Risk of Ischaemic Heart Disease in Patients with Inflammatory Bowel Disease: Cohort Study Using the General Practice Research Database

Cardiovascular manifestations of inflammatory bowel diseases and the underlying pathogenic mechanisms

Inflammatory bowel disease (IBD), consisting of ulcerative colitis and Crohn's disease, mainly affects the gastrointestinal tract but is also known to have extraintestinal manifestations because of long-standing systemic inflammation. Several national cohort studies have found that IBD is an independent risk factor for the development of cardiovascular disorders. However, the molecular mechanisms by which IBD impairs the cardiovascular system are not fully understood. Although the gut-heart axis is attracting more attention in recent years, our knowledge of the organ-to-organ communication between the gut and the heart remains limited. In patients with IBD, upregulated inflammatory factors, altered microRNAs and lipid profiles, as well as dysbiotic gut microbiota, may induce adverse cardiac remodeling. In addition, patients with IBD have a three- to four times higher risk of developing thrombosis than people without IBD, and it is believed that the increased risk of thrombosis is largely due to increased procoagulant factors, platelet count/activity, and fibrinogen concentration, in addition to decreased anticoagulant factors. The predisposing factors for atherosclerosis are present in IBD and the possible mechanisms may involve oxidative stress system, overexpression of matrix metalloproteinases, and changes in vascular smooth muscle phenotype. This review focuses mainly on 1) the prevalence of cardiovascular diseases associated with IBD, 2) the potential pathogenic mechanisms of cardiovascular diseases in patients with IBD, and 3) adverse effects of IBD drugs on the cardiovascular system. Also, we introduce here a new paradigm for the gut-heart axis that includes exosomal microRNA and the gut microbiota as a cause for cardiac remodeling and fibrosis.

Ischemic Heart Disease in Patients with Inflammatory Bowel Disease: Risk Factors, Mechanisms and Prevention

According to new research, a possible association between inflammatory bowel disease (IBD) and an increased risk of ischemic heart disease (IHD) has been demonstrated, but this concern is still debatable. The purpose of this review is to investigate the link between IHD and IBD, as well as identify further research pathways that could help develop clinical recommendations for the management of IHD risk in IBD patients. There is growing evidence suggesting that disruption of the intestinal mucosal barrier in IBD is associated with the translocation of microbial lipopolysaccharides (LPS) and other endotoxins into the bloodstream, which might induce a pro-inflammatory cytokines response that can lead to endothelial dysfunction, atherosclerosis and acute cardiovascular events. Therefore, it is considered that the long-term inflammation process in IBD patients, similar to other chronic inflammatory diseases, may lead to IHD risk. The main cardiovascular risk factors, including high blood pressure, dyslipidemia, diabetes, smoking, and obesity, should be checked in all patients with IBD, and followed by strategies to reduce and manage early aggression. IBD activity is an important risk factor for acute cardiovascular events, and optimizing therapy for IBD patients should be followed as recommended in current guidelines, especially during active flares. Large long-term prospective studies, new biomarkers and scores are warranted to an optimal management of IHD risk in IBD patients.

Endothelial Dysfunction and Arterial Stiffness in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Population-based studies have suggested that patients with inflammatory bowel disease (IBD) might be at an increased risk for cardiovascular diseases. A meta-analysis was performed on clinical studies to evaluate endothelial function, arterial stiffness, and carotid intima-media thickness (cIMT) in patients with IBD, after searching PubMed, Embase, Cochrane library, and Web of Science databases. A random-effects model was used to allow for the pooling of studies and for determination of the overall effect. After exclusion, a total of 41 eligible studies with 2330 patients with IBD and 2032 matched controls were identified and included for the analysis. It was found that cIMT was significantly increased in patients with IBD as compared with that in matched controls (Cohen's d: 0.63; 95% CI: 0.34, 0.93; I2 = 91.84%). The carotid-femoral pulse wave velocity was significantly higher in patients with IBD compared to that in matched controls (Cohen's d: 0.76; 95% CI: 0.54, 0.98; I2 = 70.03%). The augmentation index was also significantly increased in patients with IBD compared to matched control subjects (Cohen's d: 0.35; 95% CI: 0.08, 0.63; I2 = 61.37%). Brachial artery flow-mediated dilatation was significantly decreased in patients with IBD than that in matched controls (Cohen's d: -0.73; 95% CI: -1.10, -0.36; I2 = 81.02%). Based on the meta-analysis, it was found that patients with IBD exhibit significant endothelial dysfunction, increased arterial stiffness, and cIMT. Thus, patients with IBD may benefit from aggressive risk stratification for cardiovascular diseases.

