Subclinical Atherosclerosis Is Not Accelerated in Patients with Ankylosing Spondylitis with Low Disease Activity: New Data and Metaanalysis of Published Studies

Increased carotid intima-media thickness in patients with radiographic axial spondyloarthritis compared to controls and associations with markers of inflammation

OBJECTIVE

There is an increased risk for cardiovascular disease (CVD) in patients with radiographic axial spondyloarthritis (r-axSpA). In this cross-sectional study, we aimed to, overall and stratified by sex, (i) compare ultrasound derived carotid intima media thickness (cIMT), between patients and controls, and (ii) investigate associations between cIMT, clinical disease activity and inflammation-related laboratory markers in patients with r-axSpA.

METHOD

In total, 155 patients diagnosed with r-axSpA using the modified New York criteria and 400 controls were included. Bilateral carotid ultrasound, laboratory testing, and questionaries were acquired. Disease-specific assessments were carried out for patients. Linear regression analysis was used to assess associations.

RESULTS

Linear regression analyses showed that patients with r-axSpA had increased mean cIMT compared to controls (mean ± SD, 0.8 ± 0.1 mm vs 0.7± 0.1 mm, respectively, unstandardized β (95% CI) -0.076 (-0.10, -0.052), P < 0.001) adjusted for smoking status and age. Linear regression analyses for patients with r-axSpA showed that only males presented significant associations between cIMT and inflammation-related laboratory markers, white blood cell (WBC) count (mean ± SD, 6.8 ± 1.6 109/L) and monocytes (0.6 ± 0.2 109/L); WBC count (unstandardized β (95% CI) 0.019 (0.0065, 0.031), P = 0.003, R2 = 0.57) and monocytes (0.13 (0.0047, 0.26), P = 0.041, R2 = 0.55), adjusted for age, smoking status, body mass index, hypertension, dyslipidemia, diabetes mellitus, ASDAS-CRP, and treatment with DMARDs and glucocorticoids. No significant association was found between cIMT and clinical disease activity assessed by ASDAS-CRP.

CONCLUSION

Patients with r-axSpA had significantly increased cIMT compared to controls. In male patients, higher WBC and monocyte count were associated with an increase in cIMT suggesting the role of inflammation in the development of atherosclerosis. Key Points •Carotid intima-media thickness was increased in patients with radiographic axial spondyloarthritis compared to controls. •White blood cell and monocyte counts were associated with carotid intima-media thickness in male patients with radiographic axial spondyloarthritis.

Progression of subclinical atherosclerosis in ankylosing spondylitis: a 10-year prospective study

Chronic systemic inflammation contributes to increased CVD burden in Ankylosing Spondylitis (AS). Since long-term follow-up data on subclinical atherosclerosis acceleration are lacking, we examined its progression in contemporary AS patients during 10 years. Fifty-three (89% male, aged 50.4 (36.3-55.9) years,) non-diabetic, CVD-free AS patients and 53 age-sex-matched non-diabetic, control individuals were re-evaluated after 9.2-10.2 years by ultrasonography for carotid/femoral atheromatosis, pulse wave velocity (PWV) and intima-media thickness (IMT), performed by the same operator/protocol. New atheromatic plaque formation, PWV deterioration, and IMT increase were associated only with classical CVD risk factors, as reflected by the heartSCORE (age, gender, smoking status, blood pressure and cholesterol levels) by multivariate analysis, rather than disease presence. However, among AS patients, despite remission/low disease activity at follow-up end in 79%, atheromatosis progression was associated by multivariate analysis with higher BASDAI scores (p = 0.028), independently of biologic therapies administered in 2/3 of them. Moreover, in AS patients, but not in controls, PWV values at baseline were associated with plaque progression during the 10-year follow-up after taking into account baseline heartSCORE and plaque burden status (p = 0.033). Despite comparable prevalence of both hypertension and hypercholesterolemia at baseline between patients and controls, a lower percentage of AS patients had achieved "adequate" CVD risk factor control at follow-up end (11% vs 25% respectively, p = 0.076). Classical CVD risk factors and residual disease activity account for the progression of subclinical atherosclerosis in AS, pointing to the unmet needs in the contemporary management of these patients.

Cardiovascular disease in spondyloarthritis: a narrative review of risk factors and the effect of treatments

PURPOSE OF REVIEW

This review summarizes the recent evidence available regarding the epidemiology of cardiovascular disease in spondyloarthritis (SpA), including the effect of disease modifying drugs on cardiovascular risk.

RECENT FINDINGS

People with SpA suffer from an increased risk of cardiovascular disease compared to the general population. This elevated risk is explained by the high prevalence of traditional cardiovascular risk factors and inflammation from disease activity leading to endothelial dysfunction and accelerated atherosclerosis. Consequently, the American College of Cardiology/American Heart Association and the European League Against Rheumatism recommend enhanced cardiovascular risk screening in SpA patients. There is evidence from observational studies that methotrexate and tumor necrosis factor inhibitors reduce the risk of cardiovascular events in SpA. Unlike what is observed in the general population, the use of nonsteroidal anti-inflammatory drugs does not appear to increase cardiovascular disease risk in SpA.

SUMMARY

Cardiovascular diseases are increasingly recognized in patients suffering from SpA, especially axial SpA and psoriatic arthritis. Cardiovascular diseases can cause significant morbidity, mortality, and add to the overall disease burden. Disease modifying drugs may mitigate some of the cardiovascular risk; however, a multidisciplinary team is needed to monitor patients and improve cardiovascular health status.

No evidence of a causal relationship between ankylosing spondylitis and cardiovascular disease: a two-sample Mendelian randomization study

Objective

Observational studies have suggested an increased risk of cardiovascular disease in individuals with ankylosing spondylitis. However, these studies are prone to confounding factors and reverse causality. To address these limitations, we conducted a Mendelian randomization study to assess the causal relationship between AS and CVD.

