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Weber BN, Weisenfeld D, Jeffway M, Liu F, McDermott G, Coblyn J, Weinblatt ME, Shadick N, Di Carli M, Liao KP. The Association Between High-Sensitivity Cardiac Troponin T and Major Adverse Cardiovascular Events in Rheumatoid Arthritis. J Rheumatol 2024; 51:942-944. [PMID: 38879189 DOI: 10.3899/jrheum.2024-0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2024]
Affiliation(s)
- Brittany N Weber
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School
| | - Dana Weisenfeld
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Jeffway
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Feng Liu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory McDermott
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Coblyn
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael E Weinblatt
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Shadick
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo Di Carli
- Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School
| | - Katherine P Liao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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2
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Piplani S, Jelic V, Johnson A, Shah U, Kolli S, Kong S, Tanasijevic N, Bejugam VR, Goguri SR, Mogga P, Kasire SP, Chaturvedi S, Jain P. Prevalence, Causes and Outcomes of Acute Gastrointestinal Bleeding in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis. Mediterr J Rheumatol 2024; 35:210-219. [PMID: 39211013 PMCID: PMC11350423 DOI: 10.31138/mjr.230324.pca] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 09/04/2024] Open
Abstract
Aim The present study aims to investigate the prevalence, causes and outcomes of acute gastrointestinal (GI) bleeding in Rheumatoid arthritis (RA). Methods A systemic search was conducted from electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 14th November 2023. All statistical analyses were conducted in Review Manager 5.4.1. Studies meeting inclusion criteria were selected. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in prevalence and their corresponding 95% confidence interval (CI). Other outcomes were assessed using qualitative analysis. Results A total of eight studies (six observational studies and 2 trials were used to conduct this systematic review and meta-analysis. A total population of 138,041 patients was used. Pooled analysis showed a statistically significant risk of GI bleeding in RA patients receiving NSAIDs (prevalence = 2% (1%, 3%); P < 0.00001; I2 = 98%). Qualitatively, causes and outcomes were discussed. Conclusion Our study showed that 2% RA patients were subjected to GI bleeding, when they used NSAIDs. Other causes of GI bleeding were age-related factors, cardiovascular events, history of GI complications, and peptic ulcers. Outcome varied by the use of specific NSAIDs and the presence of comorbidities. Recent guidelines for the management of RA may mention GI bleeding as a potential complication, but the level of emphasis placed on this issue varies. Some guidelines provide comprehensive recommendations for its prevention and management, while others offer limited guidance.
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Affiliation(s)
- Shobhit Piplani
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Vladimir Jelic
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Adejoke Johnson
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Usman Shah
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Shiny Kolli
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Steve Kong
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Nikola Tanasijevic
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Vishal Reddy Bejugam
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Sumaja Reddy Goguri
- Frank H. Netter MD School of Medicine/St. Vincent’s Medical Centre, Connecticut, United States
| | - Phanidhar Mogga
- Frank H. Netter MD School of Medicine/St. Vincent’s Medical Centre, Connecticut, United States
| | - Sripada Preetham Kasire
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
| | - Salil Chaturvedi
- Jacobi Medical Centre/North Central Bronx, Albert Einstein College of Medicine, NYC Health and Hospitals, New York, New York, United States
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Sircana MC, Erre GL, Castagna F, Manetti R. Crosstalk between Inflammation and Atherosclerosis in Rheumatoid Arthritis and Systemic Lupus Erythematosus: Is There a Common Basis? Life (Basel) 2024; 14:716. [PMID: 38929699 PMCID: PMC11204900 DOI: 10.3390/life14060716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with rheumatoid arthritis and systemic lupus erythematosus. Traditional cardiovascular risk factors, although present in lupus and rheumatoid arthritis, do not explain such a high burden of early cardiovascular disease in the context of these systemic connective tissue diseases. Over the past few years, our understanding of the pathophysiology of atherosclerosis has changed from it being a lipid-centric to an inflammation-centric process. In this review, we examine the pathogenesis of atherosclerosis in systemic lupus erythematosus and rheumatoid arthritis, the two most common systemic connective tissue diseases, and consider them as emblematic models of the effect of chronic inflammation on the human body. We explore the roles of the inflammasome, cells of the innate and acquired immune system, neutrophils, macrophages, lymphocytes, chemokines and soluble pro-inflammatory cytokines in rheumatoid arthritis and systemic lupus erythematosus, and the roles of certain autoantigens and autoantibodies, such as oxidized low-density lipoprotein and beta2-glycoprotein, which may play a pathogenetic role in atherosclerosis progression.
