normal ventricular function pre-operatively, two developed mild left ventricular diastolic dysfunction (LVDD) at the two-year follow-up. Of 20 patients with mild LVDD pre-operatively only five had this post-operatively. Overall, 15 patients had normal LV diastolic function before their operation and 28 patients had normal LV function at the two-year follow-up.

The clinical improvement was 15 out of 20 (75.0%): cardiac function in patients with AS whose kyphosis was treated by PSO was significantly improved.

Cite this article: Bone Joint J 2015;97-B:1405–10.

Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality: A Population-Based Study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine in young adults. It is associated with excess cardiovascular and cerebrovascular morbidity.

OBJECTIVE

To determine whether patients with AS are at increased risk for cardiovascular and cerebrovascular mortality.

DESIGN

Population-based retrospective cohort study using administrative health data.

SETTING

Ontario, Canada.

PATIENTS

21 473 patients with AS aged 15 years or older and 86 606 comparators without AS, matched for age, sex, and location of residence.

MEASUREMENTS

The primary outcome was a composite of cardiovascular and cerebrovascular death. Hazard ratios (HRs) for vascular death were calculated; adjusted for history of cancer, diabetes, dementia, inflammatory bowel disease, hypertension, chronic kidney disease, and peripheral vascular disease; and, among those aged 66 years or older, relevant drug therapies. Independent risk factors for vascular mortality were identified in patients with AS.

RESULTS

The mean age of patients with AS was 46 years, and 53% were male. Patients and comparators were followed for 166 920 and 686 461 patient-years, respectively. Adjusted HRs for vascular death in AS were 1.36 (95% CI, 1.13 to 1.65) overall, 1.46 (CI, 1.13 to 1.87) in men, and 1.24 (CI, 0.92 to 1.67) in women. Significant risk factors for vascular death were age; male sex; lower income; dementia; chronic kidney disease; peripheral vascular disease; and, among patients aged 65 years or older, lack of exposure to nonsteroidal anti-inflammatory drugs and statins.

LIMITATION

Diagnosis codes for AS were not validated in Ontario.

CONCLUSION

Ankylosing spondylitis is associated with increased risk for vascular mortality. A comprehensive strategy to screen and treat modifiable vascular risk factors in AS is needed.

PRIMARY FUNDING SOURCE

The Arthritis Program, University Health Network, Toronto; and The Arthritis Society, Canada.

Cardiovascular and selected comorbidities in early arthritis and early spondyloarthritis, a comparative study: results from the ESPOIR and DESIR cohorts

Objectives

To investigate the prevalence of comorbidities in early rheumatoid arthritis (ERA) and early axial spondyloarthritis (ESpA) versus the general population.

Methods

Baseline data of 689 patients with ERA from the Etude et Suivi des Polyarthrites Indifférenciées Récentes (ESPOIR) cohort (age 48.2±12.1 years, symptoms duration 14.2±14.5 weeks) and 645 patients with ESpA from Devenir des Spondylarthropathies Indifférenciées Récentes (DESIR; age 32.8±8.4 years, axial symptoms duration 79.0±45.7 weeks) were analysed. Metabolic and cardiovascular diseases (CVD), infections and neoplasia were determined in each cohort. The prevalence (95% CI) of several comorbidities was compared with that in the French general population. For patients without CVD, the 10-year risk of developing CVD was calculated using the Framingham and SCORE equations. The heart age was calculated using the 2008 Framingham points system.

Results

42% of patients with ERA and 20.3% of patients with ESpA had at least 1 comorbidity; the most common were arterial hypertension (AHT) and dyslipidaemia. AHT prevalence (95% CI) in ERA (18.2% (15.5% to 21.3%)), but not in ESpA (5.08% (3.57% to 7.14%)), was significantly increased (p<0.05) compared with the general population (7.58%). Prevalence of tuberculosis history was higher in ERA (4.7% (3.3% to 6.6%)), and ESpA (0.99% (0.4% to 2.3%)) than in the general population (0.02%; both p<0.05). No differences were observed in malignancies, coronary heart disease or diabetes. In ERA, among patients without a history of CVD, an intermediate to high CVD risk was found. The heart age exceeded the real age by 4.1±9.6 years in ERA and by 2.1±7.0 years in ESpA (p<0.001).