Methods

The study population comprises 9,069 individuals with ankylosing spondylitis and 509,093 individuals with either of six common cardiovascular diseases and a related indicator. Causal analysis using summary effect estimates and inverse variance weighting were employed as the main methods.

Results

The CAUSE analysis showed no evidence of a causal relationship between AS and CVD. The odds ratios for total CVD, heart failure, myocardial infarction, valvular heart disease, ischemic heart disease, and venous thromboembolism, Arterial stiffness index, were as follows: OR, 1.01; 95% confidence interval, 0.96-1.05; P = 0.91; OR, 1.03; 95% CI, 0.99-1.08; P = 0.50; OR, 0.94; 95% CI, 0.86-1.03; P = 0.53; OR, 0.99; 95% CI, 0.94-1.04; P = 0.99; OR, 0.98; 95% CI, 0.91-1.04; P = 0.94; OR, 0.98; 95% CI, 0.91-1.04; P = 0.99; β, -0.0019; 95% CI, 0.97-1.01; P = 0.99. The IVW and weighted median methods also yielded consistent results, and no heterogeneity or pleiotropy was found. Likewise, a reverse Mendelian randomization analysis did not uncover a heritable causal relationship between AS and CVD.

Conclusion

This Mendelian randomization study does not support a causal relationship between AS and CVD. Further research is needed to confirm this association.

Cardiovascular risk in axial spondyloarthritis-a systematic review

Cardiovascular manifestations are common in patients suffering axial spondyloarthritis and can result in substantial morbidity and disease burden. To give an overview of this important aspect of axial spondyloarthritis, we conducted a systematic literature search of all articles published between January 2000 and 25 May 2023 on cardiovascular manifestations. Using PubMed and SCOPUS, 123 out of 6792 articles were identified and included in this review. Non-radiographic axial spondyloarthritis seems to be underrepresented in studies; thus, more evidence for ankylosing spondylitis exists. All in all, we found some traditional risk factors that led to higher cardiovascular disease burden or major cardiovascular events. These specific risk factors seem to be more aggressive in patients with spondyloarthropathies and have a strong connection to high or long-standing disease activity. Since disease activity is a major driver of morbidity, diagnostic, therapeutic, and lifestyle interventions are crucial for better outcomes. Key Points • Several studies on axial spondyloarthritis and associated cardiovascular diseases have been conducted in the last few years addressing risk stratification of these patients including artificial intelligence. • Recent data suggest distinct manifestations of cardiovascular disease entities among men and women which the treating physician needs to be aware of. • Rheumatologists need to screen axial spondyloarthritis patients for emerging cardiovascular disease and should aim at reducing traditional risk factors like hyperlipidemia, hypertension, and smoking as well as disease activity.

Cardiovascular Disease and Cardiac Imaging in Inflammatory Arthritis

Cardiovascular morbidity and mortality are more prevalent in inflammatory arthritis (IA) compared to the general population. Recognizing the importance of addressing this issue, the European League Against Rheumatism (EULAR) published guidelines on cardiovascular disease (CVD) risk management in IA in 2016, with plans to update going forward based on the latest emerging evidence. Herein we review the latest evidence on cardiovascular disease in IA, taking a focus on rheumatoid arthritis, psoriatic arthritis, and axial spondylarthritis, reflecting on the scale of the problem and imaging modalities to identify disease. Evidence demonstrates that both traditional CVD factors and inflammation contribute to the higher CVD burden. Whereas CVD has decreased with the newer anti-rheumatic treatments currently available, CVD continues to remain an important comorbidity in IA patients calling for prompt screening and management of CVD and related risk factors. Non-invasive cardiovascular imaging has been attracting much attention in view of the possibility of detecting cardiovascular lesions in IA accurately and promptly, even at the pre-clinical stage. We reflect on imaging modalities to screen for CVD in IA and on the important role of rheumatologists and cardiologists working closely together.

Benefits of tumor necrosis factor inhibitors for cardiovascular disease in ankylosing spondylitis

Ankylosing spondylitis (AS) has been associated with an increased cardiovascular disease (CVD) risk, with current guidelines recommending multiple CVD-related risk assessment strategies. CVD risk prediction using a scoring model with lipids might be another promising alternative, for which ultrasound screening for subclinical atherosclerosis may be considered together with surrogate markers. Theoretically, tumor necrosis factor inhibitors (TNFi), which are known to inhibit endothelial activation and inflammation caused by the disease and underlying metabolic dysfunction, might prevent microvascular events. In this narrative review, we summarized the evidence of TNFi effects on CVD in AS. Although early case reports revealed that CVD occurred during TNFi treatment, more recent evidence shows that it could be successfully treated. Studies of TNFi on lipid changes and subclinical atherosclerosis have shown controversial results, possibly due to genetic predisposition, differences in affinity for membrane-bound TNF leading to insufficient inhibition of inflammation or primary failure response to TNFi, and not enough follow-up time to identify potential significance. Overall, patients vulnerable to CVD could benefit from long-term administration of TNFi when inflammation is under control. Besides healthy lifestyle modification, traditional CVD risk factors and metabolic syndrome-related diseases should be further assessed and treated if necessary.

Endothelial dysfunction and increased carotid intima-media thickness in patients with spondyloarthritis without traditional cardiovascular risk factors

Background

The aim of our study was to assess subclinical atherosclerosis in spondyloarthritis (SpA) by combining three ultrasound methods (flow-mediated dilation (FMD), carotid intima–media thickness (cIMT) and Ankle Brachial Index (ABI)) and to determine the predictive factors of theses parameters.