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Affiliation(s)
| | | | | | - Roberto Manetti
- Department of Medical, Surgical and Pharmacology, University of Sassari, 07100 Sassari, Italy; (G.L.E.); (F.C.)
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4
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Yamada Z, Muraoka S, Kawazoe M, Hirose W, Kono H, Yasuda S, Sugihara T, Nanki T. Long-term effects of abatacept on atherosclerosis and arthritis in older vs. younger patients with rheumatoid arthritis: 3-year results of a prospective, multicenter, observational study. Arthritis Res Ther 2024; 26:87. [PMID: 38627782 PMCID: PMC11022315 DOI: 10.1186/s13075-024-03323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 04/14/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND We aimed to reveal the effect of abatacept (ABT) on atherosclerosis in rheumatoid arthritis (RA) patients, 3-year efficacy for arthritis, and safety in a population of older vs. younger patients. METHODS In this open-label, prospective, observational study, patients were stratified into four groups: younger (20-64 years old) and older (≥ 65 years) patients taking ABT (AY and AO) and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) (CY and CO). Primary endpoints were change from baseline in mean intima-media thickness (IMT) of the common carotid artery, IMT max (bulbus, bifurcation, and internal and common carotid artery), and plaque score at Week 156. Disease activity, retention rate, and adverse effects were also evaluated. RESULTS The ABT group (AY + AO) tended to have smaller increases in mean IMT, max IMT, and plaque score than the csDMARD group (CY + CO) at Week 156, although the differences between groups were not statistically significant. Multivariate analysis showed significantly lower increases in plaque score with ABT than with csDMARDs, only when considering disease activity at 156 weeks (p = 0.0303). Proportions of patients with good or good/moderate European League Against Rheumatism response were higher in the ABT group, without significant difference between older and younger patients. No significant differences were observed in ABT retention rates between older and younger patients. Serious adverse effects, especially infection, tended to be more frequent with ABT than with csDMARDs, although no significant differences were found. CONCLUSIONS ABT may decelerate atherosclerosis progression and may be useful for patients with high risk of cardiovascular disease, such as older patients. TRIAL REGISTRATION NUMBER UMIN000014913.
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Affiliation(s)
- Zento Yamada
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Sei Muraoka
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Mai Kawazoe
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Wataru Hirose
- Hirose Clinic of Rheumatology, 2-14-7 Midoricho, Tokorozawa, 359-1111, Saitama, Japan
| | - Hajime Kono
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1, Kaga, Itabshi- ku, Tokyo, 173-8606, Japan
| | - Shinsuke Yasuda
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Faculty of Medicine, Hokkaido University, Kita 14, Nishi 5, Kita-ku, Sapporo, 060-8648, Japan
| | - Takahiko Sugihara
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, 35-2, Sakaecho, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan.