Inflammatory bowel disease and cardiovascular diseases: a concise review

Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality despite aggressive treatment of traditional risk factors. Chronic inflammation plays an important role in the initiation and progression of CVDs. Inflammatory bowel disease (IBD) is a systemic state of inflammation exhibiting increased levels of pro-inflammatory cytokines including tumour necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6. Importantly, IBD is associated with increased risk for CVDs especially in women and young adults, including coronary artery disease, stroke, thromboembolic diseases, and arrhythmias. Potential mechanisms underlying the increased risk for CVDs in IBD patients include increased levels of inflammatory cytokines and oxidative stress, altered platelet function, hypercoagulability, decreased numbers of circulating endothelial progenitor cells, endothelial dysfunction, and possible interruption of gut microbiota. Although IBD does not appear to exacerbate the traditional risk factors for CVDs, including hypertension, hyperlipidaemia, diabetes mellitus, and obesity, aggressive risk stratifications are important for primary and secondary prevention of CVDs for IBD patients. Compared to 5-aminosalicylates and corticosteroids, anti-TNF-α therapy in IBD patients was consistently associated with decreasing cardiovascular events. In the absence of contraindications, low-dose aspirin and statins appear to be beneficial for IBD patients. Low-molecular-weight heparin is also recommended for patients who are hospitalized with acute IBD flares without major bleeding risk. A multidisciplinary team approach should be considered for the management of IBD patients.

Cardiovascular Risk Assessment and Impact of Medications on Cardiovascular Disease in Inflammatory Bowel Disease

There is increased risk of cardiovascular disease in patients with chronic inflammatory disorders such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus. Studies have shown association between cardiovascular disease (eg, myocardial infarction, heart failure, stroke) and inflammatory bowel disease. Medications such as infliximab and adalimumab (monoclonal antibodies to tumor necrosis factor α) may help decrease the inflammatory burden and cardiovascular risk; however, there have been reports of hypertriglyceridemia and worsening of moderate to severe heart failure with these medications. Janus kinase inhibitors, such as tofacitinib, have been associated with hyperlipidemia and thromboembolism. We aim to discuss clinical and imaging modalities to assess cardiovascular risk in inflammatory bowel disease patients and review the role of various medications with respect to cardiovascular disease in this population.

Disease Activity in Inflammatory Bowel Disease Is Associated With Arterial Vascular Disease

BACKGROUND AND AIMS

There is evidence that several inflammatory diseases are associated with increased cardiovascular risk. Whether this is true for inflammatory bowel diseases remains controversial. We aimed to assess this risk, corrected for the effects of conventional vascular risk factors and IBD disease activity.

METHODS

We conducted a cohort study in British general practice and hospital records from the Clinical Practice Research Datalink. We extracted the records of subjects with IBD and matched controls from 1997 to 2017. We conducted Cox proportional hazards and self-controlled case series analyses to examine the associations of IBD, disease activity, and hospitalization with the risk of myocardial infarction, stroke, and cardiovascular death in a manner attempting to remove the effect of likely confounders.

RESULTS

We identified 31,175 IBD patients (16,779 UC, 10,721 Crohn's disease, and 3675 unclassifiable cases) and 154,412 matched controls. Five hundred thirty-two myocardial infarctions, 555 strokes, and 469 cardiovascular deaths were observed in IBD cases. Our Cox regression models, adjusted for potential confounders, showed no significant excess of vascular events for IBD patients overall. There was, however, an increased hazard of myocardial infarction in ambulatory patients for acute disease (hazard ratio, 1.83 [1.28-2.62]) and chronic activity (hazard ratio, 1.69 [1.24-2.30]). This effect of disease activity was confirmed in our case series analysis.