Methods

This was a case control study conducted over 12 months including 47 patients with SpA-free-cardiovascular (CV) disease in comparison with age and sex matched 47 healthy controls. Sociodemographic, clinical and biological features as well as therapeutic modalities were recorded in our patients. All subjects had Doppler ultrasound with measurement of cIMT, FMD and ABI. Ultrasound measurements were compared between patients and controls. Linear regression was performed and assessed by machine learning to determine the predictive models of markers of subclinical atherosclerosis.

Results

We found higher cIMT (p<0.0001), lower FMD (p=0.008) and higher left ABI (0.048) in patients with SpA compared with controls. cIMT was positively correlated to patient-related parameters (age, systolic blood pressure) and disease parameters (age at onset of SpA, disease duration and renal involvement). Biologically, cIMT was positively correlated with creatinine, blood-glocose, total cholesterol (CT) and CT/cholesterol-high density lipoprotein ratio. FMD was negatively correlated with male gender, age, systolic blood pressure, creatinine, blood glucose and Left Lequesne Index. ABI was significantly associated with diastolic blood pressure. Multiple regression analysis identified age, CT and creatinine as independents predictive factors for increased cIMT. Regarding endothelial dysfunction, blood glucose and Left Lequesne Index were the independents predictive factors of decreased FMD.

Conclusion

Our study supported the accelerated subclinical atherosclerosis in patients with SpA. This subclinical atherosclerosis was mainly mediated by traditional CV risk factors.

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).

The second decade of anti-TNF-a therapy in clinical practice: new lessons and future directions in the COVID-19 era

Since the late 1990s, tumor necrosis factor alpha (TNF-α) inhibitors (anti-TNFs) have revolutionized the therapy of immune-mediated inflammatory diseases (IMIDs) affecting the gut, joints, skin and eyes. Although the therapeutic armamentarium in IMIDs is being constantly expanded, anti-TNFs remain the cornerstone of their treatment. During the second decade of their application in clinical practice, a large body of additional knowledge has accumulated regarding various aspects of anti-TNF-α therapy, whereas new indications have been added. Recent experimental studies have shown that anti-TNFs exert their beneficial effects not only by restoring aberrant TNF-mediated immune mechanisms, but also by de-activating pathogenic fibroblast-like mesenchymal cells. Real-world data on millions of patients further confirmed the remarkable efficacy of anti-TNFs. It is now clear that anti-TNFs alter the physical course of inflammatory arthritis and inflammatory bowel disease, leading to inhibition of local and systemic bone loss and to a decline in the number of surgeries for disease-related complications, while anti-TNFs improve morbidity and mortality, acting beneficially also on cardiovascular comorbidities. On the other hand, no new safety signals emerged, whereas anti-TNF-α safety in pregnancy and amid the COVID-19 pandemic was confirmed. The use of biosimilars was associated with cost reductions making anti-TNFs more widely available. Moreover, the current implementation of the “treat-to-target” approach and treatment de-escalation strategies of IMIDs were based on anti-TNFs. An intensive search to discover biomarkers to optimize response to anti-TNF-α treatment is currently ongoing. Finally, selective targeting of TNF-α receptors, new forms of anti-TNFs and combinations with other agents, are being tested in clinical trials and will probably expand the spectrum of TNF-α inhibition as a therapeutic strategy for IMIDs.

Factors Associated with the Risk of Major Adverse Cardiovascular Events in Patients with Ankylosing Spondylitis: A Nationwide, Population-Based Case-Control Study

Background: Potential risk factors for major adverse cardiovascular events (MACE) in patients with ankylosing spondylitis (AS) requiring medical therapy should be investigated. Methods: We identified newly diagnosed AS patients without previous MACE from 2004 to 2012 using the National Health Insurance Research Database, matched MACE cases with non-MACE controls at a 1:4 ratio for age, gender, AS duration, and index date, and included 947 AS patients with MACE and 3896 matched controls for final analyses. By using conditional logistic regression analyses, we examined the associations of MACE with low income, urbanisation, comorbidities, common extra-articular manifestations (EAM), and medications, including nonsteroidal anti-inflammatory drugs (NSAID) of three categories (traditional NSAIDs, selective cyclooxygenase-2 inhibitors (COX-2i), and preferential COX-2is) with their annual cumulative defined daily dose (cDDD) within a year before MACE development. Results: MACE development was associated with the use of selective COX-2is (especially with annual cDDD > 132) and corticosteroids, residence in rural regions, and well-known associated comorbidities, but not with the use of traditional NSAIDs, preferential COX-2i, biologics, methotrexate, sulfasalazine, and common EAMs. Conclusions: The risk factors of MACE in newly diagnosed AS patients include residence in rural regions, well-known associated comorbidities, and the use of corticosteroids and selective COX-2is. A major limitation was the lack of information on individual lifestyle patterns and disease activity.

Subclinical Atherosclerosis Measure by Carotid Ultrasound and Inflammatory Activity in Patients with Rheumatoid Arthritis and Spondylarthritis