Conclusions

We found an increased prevalence of AHT and tuberculosis history in ERA and ESpA, and an increased CVD risk. These results should prompt rheumatologists to check these comorbidities early in the disease.

Ankylosing spondylitis and risk of ischaemic heart disease: a population-based cohort study

OBJECTIVE

To investigate the incidence and risk of ischaemic heart disease (IHD) and acute myocardial infarction (AMI), including the role of non-steroidal anti-inflammatory drugs (NSAID), in patients with ankylosing spondylitis (AS) compared with population controls.

METHODS

All patients with newly diagnosed AS (n=3809) from the British Clinical Practice Research Datalink (1987-2012) were matched with up to seven persons without AS by year of birth, gender and practice (n=26 197). Incidence rate ratios (IRR) and HRs for development of IHD and AMI were calculated. Stepwise analyses were performed adjusting for age, gender, comorbidity and drug use, including NSAIDs.

RESULTS

At baseline, 4.3% of the patients had IHD and 1.8% had AMI compared with 3.4% and 1.4% of the controls, respectively. After exclusion of pre-existing IHD or AMI, the IRRs were 1.18 (95% CI 0.96 to 1.46) and 0.91 (95% CI 0.65 to 1.27) for IHD and AMI, respectively. Compared with controls, the age-gender adjusted HR for developing IHD was 1.20 (95% CI 0.97 to 1.48), and for AMI 0.91 (95% CI 0.65 to 1.28). In female patients, the risk of developing IHD was increased (HR 1.88, 95% CI 1.22 to 2.90), but after adjustment for all possible risk factors only a non-significant trend was found (HR 1.31, 95% CI 0.83 to 2.08). In particular, NSAID use explained this change (HR IHD adjusted for age-gender-NSAID use 1.57, 95% CI 0.99 to 2.48).

CONCLUSIONS

Female patients with AS had an increased age-adjusted risk of developing IHD, but after adjustment for NSAID use only a non-significant trend towards increased risk was found.

Cardiovascular events in ankylosing spondylitis: an updated meta-analysis

OBJECTIVES

Rheumatoid arthritis is associated with increased cardiovascular risk. In the guidelines, ankylosing spondylitis (AS) is considered to have an equally high cardiovascular risk. The literature findings remain controversial. This study aims to assess the risk of myocardial infarction (MI) and stroke in AS patients.

METHODS

An updated meta-analysis with a new systematic literature review using PubMed was conducted up to January 2014. Incidence of MI or stroke was calculated by metaproportion.

RESULTS

In addition to the 11 previously included studies, six new studies assessed the occurrence of MI or stroke in AS patients. (1) MI. A total of 2131 MI were reported in AS patients (n = 27,532) over a mean follow-up of 15 years: incidence 5.3% (1.6%-11.0%), i.e., 0.36/100 pyrs. Seven studies revealed 17,410 MI [2.5% (95% CI: 1.8%-3.4%)] in the control group (n = 1,349,964). Meta-analysis of the seven longitudinal studies showed a significant increase in MI [OR = 1.60 (95% CI: 1.32-1.93)] in AS patients. (2) Stroke. In 11 longitudinal studies (n = 51,990), 1807 strokes were reported in AS patients over 17.6 years of follow-up: incidence 3.6% (1.5%-6.5%), i.e., 0.24/100 pyrs. Three studies reported 22,899 strokes in controls (n = 1,239,041), giving an incidence of 1.78% (1.75%-1.80%). A significant increase in stroke [OR = 1.50 (95% CI: 1.39-1.62)] in AS patients was found.

CONCLUSION

AS patients appear to have a higher risk of MI and stroke. Management of cardiovascular risk factors and control of systemic inflammation should be taken into account in AS to decrease this high cardiovascular risk.

Current smoking is associated with incident ankylosing spondylitis -- the HUNT population-based Norwegian health study

OBJECTIVE

Smoking contributes to progression of ankylosing spondylitis (AS). Because smoking is also a risk factor for incident rheumatoid arthritis (RA) and psoriatic arthritis, our aim was to test whether smoking habits are associated with incident AS.

METHODS

Using data from the HUNT health study of the entire adult population of Nord-Trøndelag, Norway, participants in HUNT2 (1995-1997) and HUNT3 (2006-2008) were identified who reported a diagnosis of AS in HUNT3 but not in HUNT2 (n = 107). Incident AS cases were compared with AS-unaffected individuals (n = 35,278) in a case-control design. Participants with RA were excluded.