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5
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Song YK, Lee G, Hwang J, Kim JW, Kwon JW. Cardiovascular risk of Janus kinase inhibitors compared with biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis without underlying cardiovascular diseases: a nationwide cohort study. Front Pharmacol 2023; 14:1165711. [PMID: 37964868 PMCID: PMC10642260 DOI: 10.3389/fphar.2023.1165711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/16/2023] [Indexed: 11/16/2023] Open
Abstract
Objectives: Despite the ethnic differences in cardiovascular (CV) risks and recent increase in the prescription of Janus kinase (JAK) inhibitors, limited evidence is available for their CV outcomes in Asian patients with rheumatoid arthritis (RA). We aimed to compare the major adverse CV events (MACEs) of JAK inhibitors to those of biologic disease-modifying antirheumatic drugs (bDMARDs) in Korean patients with RA without baseline CV disease (CVD). Methods: In a nationwide retrospective cohort study, patients newly diagnosed with RA without a history of CVD between 2013 and 2018 were identified using the National Health Insurance Service database. The cohort was followed up until the end of 2019 for the development of MACEs. Hazard ratios (HRs) for MACEs such as myocardial infarction, stroke, coronary revascularization, or all-cause death, were estimated using Cox proportional hazard regression in a propensity score-matched cohort. Results: In total, 4,230 matched patients with RA were included (846 JAK inhibitor users and 3,384 bDMARD users). The crude incidence rate (95% confidence intervals, CI) per 100 patient-years for MACEs was 0.83 (0.31-1.81) and 0.74 (0.53-1.02) in the JAK inhibitor and bDMARD groups, respectively. The risk of MACEs was not significantly different between JAK inhibitor and bDMARD users with an adjusted HR (95% CI) of 1.28 (0.53-3.11). There were no significant differences in the risk of MACEs between JAK inhibitors and bDMARDs in each subgroup according to the types of bDMARDs, age, sex, Charlson comorbidity index score, and comorbidities. Conclusion: Compared to bDMARDs, JAK inhibitors were not associated with the occurrence of MACEs in Korean patients with RA without a history of CVD.
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Affiliation(s)
- Yun-Kyoung Song
- College of Pharmacy, Daegu Catholic University, Gyeongsangbuk-do, Republic of Korea
| | - Gaeun Lee
- Department of Statistics, Daegu University, Gyeongsangbuk-do, Republic of Korea
| | - Jinseub Hwang
- Department of Statistics, Daegu University, Gyeongsangbuk-do, Republic of Korea
| | - Ji-Won Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jin-Won Kwon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Republic of Korea
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6
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Johnson TM, Yang Y, Roul P, Sauer BC, Cannon GW, Kunkel G, Michaud K, Baker JF, Mikuls TR, England BR. A Narrowing Mortality Gap: Temporal Trends of Cause-Specific Mortality in a National Matched Cohort Study in US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:1648-1658. [PMID: 36331101 PMCID: PMC10275614 DOI: 10.1002/acr.25053] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/17/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine temporal trends in all-cause and cause-specific mortality in patients with rheumatoid arthritis (RA) in the Veterans Health Administration (VHA). METHODS We conducted a matched cohort study in the VHA from January 1, 2000 to December 31, 2017. Incident RA patients were matched up to 1:10 on age, sex, and VHA enrollment year to non-RA patients, then followed until death or end of study period. Cause of death was obtained from the National Death Index. Multivariable Cox regression models stratified by RA diagnosis years were used to examine trends in RA-related risk of all-cause and cause-specific mortality. RESULTS Among 29,779 incident RA patients (matched to 245,226 non-RA patients), 9,565 deaths occurred. RA patients were at increased risk of all-cause (adjusted hazard ratio [HRadj ] 1.23 [95% confidence interval (95% CI) 1.20-1.26]), cardiovascular (HRadj 1.19 [95% CI 1.14-1.23]), cancer (HRadj 1.19 [95% CI 1.14-1.24]), respiratory (HRadj 1.46 [95% CI 1.38-1.55]), and infection-related mortality (HRadj 1.59 [95% CI 1.41-1.80]). Interstitial lung disease was the cause of death most strongly associated with RA (HRadj 3.39 [95% CI 2.88-3.99]). Nearly 70% of excess deaths in RA were attributable to cardiopulmonary disease. All-cause mortality risk related to RA was lower among those diagnosed during 2012-2017 (HRadj 1.10 [95% CI 1.05-1.15]) compared to 2000-2005 (HRadj 1.31 [95% CI 1.26-1.36]), but still higher than for non-RA controls (P < 0.001). Cause-specific mortality trends were similar. CONCLUSION Excess RA-related mortality was driven by cardiovascular, cancer, respiratory, and infectious causes, particularly cardiopulmonary diseases. Although our findings support that RA-related mortality risk is decreasing over time, a mortality gap remains for all-cause and cause-specific mortality in RA.