Objective: To compare the effect of inflammation on subclinical atherosclerosis using carotid ultrasound in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods: Cross-sectional study including 347 participants (148 RA, 159 SpA, and 40 controls). We measured the carotid intima media thickness (cIMT) and detection of atheromatous plaques using carotid ultrasound. We recorded disease activity (DAS28-CRP/ASDAS-CRP) and traditional cardiovascular risk factors. We performed descriptive, bivariate, and linear multivariate analyses (dependent variable: cIMT) to evaluate the influence of diagnosis on cIMT in all patients. Two additional multivariate analyses were performed by stratifying patients according to their inflammatory activity. Results: cIMT correlated with the mean CRP during the previous 5 years in RA, but not with CRP at the cut-off date. We did not find such differences in patients with SpA. The first multivariate model revealed that increased cIMT was more common in patients with RA than in those with SpA (β coefficient, 0.045; 95% confidence interval (95% CI), 0.0002–0.09; p = 0.048) after adjusting for age, sex, disease course, and differential cardiovascular risk factors (arterial hypertension, smoking, statins, and corticosteroids). The second model revealed no differences in cIMT between the 2 groups of patients classified as remission–low activity (β coefficient, 0.020; 95% CI, −0.03 to 0.080; p = 0.500). However, when only patients with moderate–high disease activity were analysed, the cIMT was 0.112 mm greater in those with RA (95% CI, 0.013–0.212; p = 0.026) than in those with SpA after adjusting for the same variables. Conclusions: Subclinical atherosclerosis measured by carotid ultrasound in patients with RA and SpA is comparable when the disease is well controlled. However, when patients have moderate–high disease activity, cIMT is greater in patients with RA than in those with SpA after adjusting for age, sex, disease course, and cardiovascular risk factors. Our results point to greater involvement of disease activity in subclinical atherosclerosis in patients with RA than in those with SpA.

The Risk of Cardiovascular Diseases in Axial Spondyloarthritis. Current Insights

There is an increased cardiovascular (CV) risk in axial spondyloarthritis (axSpA), leading to increased CV mortality and morbidity in these patients. The factors that may explain this enhanced CV risk in axSpA are multiple, including traditional CV risk factors such as smoking, but also the inflammatory process and probably the use of non-steroidal anti-inflammatory drugs (NSAIDs). The CV involvement of axSpA may be detected at an early and pre-clinical stage, using non-invasive techniques. While NSAIDs play a deleterious role in the CV risk of axSpA, TNF inhibitors seem to have a beneficial impact, but this remains to be demonstrated in specific clinical studies. More data are needed to determine the potential effects of IL-17 inhibitors on the CV risk of axSpA. CV comorbidity has been mainly assessed in the radiographic form of axSpA, while limited data are available in patients with the non-radiographic form. The current management of axSpA must consider this CV comorbidity according to the EULAR recommendations. Rheumatologists play a determinant role in the detection of CV risk and current management of these patients is focused on the control of disease activity, suppression of inflammation, screening for and management of traditional CV risk factors, as well as the restriction of NSAID use.

Effect of Biologics on Cardiovascular Inflammation: Mechanistic Insights and Risk Reduction

It is increasingly recognized that atherosclerosis and consequently cardiovascular disease (CVD) are closely linked with inflammatory processes. The latter is in the center of the pathogenic mechanism underlying autoimmune rheumatic diseases (ARD). It follows then, that optimal control of inflammation in ARDs may lead to a decrease of the accompanied CVD risk. Major trials (eg, CANTOS, CIRT), aimed at examining the possible benefits of immunomodulatory treatments in CVD, demonstrated conflicting results. On the other hand, substantial evidence is accumulating about the possible beneficial effects of biologic disease modifying antirheumatic drugs (bDMARDs) in patients with ARDs, particularly those with rheumatoid arthritis (RA). It seems that bDMARDs (some more than others) alter the lipid profile in RA patients but do not adversely affect, in most cases, the TC/HDL ratio. Favorable effects are noted for arterial stiffness and endothelial function. This is reflected in the lower risk for CVD events, seen in observational studies of RA patients treated with bDMARDs. It should be stressed that more data exist for the TNF-inhibitors than for other bDMARDs, such as tocilizumab, abatacept and rituximab. As regards the spondyloarthropathies (SpA), data are less robust. For TNF-inhibitors, effects appear to be on par with those seen in RA but no conclusions can be drawn for newer biologic drugs used in SpA (eg, IL-17 blockers). Finally, there is accumulating evidence for a beneficial effect of immunosuppressive treatment in cardiac inflammation and function in several ARDs. Introduction of newer therapeutic options in clinical practice seem to have a positive impact on CVD in the setting of ARD. This is probably due to better control of inflammation, but direct improvement in vascular pathology is also a valid hypothesis. Most data are derived from observational studies and, therefore, randomized controlled trials are needed to assess the possible favorable effect of bDMARDs on CVD outcomes.

Subclinical atherosclerotic disease in ankylosing spondylitis and non-radiographic axial spondyloarthritis. A multicenter study on 806 patients

OBJECTIVES

To compare the atherosclerosis disease burden between ankylosing spondylitis (AS) and non-radiographic (nr) axial spondyloarthritis (axSpA) and establish a model that allows to identify high-cardiovascular (CV) risk in axial spondyloarthritis patients.

METHODS

Cross-sectional study from the AtheSpAin cohort, a Spanish multicenter cohort aimed to study atherosclerosis in axSpA. Carotid ultrasound (US) was performed to determine the carotid intima-media wall thickness (cIMT) and detect the presence of carotid plaques. The European cardiovascular disease risk assessment model, the Systematic COronary Risk Evaluation (SCORE), was also applied.

RESULTS

A set of 639 patients with AS and 167 patients with nr-axSpA without history of CV events were recruited. AS patients were older showing more CV risk factors and higher values of C reactive protein and erythrocyte sedimentation rate (ESR) than those with nr-axSpA. However, no difference in the prevalence of carotid plaques or in the cIMT was found between both groups in the adjusted analysis. The percentage of patients reclassified from the low and moderate CV risk categories to the very high-risk category due to the presence of carotid plaques was comparable in AS and nr-axSpA (10.7% versus 10.1% and 40.5% versus 45.5%, respectively). A model containing age, BASFI and ESR applied to moderate risk axSpA patients identified 41% of these patients as having very high-risk patients with high specificity (88%).

CONCLUSION

The atherosclerosis burden is similar in nr-axSpA and AS. As occurred for AS, more than 40% of axSpA patients included in the category of moderate CV risk according to the SCORE are reclassified into very high risk after carotid US, and a clinically relevant proportion of them can be detected by applying a model containing age, BASFI and ESR.