CONCLUSIONS

Though we have found no evidence of an overall excess of vascular events in IBD patients, our findings of increased risk with more active disease suggest the potential for anti-inflammatory therapies to reduce cardiovascular risk in this patient group.

Increased risk of ischemic heart disease and diabetes in inflammatory bowel disease

BACKGROUND

 Previous studies showed inconsistent results regarding associations between inflammatory bowel disease (IBD) and risk of ischemic heart disease (IHD) and diabetes. The present study aimed to make a meta-analysis to assess the risk of IHD and diabetes in IBD.

METHODS

 We searched for articles published before February 2020 in the databases as follows: PubMed, Web of Science, Medline, EMBASE, and Google Scholar. We computed odds ratio (OR) or relative risk (RR) and 95 % confidence intervals (CI) regarding the association between IBD and risk of IHD or diabetes by using STATA 13.0 software.

RESULTS

 The present meta-analysis showed that IBD was associated with higher risk of IHD (OR/RR = 1.26, 95 % CI 1.20 to 1.32, I2 = 88.3 %, p < 0.0001). Additionally, both ulcerative colitis (UC) and Crohn's disease (CD) were associated with higher risk of IHD (UC: OR/RR = 1.19, 95 % CI 1.13 to 1.26, I2 = 65.6 %, p = 0.001; CD: OR/RR = 1.33, 95 % CI 1.17 to 1.51, I2 = 89.5 %, p < 0.0001). The study showed that IBD was associated with elevated risk of diabetes (OR/RR = 1.26, 95 % CI 1.03 to 1.53, I2 = 92.1 %, I2 = 92.1 %, p < 0.0001). Additionally, both UC and CD were associated with higher risk of diabetes (UC: OR/RR = 1.33, 95 % CI 1.03 to 1.71, I2 = 93.8 %, p < 0.0001; CD: OR/RR = 1.39, 95 % CI 1.10 to 1.76, I2 = 76.7 %, p = 0.002).

CONCLUSION

 In conclusion, patients with IBD are at increased risk of IHD and diabetes. Thus, regular monitoring of biomarkers of IHD and blood glucose levels should be considered for the early detection of IHD and diabetes in IBD patients.

Association between Corrected QT Interval and C-Reactive Protein in Patients with Inflammatory Bowel Diseases

Background and objectives: Electrocardiograph abnormalities (i.e., QT interval prolongation) have been described in inflammatory bowel diseases (IBD). We aimed to measure the QT interval in a cohort of patients with IBD and to analyze its relationship with clinical and inflammatory activity. Materials and Methods: We performed a cross-sectional study that included 38 IBD outpatients and 38 “age- and sex-matched” healthy controls. Nine patients had active IBD, and 29 were in clinical remission. Among the latter, 10 patients had sustained (lasting >1 year) and 19 had short-term remission (≤1 year). Corrected QT (QTc) interval was measured on standard 12-lead electrocardiograph. A systematic review of the literature on studies investigating the QT interval in patients with IBD was also performed. Results: QTc interval values were similar between IBD patients and healthy controls (417.58 ± 22.05 ms vs. 409.13 ± 19.61 ms, respectively; p: 0.479). Patients with active IBD had significantly higher QTc values (435.11 ± 27.31 ms) than both controls (409.13 ± 19.61 ms) and patients in remission (412.14 ± 17.33 ms) (p: 0.031). Post hoc analysis showed that the difference in QTc values between active IBD and remission was attributable to the group of patients with sustained remission (p < 0.05). Lastly, a significant correlation between QTc interval and C-reactive protein (CRP) values was observed (Spearman test: r = 0.563; p: 0.0005). Conclusions: Our study demonstrates an association between QTc duration and both clinical and inflammatory activity in patients with IBD. The higher the CRP value, the longer is the QTc duration. For practical purposes, all patients with active IBD should undergo a standard ECG. Prescription of drugs able to modify the QT interval should be avoided in patients with active IBD. The systematic review of the literature indicated that this is the first published study demonstrating an association between the QTc duration and CRP values in patients with IBD.