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Affiliation(s)
- Tate M. Johnson
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
| | - Brian C. Sauer
- Salt Lake City VA Medical Center, Salt Lake City, UT
- University of Utah, Salt Lake City, UT
| | - Grant W. Cannon
- Salt Lake City VA Medical Center, Salt Lake City, UT
- University of Utah, Salt Lake City, UT
| | - Gary Kunkel
- Salt Lake City VA Medical Center, Salt Lake City, UT
- University of Utah, Salt Lake City, UT
| | - Kaleb Michaud
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
- FORWARD (National Data Bank for Rheumatic Disease), Wichita, KS
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ted R. Mikuls
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
| | - Bryant R. England
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center (UNMC), Omaha, NE
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Madenidou AV, Mavrogeni S, Nikiphorou E. Cardiovascular Disease and Cardiac Imaging in Inflammatory Arthritis. Life (Basel) 2023; 13:life13040909. [PMID: 37109438 PMCID: PMC10143346 DOI: 10.3390/life13040909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/01/2023] Open
Abstract
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.
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8
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Misra DP, Hauge EM, Crowson CS, Kitas GD, Ormseth SR, Karpouzas GA. Atherosclerotic Cardiovascular Risk Stratification in the Rheumatic Diseases:: An Integrative, Multiparametric Approach. Rheum Dis Clin North Am 2023; 49:19-43. [PMID: 36424025 DOI: 10.1016/j.rdc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiovascular disease (CVD) risk is increased in most inflammatory rheumatic diseases (IRDs), reiterating the role of inflammation in the initiation and progression of atherosclerosis. An inverse association of CVD risk with body weight and lipid levels has been described in IRDs. Coronary artery calcium scores, plaque burden and characteristics, and carotid plaques on ultrasound optimize CVD risk estimate in IRDs. Biomarkers of cardiac injury, autoantibodies, lipid biomarkers, and cytokines also improve risk assessment in IRDs. Machine learning and deep learning algorithms for phenotype and image analysis hold promise to improve CVD risk stratification in IRDs.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow 226014, India
| | - Ellen M Hauge
- Division of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 DK-8200, Aarhus, Denmark
| | - Cynthia S Crowson
- Department of Quantitative Health Sciences and Division of Rheumatology, Mayo Clinic, 200 first St SW, Rochester, MN 55905, USA
| | | | - Sarah R Ormseth
- The Lundquist Institute and Harbor-UCLA Medical Center, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA
| | - George A Karpouzas
- The Lundquist Institute and Harbor-UCLA Medical Center, 1124 West Carson Street, Building E4-R17, Torrance, CA 90502, USA.
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9
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Södergren A, Solbritt Rantapää-Dahlqvist, Ljung L. Time Trends of Cardiovascular Disease in the General Population and Inflammatory Arthritis. Rheum Dis Clin North Am 2023; 49:1-17. [PMID: 36424020 DOI: 10.1016/j.rdc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiovascular diseases (CVDs) are the leading causes of death in the world, but declining trends for cardiovascular (CV) mortality and morbidity have been observed during the last decades. Reports on secular trends regarding the excess CV mortality and morbidity in rheumatoid arthritis show diverging results. Data support that also patients with inflammatory arthritis have benefited from improved treatment and prevention for CVD, which can be observed, for example, in decreased case fatality after CV event. However, several recent studies indicate a remaining excess CV risk in patients with inflammatory arthritis.