Extrinsic and Intrinsic Responses in the Development and Progression of Atherosclerosis

Atherosclerosis is a multifactorial disease that is thought to be primarily inflammatory in origin. Given the contribution of inflammation to the development and progression of atherosclerosis, other conditions that are characterised by a dysregulated inflammatory response have also been proposed to play a role. The purpose of this review is to organise and present the various inflammatory processes that can affect atherosclerosis into two broad categories: extrinsic or host-independent and intrinsic or host-dependent. Within these two categories, we will discuss various processes that may contribute to the development and progression of atherosclerosis and the clinical studies describing these associations. Although the clinical trials investigating anti-inflammatory therapies have to date provided mixed results, further studies, particularly in conjunction with lipid-lowering and blood pressure lowering therapies should be considered.

Prevalence of Subclinical Carotid Atherosclerosis and Vitamin D Deficiency in Egyptian Ankylosing Spondylitis Patients

Objectives

This study aims to investigate the relationship between subclinical carotid atherosclerosis and vitamin D deficiency in Egyptian ankylosing spondylitis (AS) patients and their impact on disease activity.

Patients and methods

This cross-sectional study included 40 AS patients (36 males, 4 females; mean age 45.9±8.4 years; range 33 to 55 years) diagnosed according to the 1984 modified New York criteria with equal number of healthy controls (26 males, 14 females; mean age 48.4±7.8 years; range 31 to 55 years). Patients' histories were taken and clinical examinations were performed. Disease activity was assessed with Bath AS metrology index (BASMI), Bath AS disease activity index (BASDAI), and Bath AS functional index (BASFI) scores. Laboratory evaluation included lipid profile and 25-hydroxyvitamin D [25(OH)D] was determined by enzyme-linked immunosorbent assay. Bilateral carotid intima-media thickness (CIMT) was measured by a high-resolution ultrasound with linear 7-12 MHz transducer. Average of CIMT of right and left common carotid arteries was used.

Results

Statistically significant differences were found between patients and controls in terms of CIMT (p<0.001), 25(OH)D3 (p<0.001) and triglycerides (p=0.02). A significant positive correlation was present between CIMT and disease duration (r=0.74), disease activity scores [BASFI (r=0.60), BASMI (r=0.49), BASDAI (r=0.65)] and lipid profile except for high-density lipoprotein (HDL) that had a negative correlation (r=-0.52). A significant negative correlation was present between 25(OH)D3 levels and CIMT (r=-0.38) and lipid profile except for HDL having a positive correlation (r=0.40).

Conclusion

Prevalence of subclinical carotid atherosclerosis in AS patients compared to the healthy population was associated with high disease activity and functional limitations. In AS patients, 25(OH)D3 deficiency is a risk factor for accelerated atherosclerosis.

Cardiovascular Consequences of Autoimmune Rheumatic Diseases

The increased risk of cardiovascular disease (CVD) among patients with autoimmune rheumatic diseases such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus has been extensively documented. Sub-clinical atherosclerosis can be assessed using various non-invasive imaging techniques. However, the mechanisms underlying the higher risk of atherosclerotic CVD in patients with autoimmune rheumatic diseases are not fully known, although they seem to include chronic low-grade systemic inflammation leading to prolonged endothelial activation, accompanied by a pro-thrombotic/pro-coagulant and autoantibody state. Furthermore, sub-clinical atherosclerosis is also influenced by other traditional risk factors for CVD. Including the individual components of the metabolic syndrome (MetS: obesity, impaired glucose metabolism, dyslipidemia and high blood pressure), the degree of which is higher in these patients than in controls. The aim of this narrative review is to discuss the CV manifestations and risk factors involved in the increased risk of CVD among patients with autoimmune rheumatic diseases.

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.

Cerebral hemodynamics in patients with ankylosing spondylitis

OBJECTIVE

The aim of this study was to assess the cerebral blood flow velocity as a marker by using transcranial Doppler (TCD) ultrasonography in patients with ankylosing spondylitis (AS).

METHODS

A total of 30 AS patients aged 20 to 50 were enrolled in the AS group (male/female: 4/26, mean age: 34.7 ± 5.9) consecutively. The control group (non-AS group; male/female: 4/26, mean age: 32.3 ± 4.7) consisted of 30 age- and sex-matched, randomly selected patients without AS who had other diagnoses such as fibromyalgia and did not have risk factors for atherosclerosis. Bilateral middle cerebral artery (MCA) peak-systolic, end-diastolic, and mean blood flow velocities, Gosling's pulsatility index values, and Pourcelot's resistance index values were recorded with TCD by a neurosonologist blinded to the AS and control groups.

RESULTS

The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels and cerebral blood flow velocities of bilateral MCA were significantly higher in the AS group than in the control group.

CONCLUSIONS

This study highlights that the increased cerebral blood flow is indirectly associated with atherosclerosis regarding persistent inflammation in patients with AS.

Assessment of subclinical atherosclerotic cardiovascular disease in patients with ankylosing spondylitis

Objective:

The aim of the present study was to compare patients with ankylosing spondylitis (AS) with healthy controls with respect to subclinical atherosclerotic cardiovascular disease (CVD).

Methods:

A total of 44 patients with AS with no history of CVD, diabetes mellitus, hypertension, chronic kidney disease, and lipid-lowering drug use were compared with 40 age- and sex-matched healthy controls with respect to carotid intima-media thickness (CIMT) and pulse wave velocity (PWV), which are surrogate markers of subclinical atherosclerosis. Correlation analysis was also performed to examine the association between surrogate markers and disease activity with inflammation [Ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP)].