Cardiocerebral and peripheral vascular risks in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disease that mainly affects the digestive tract. In addition to intestinal manifestations, it also has many extraintestinal manifestations. There have been a number of reports of IBD with secondary opportunistic infections, perforation, cancer, etc. IBD is reported with more and more cardiovascular events, but the conclusions are still controversial. At present, clinicians pay insufficient attention to the assessment of cardiocerebral and peripheral vascular risks in IBD. This article reviews the relevant literature on cardiovascular, cerebrovascular and peripheral vascular risks in IBD published in recent years, with an aim to help clinicians be familiar with these risks and develop individualized management regimens in clinical practice.

Heart Under Attack: Cardiac Manifestations of Inflammatory Bowel Disease

There is a well-established association between chronic inflammation and an elevated risk of heart disease among patients with systemic autoimmune conditions. This review aims to summarize existing literature on the relationship between inflammatory bowel disease and ischemic heart disease, heart failure, arrhythmia, and pericarditis, with particular attention to approaches to management and treatment.

Chromogranin-A and its derived peptides and their pharmacological effects during intestinal inflammation

The gastrointestinal tract is the largest endocrine organ that produces a broad range of active peptides. Mucosal changes during inflammation alter the distribution and products of enteroendocrine cells (EECs) that play a role in immune activation and regulation of gut homeostasis by mediating communication between the nervous, endocrine and immune systems. Patients with inflammatory bowel disease (IBD) typically have altered expression of chromogranin (CHG)-A (CHGA), a major soluble protein secreted by EECs that functions as a pro-hormone. CHGA gives rise to several bioactive peptides that have direct or indirect effects on intestinal inflammation. In IBD, CHGA and its derived peptides are correlated with the disease activity. In this review we describe the potential immunomodulatory roles of CHGA and its derived peptides and their clinical relevance during the progression of intestinal inflammation. Targeting CHGA and its derived peptides could be of benefit for the diagnosis and clinical management of IBD patients.

Inflammatory Bowel Disease and Risk of Ischemic Heart Disease: An Updated Meta-Analysis of Cohort Studies

Background

Several immune‐mediated diseases have been shown to be associated with an increased risk of cardiovascular disease. However, studies evaluating the association between inflammatory bowel disease and risk of cardiovascular disease reported inconsistent results. We assessed the association between inflammatory bowel disease and risk of ischemic heart disease in a meta‐analysis of cohort studies.

Methods and Results

We conducted a literature search of PubMed and Embase up to October 2016 to identify relevant studies. The summary relative risks were calculated using the random‐effects models. To explore the source of heterogeneity, we performed subgroup and sensitivity analysis. We included 10 cohort studies that satisfied our inclusion criteria. Patients with inflammatory bowel disease were associated with an increased risk of ischemic heart disease (relative risk: 1.244; 95% CI, 1.142–1.355). Considerable heterogeneity was observed. Crohn's disease showed a significantly increased risk of ischemic heart disease (relative risk=1.243; 95% CI, 1.042–1.482) and a positive association was also observed in ulcerative colitis (relative risk=1.206; 95% CI, 1.170–1.242).

Conclusions

Based on meta‐analysis of cohort studies, we found an increased risk of ischemic heart disease in patients with inflammatory bowel disease. Large long‐term prospective studies are warranted to confirm our results.

Eosinophilia and Ulcerative Colitis Associated with Eosinophilic Myocarditis

Reactive eosinophilia is associated with inflammatory bowel disease, but its association with eosinophilic myocarditis is rare. We report a case of a 42-year-old man who presented with hypovolemic shock secondary to diarrhea and recently diagnosed nonischemic cardiomyopathy (left ventricular ejection fraction, 0.29). Laboratory evaluation revealed marked peripheral eosinophilia. Cardiac magnetic resonance imaging showed evidence of subacute-to-chronic myocarditis, and endomyocardial biopsy results were consistent with eosinophilic myocarditis. Colonic biopsy specimens revealed ulcerative colitis and no eosinophils. Hematologic evaluation was negative for an alternative cause of eosinophilia. The patient was given corticosteroids; his diarrhea resolved, but there was no short-term improvement in his ejection fraction, so an implantable cardioverter-defibrillator was placed. Follow-up at one year showed that the patient's left ventricular ejection fraction had improved to 0.42.