RESULTS

Present smoking was significantly associated with incident self-reported AS in logistic regression adjusted for potential confounders (OR 1.99, 95% CI 1.28-3.11, p = 0.002). Previous smoking (OR 1.15, 95% CI 0.66-2.02, p = 0.62) or total pack-years at HUNT2 (OR 1.01, 95% CI 0.99-1.04, p = 0.21) were not significant. The association with present smoking remained significant in various sensitivity analyses: including only cases with high probability of true AS diagnosis (OR 1.82, 95% CI 1.03-3.19, p = 0.04); including only cases with AS reported more than 3-5 years after HUNT2 (OR 2.34, 95% CI 1.09-5.03, p = 0.029), or including only participants genotyped for HLA-B27 (94 cases and 859 controls) adjusting for genotype (OR 1.79, 95% CI 1.04-2.85, p = 0.033). Hypertension was also significantly associated with incident AS (OR from 1.65 to 2.81).

CONCLUSION

In the HUNT population-based study, incident AS was associated with current smoking and hypertension. If verified in further studies, this suggests that smoking should be discouraged in those at a higher AS risk, e.g., with a family history or carrying HLA-B27.

Injury Location and Mechanism for Complex Regional Pain Syndrome: A Nationwide Population-Based Case-Control Study in Taiwan

BACKGROUND

Few studies have investigated the relationship between injury location, mechanism and their association with complex regional pain syndrome (CRPS). We conducted a nationwide database survey to explore this issue.

METHODS

This was a population-based case-control study. Five hundred and eighty-nine patients with at least one ambulatory visit or admission with a principal diagnosis of CRPS from 2004 to 2009 were selected. For each CRPS patient, ten age- and sex-matched non-CRPS subjects were randomly selected. The odds ratios (PLoS One. 2013;8:e57205) and 95% confidence intervals (95% CIs) of risk factors for CRPS were derived from multivariate logistic regression models.

RESULTS

Injury was a risk factor for CRPS (OR, 2.96; 95% CI, 2.18 to 4.02) independent of age and sex. In adjusted models, open wound on the upper limbs (OR 1.25, 95% CI 1.02 to 1.54) conferred higher CRPS risk. Injury mechanisms including nerve and spinal cord injury (OR 2.42, 95% CI 1.44 to 4.08), muscle and joint sprain and strain (OR 1.69, 95% CI 1.40 to 2.03), superficial injury (OR 1.23, 95% CI 1.00 to 1.51), and contusion (OR 1.44, 95% CI 1.20 to 1.74), but not fracture, increased the risk of CRPS.

CONCLUSION

Injury in the extremities rather than the trunk is an important risk factor for CRPS. Certain injury mechanisms confer higher risk of CRPS. This nationwide study demonstrated that injury increased CRPS nearly threefold. Open wound, sprain and strain, superficial injury, contusion, and nerve and spinal cord injury are main injury mechanisms. Injury in the extremities confers a higher risk of CRPS.

Increased risk of ischemic stroke in young patients with ankylosing spondylitis: a population-based longitudinal follow-up study

Background

Prospective data on the association between ischemic stroke and ankylosing spondylitis (AS) in the young are sparse. The purpose of this population-based, age- and sex-matched longitudinal follow-up study was to investigate the risk of developing ischemic stroke in young patients with AS.

Methods

A total of 4562 patients aged 18- to 45-year-old with at least two ambulatory visits in 2001 with a principal diagnosis of AS were enrolled in the AS group. The non-AS group consisted of 22810 age- and sex-matched, randomly sampled subjects without AS. The two-year ischemic stroke-free survival rate for each group were calculated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to estimate the hazard ratio of ischemic stroke after adjusting for demographic and clinical covariates.

Results

During follow-up, 21 patients in the AS group and 53 in the non-AS group developed ischemic stroke. The ischemic stroke-free survival rate over the 2 year follow-up was lower in the AS group than the non-AS group (p = 0.0021). The crude hazard ratio of ischemic stroke for the AS group was 1.98 (95% CI, 1.20–3.29; p = 0.0079) and the adjusted hazard ratio after controlling for demographic and comorbid medical disorders was 1.93 (95% CI, 1.16–3.20; p = 0.0110).

Conclusion

Our study showed an increased risk of developing ischemic stroke in young patients with AS.