Results:

In addition to age and sex, both groups were comparable with respect to cigarette smoking, body mass index, and high-density lipoprotein cholesterol (p=0.425, p=0.325, and p=0.103, respectively). The level of total cholesterol was significantly lower in patients with AS (p=0.002). Nonsteroidal anti-inflammatory drug and tumor necrosis factor alpha inhibitor use ratios in patients with AS were 79.5% and 65.9%, respectively. There was no significant difference between both groups regarding PWV and CIMT (p=0.788 and p=0.253, respectively). In patients with AS, there was a significant correlation between ASDAS-CRP and CIMT (r=0.315, p=0.038), but the correlation between ASDAS-CRP and PWV was not significant (r=−0.183, p=0.234).

Conclusion:

The results of the present study could not provide sufficient evidence whether disease activity with inflammation caused subclinical atherosclerotic CVD in patients with AS without overt CVD. The increased atherosclerotic CVD risk is most probably multifactorial in patients with AS, but the extent of the contribution of disease activity with inflammation to increased atherosclerosis is controversial.

Cardiovascular risk in ankylosing spondylitis and the effect of anti-TNF drugs: a narrative review

Introduction: Cardiovascular (CV) mortality is increased in patients with ankylosing spondylitis (AS), but little is known about CV morbidity beyond the fact that they have a two-fold higher prevalence of ischemic heart disease than controls due to the inflammatory pattern of the disease itself, and a higher prevalence of traditional CV risk factors than the general population. Anti-TNF drugs reduce inflammation and a number of studies have reported a reduction in sub-clinical atherosclerosis in AS patients treated with anti-TNF drugs, thus suggesting that inflammation contributes to their higher CV risk. Anti-TNF drugs also alter the lipid profiles of AS patients, although these changes may reflect their normalization secondary to inflammation control, and improve their other myocardial alterations.Areas covered: This review concentrates on the risk of cardiovascular morbidity and mortality among AS patients and the effect of anti-TNF drugs on this risk, with particular emphasis on the putative causes involved and the aspects that are relevant in clinical practice.Expert opinion: The growing evidence of CV disease in AS means that all clinicians need to know how to prevent it and treat patients appropriately. It is important to bear in mind the EULAR guidelines, which state that a rheumatologist is responsible for monitoring all AS patients for signs of CV involvement because this is essential in order to ensure that they are treated properly. As there is little clinical evidence concerning the effects of biological drugs other than anti-TNF agents, treatment should be decided on the basis of the clinical aspects of the type of AS and the CV co-morbidity: for example, patients who are hypertensive or dyslipidemic should immediately start treatment with an anti-hypertensive agent and/or a statin. All of the patients should be educated to prevent CV events by keeping to a balanced healthy diet, avoiding tobacco smoking, and maintaining normal blood pressure, LDL-cholesterol and glucose levels. Finally, all clinicians (but particularly rheumatologists) should always bear in mind CV complications in order to guarantee that the quality of life of AS patients is as good as possible.

Epicardial adipose tissue thickness as a new risk factor for atherosclerosis in patients with ankylosing spondylitis

PURPOSE

The aim of this study was to compare epicardial adipose tissue thickness (EATT), which is a novel cardiometabolic risk factor in patients with ankylosing spondylitis (AS), and carotid intima media thickness (CIMT) with healthy controls to assess the relationship between these markers and disease activity.

MATERIALS AND METHODS

This study involved 38 patients with AS and 38 controls with no history of cardiovascular disease. CIMT was measured by Doppler ultrasound, and EATT by echocardiography, in all participants. Total cholesterol (TC), low density lipoprotein (LDL) cholesterol, high density lipoprotein cholesterol, triglycerides, thyroid stimulating hormone, erythrocyte sedimentation rate, C-reactive protein, and hemogram measurements were performed in all subjects after 8 hours of fasting. In addition, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) scores of the patients with AS were recorded.

RESULTS

EATT was significantly higher in patients with AS (0.45 ± 0.17 mm) compared with healthy (0.37 ± 0.10 mm) controls (p= 0.01). Significant positive correlations were detected between EAT thickness and BASFI, CIMT, and disease duration in patients with AS (p= 0.008, p= 0.024, and p= 0.012, respectively). Significant negative correlations were observed between EATT and TC and LDL cholesterol concentrations (p= 0.016 and p= 0.009, respectively). No significant difference was detected in CIMT between the patients (0.515 ± 0.08 mm) and the controls (0.517 ± 0.094 mm, p= 0.98). No significant correlation was observed between CIMT of the patients with AS and the BASDAI, BASFI, TC, HDL cholesterol, systolic blood pressure, or diastolic blood pressure values. Significant positive correlations were observed between CIMT and waist circumference, weight, body mass index, and LDL cholesterol in patients with AS and the controls.

CONCLUSIONS

This study demonstrated increased EATT in patients with AS compared with a healthy population, which was positively correlated with disease duration and BASFI.

Evaluation of subclinical atherosclerosis using ultrasound radiofrequency data technology in patients diagnosed with ankylosing spondylitis

OBJECTIVE

The present study aims to identify the cardiovascular risk associated with chronic inflammation and disease activity in patients with ankylosing spondylitis (AS) using noninvasive ultrasonographic radiofrequency data technology.

METHODS

In this study, a total of 87 participants, 38 patients with AS and 49 healthy controls, were evaluated by Doppler ultrasonography. Intima-media thickness (IMT) and arterial stiffness were measured from the bilateral common carotid artery using the radiofrequency method.

RESULTS

No statistically significant difference was found between the AS patients and healthy controls concerning the right common carotid artery, left common carotid artery, IMT, distensibility coefficient, elasticity coefficient, α and β stiffness indexes, and pulse wave velocities (P > .05). The symptom duration of the AS patients had a positive correlation that was moderate and was detected with the α stiffness index and pulse wave velocity (P < .05). The duration of diagnosis and treatment of the AS patients had a positive correlation that was moderate, was detected with the α stiffness index, the β stiffness index, and pulse wave velocity (P < .05). The mean IMT and elasticity coefficient values of the AS patients whose Bath Ankylosing Spondylitis Disease Activity Index score was 4 and above, were substantially higher than the values in the patients with scores lower than 4 (P = .038 and P = .33, respectively).

CONCLUSIONS

Subclinical atherosclerosis is not accelerated in AS patients with low disease activity, although insufficiently controlled disease activity may result in increased carotid IMT and atheromatosis. Radiofrequency data technology provides a noninvasive method for accurately and quantitatively demonstrating CCA-IMT elevation and the decrease in vascular elasticity in patients with AS.

Microvascular dysfunction in ankylosing spondylitis is associated with disease activity and is improved by anti-TNF treatment

Ankylosing spondylitis (AS) is associated with high cardiovascular morbidity and mortality. Recent studies indicate that microvascular dysfunction may underlie cardiovascular risk in AS. We hypothesized, that microvascular morphology and dysfunction is linked to AS activity and is modifiable by TNF-α inhibitor (TNFi) treatment. Functional Laser Doppler Flowmetry with post-occlusive reactive hyperemia, and structural nailfold capillaroscopy were performed in 54 patients with AS and 28 matched controls. Active AS was diagnosed based on BASDAI ≥ 4 (n = 37). Effects of 3-month TNFi on microcirculation in active AS were studied. AS was associated with prolonged time to peak hyperemia compared to healthy controls. High disease activity was associated with increased time to peak hyperemia and decreased peak hyperemia when compared to patients with inactive AS. In capillaroscopy, AS was associated with morphological abnormalities indicating increased neoangiogenesis and pericapillary edema compared to controls. Microvascular function improved following 3 months of TNFi in reference to basal flow as well as post-occlusive parameters. TNFi reduced pericapillary edema, while other parameters of capillary morphology remained unchanged. Microvascular dysfunction and capillary neovascular formation are associated with disease activity of AS. Anti-TNF-α treatment may restore microcirculation function and capillary edema but does not modify microvascular structural parameters.

Carotid Intima-Media Thickness in Patients with Ankylosing Spondylitis: A Systematic Review and Updated Meta-Analysis

Aim: Inflammatory arthritis (IA) diseases are relevant with subclinical atherosclerosis, but the data in ankylosing spondylitis (AS) were inconsistent. Therefore, we performed this meta-analysis to explore the relationship between the marker of subclinical atherosclerosis (carotid intima-media thickness (IMT)) and AS.

Methods: We performed a systematic literature review using PubMed, Web of Science, Chinese National Knowledge Infrastructure (CNKI) and Chinese Biomedical Database (CBM) databases up to March 2018. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated to assess the association between carotid IMT and AS. Subgroup analysis, sensitivity analysis, and meta-regression were applied to explore the sources of heterogeneity, and publication bias was calculated to access the quality of pooled studies.

Results: A total of 24 articles were collected. The carotid IMT was significantly increased in AS compared with healthy controls (SMD = 0.725, 95% CI = 0.443–1.008, p < 0.001). Subgroup analyses showed the Bath Ankylosing Spondylitis Activity Index (BASDAI) was the source of heterogeneity. Notably, IMT was not significantly increased in those studies that included > 50% patients treated with anti-TNF. Meta-regression revealed severe inflammation status (BASDAI and C-reactive protein (CRP)) could significantly impact carotid IMT in AS.

Conclusions: Carotid IMT was significantly increased in patients with AS compared with healthy controls, which suggested subclinical atherosclerosis is related to AS.

Differences in carotid atherosclerosis between patients with ankylosing spondylitis treated with tumor necrosis factor-α antagonists and healthy matched controls

An increased vascular risk is present in patients with ankylosing spondylitis (AS). In this report, we evaluate the presence and grade of atherosclerosis in patients with AS, uninterruptedly treated with tumor necrosis factor-α (TNF-α) antagonists for 2 years, in comparison to that in a nontreated group of healthy controls.Fourteen patients with AS and 14 healthy controls underwent carotid sonography to measure intima-media thickness (IMT) and to evaluate the presence of plaque. Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Functional Index scores, erythrocyte sedimentation rate, C-reactive protein, glycemia, total cholesterol, and triglyceride levels were also recorded.Patients with AS showed significantly lower values of mean and maximum IMT at the level of the common carotid (P = .02 and .04, respectively) and the carotid bulb (P = .0006 and .0005, respectively) compared to those of healthy controls. They also had a number of carotid plaques significantly lower than that of healthy controls (P = .02). No differences were found in IMT values at the level of internal carotid between the 2 populations.The significantly lower carotid atherosclerosis found in patients with AS treated with TNF antagonists than in healthy controls shows the important complementary role of this treatment in reducing vascular disease progression probably by decreasing inflammation.

Systemic Inflammatory Response and Atherosclerosis: The Paradigm of Chronic Inflammatory Rheumatic Diseases

Patients with Chronic Inflammatory Rheumatic diseases (CIRD) are at increased risk of cardiovascular disease (CVD), ascribed not only to classical risk factors, but also to the presence of chronic systemic inflammatory response. Αtherosclerosis, the cornerstone of CVD, is known to be accelerated in CIRD; rheumatoid arthritis promotes atheromatosis and associates with preclinical atherosclerosis equivalent to Diabetes Mellitus, which also seems to apply for systemic lupus erythematosus. Data on ankylosing spondylitis and psoriatic arthritis, albeit more limited, also support an increased CV risk in these patients. The association between inflammation and atherosclerosis, has been thoroughly investigated in the last three decades and the role of inflammation in the pathogenesis and progression of atherogenesis has been well established. Endothelial dysfunction, oxidative stress in vascular endothelial cells and macrophage accumulation, toll-like receptor signaling, NLPR-3 formation and subsequent pro-inflammatory cytokine production, such as TNFa, IL-1β, IL-6, and TNF-like cytokine 1A, are few of the mechanisms implicated in the atherogenic process. Moreover, there is evidence that anti-inflammatory biologic drugs, such as anti-TNF and anti-IL1β agents, can decelerate the atherogenic process, thus setting new therapeutic targets for early and effective disease control and suppression of inflammation, in addition to aggressive management of classical CV risk factors.

Ankylosing Spondylitis Is Associated with Increased Prevalence of Left Ventricular Hypertrophy

OBJECTIVE

Ankylosing spondylitis (AS) is associated with increased risk for cardiovascular disease (CVD). Left ventricular (LV) hypertrophy is a strong precursor for clinical CVD. The aim of our study was to assess whether having AS was associated with increased prevalence of LV hypertrophy.

METHODS

Clinical and echocardiographic data from 139 AS patients and 126 age- and sex-matched controls was used. LV mass was calculated according to guidelines and indexed to height^2.7. LV hypertrophy was considered present if LV mass index was > 49.2 g/m^2.7 in men and > 46.7 g/m^2.7 in women.

RESULTS

Patients with AS were on average 49 ± 12 years old, and 60% were men. The prevalence of hypertension (HTN; 35% vs 41%) and diabetes (5% vs 2%) was similar among patients and controls, while patients with AS had higher serum C-reactive protein level (CRP; p < 0.001). The prevalence of LV hypertrophy was higher in patients with AS compared to controls (15% vs 6%, p = 0.01). In multivariable logistic regression analysis, having AS was associated with OR 6.3 (95% CI 2.1-19.3, p = 0.001) of having LV hypertrophy independent of the presence of HTN, diabetes, and obesity. In multivariable linear regression analyses, having AS was also associated with higher LV mass (β 0.15, p = 0.007) after adjusting for CVD risk factors including sex, body mass index, systolic blood pressure, diabetes, and serum CRP (multiple R² = 0.41, p < 0.001).

CONCLUSION

Having AS was associated with increased prevalence of LV hypertrophy independent of CVD risk factors. This finding strengthens the indication for thorough CVD risk assessment in patients with AS.

Atherogenic index of plasma: a useful marker for subclinical atherosclerosis in ankylosing spondylitis : AIP associate with cIMT in AS

Ankylosing spondylitis (AS) is associated with an increased risk of atherosclerotic cardiovascular disease (ACD). The atherogenic index of plasma (AIP), which is the logarithmic transformation of the plasma triglyceride (TG) level to the high-density lipoprotein level (HDL) ratio, has been suggested to be a novel marker in the identification of atherosclerosis risk. Therefore, this study aims to determine if the AIP can act as an accurate marker for the detection of subclinical atherosclerosis. Fifty-two male patients with AS and 52 age-, gender-, and body mass index (BMI)-matched healthy control subjects were included in the study. For each patient, AIP and total cholesterol (TC)/HDL values were calculated and carotid artery intima-media thickness (cIMT) was measured. The mean (SD) cIMT and median (range) AIP values for AS patients were higher than that of the healthy control subjects (0.60 ± 0.18 vs. 0.51 ± 0.10, p = 0.003 and 0.23 [- 0.32 to 0.85] vs. 0.09 [- 0.53 to 0.49], p = 0.007, respectively). A positive correlation was found between the patients' cIMT and AIP values (r = 0.307, p = 0.002) and TC/HDL values (r = 0.241, p = 0.014). Regression analysis revealed an independent association between the subclinical atherosclerosis and AIP (beta [β] = 0.309, p = 0.002). There were no independent correlations between subclinical atherosclerosis and TC (β = 0.245, p = 0.065), TG (β = 0.185, p = 0.515), HDL (β = 0.198, p = 0.231), TC/HDL (β = 0.032, p = 0.862), and low-density lipoprotein (LDL) (β = 0.151, p = 0.246). A strong and independent correlation exists between AIP and cIMT values. Therefore, the AIP could serve as a better marker than the TC/HDL ratio for the detection of subclinical atherosclerosis in AS patients.

Atherosclerosis is not accelerated in rheumatoid arthritis of low activity or remission, regardless of antirheumatic treatment modalities

Objectives

RA associates with increased cardiovascular disease (CVD) morbidity and mortality due to accelerated atherosclerosis, attributed to both classical risk factors and chronic inflammation. The aim of this study was to test the hypothesis that effective disease control over 3 years modifies acceleration of atherosclerosis in RA.

Methods

Consecutive, non-diabetic RA patients previously examined by ultrasonography for subclinical atherosclerosis were re-evaluated after 3.2 (0.2) years, provided that they were in remission/low disease activity (DAS28 <3.2) for at least 75% of this period. Patients (n = 139) were demographically matched with 139 non-diabetic, non-RA control individuals studied in parallel.

Results

Patients and controls (mean age of 56 years at baseline) had a comparable burden of classical CVD risk factors. Patients' pulse wave velocity (reflecting arterial stiffness) changed by 0.07 m/s/year and left carotid intima-media thickness (reflecting wall hypertrophy) increased by 0.009 mm/year; formation of new atheromatic plaques in carotid and/or femoral arterial beds occurred in 22%. Multivariate analysis after correcting for all classical CVD risk factors and anti-hypertensive/lipid-lowering therapies demonstrated no significant differences between patients and controls in any of the subclinical atherosclerosis indices. Changes in all atherosclerosis indices from baseline to end of follow-up were comparable between those 56 patients treated with biologic DMARDs and their demographically matched patients treated with synthetic DMARDs.

Conclusion

Effective disease control may abrogate any RA-specific effect on the progression of atherosclerosis regardless of treatment. Whether early and sustained RA control translates to the CVD outcomes expected in the general population should be examined in prospective studies.