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Affiliation(s)
- Anna Södergren
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, 901 87 Umeå, Sweden; Wallenberg Centre for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden.
| | | | - Lotta Ljung
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, 901 87 Umeå, Sweden; Center for Rheumatology, Academic Specialist Center, Stockholm Health Services, Box 6357, Stockholm 102 35, Sweden. https://twitter.com/lotta_ljung
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10
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Popescu D, Rezus E, Badescu MC, Dima N, Seritean Isac PN, Dragoi IT, Rezus C. Cardiovascular Risk Assessment in Rheumatoid Arthritis: Accelerated Atherosclerosis, New Biomarkers, and the Effects of Biological Therapy. Life (Basel) 2023; 13:life13020319. [PMID: 36836675 PMCID: PMC9965162 DOI: 10.3390/life13020319] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Rheumatoid arthritis (RA), one of the most common of the chronic inflammatory autoimmune diseases (CIADs), is recognized as an independent cardiovascular risk factor. Traditional risk factors such as smoking, arterial hypertension, dyslipidemia, insulin resistance, and obesity are frequently found in RA. Given the increased risk of mortality and morbidity associated with cardiovascular disease (CVD) in RA patients, screening for risk factors is important. Moreover, there is a need to identify potential predictors of subclinical atherosclerosis. Recent studies have shown that markers such as serum homocysteine, asymmetric dimethylarginine, or carotid intima-media thickness (cIMT) are correlated with cardiovascular risk. Although RA presents a cardiovascular risk comparable to that of diabetes, it is not managed as well in terms of acute cardiovascular events. The introduction of biological therapy has opened new perspectives in the understanding of this pathology, confirming the involvement and importance of the inflammatory markers, cytokines, and the immune system. In addition to effects in inducing remission and slowing disease progression, most biologics have demonstrated efficacy in reducing the risk of major cardiovascular events. Some studies have also been conducted in patients without RA, with similar results. However, early detection of atherosclerosis and the use of targeted therapies are the cornerstone for reducing cardiovascular risk in RA patients.
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Affiliation(s)
- Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore. T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence: (E.R.); (M.C.B.)
| | - Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (E.R.); (M.C.B.)
| | - Nicoleta Dima
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Petronela Nicoleta Seritean Isac
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ioan-Teodor Dragoi
- Department of Rheumatology and Physiotherapy, “Grigore. T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Internal Medicine Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
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11
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Kang S, Han K, Jung JH, Eun Y, Kim IY, Hwang J, Koh EM, Lee S, Cha HS, Kim H, Lee J. Associations between Cardiovascular Outcomes and Rheumatoid Arthritis: A Nationwide Population-Based Cohort Study. J Clin Med 2022; 11:jcm11226812. [PMID: 36431290 PMCID: PMC9695475 DOI: 10.3390/jcm11226812] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022] Open
Abstract
Despite a growing burden posed by cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, large-scale studies on the association between the characteristics of RA patients and CVD risks and studies adjusted for various confounding factors are lacking. In this large-scale nationwide cohort study, we aimed to investigate the association between CVD risk and RA and factors that may increase CVD risk using a dataset provided by the Korean National Health Insurance Service (NHIS). We enrolled 136,469 patients with RA who participated in national health examinations within two years of RA diagnosis between 2010 and 2017 and non-RA controls matched by age and sex (n = 682,345). The outcome was the occurrence of myocardial infarction (MI) or stroke. MI was defined as one hospitalization or two outpatient visits with ICD-10-CM codes I21 or I22. Stroke was defined as one hospitalization with ICD-10-CM codes I63 or I64 and a claim for brain imaging (CT or MRI). The Cox proportional hazard model and Kaplan-Meier curve were used for analysis. The mean follow-up duration was 4.7 years, and the incidence rate of CVD was higher in the RA group than the control group (MI: 3.20 vs. 2.08; stroke: 2.84 vs. 2.33 per 1000 person-years). The risk of MI and stroke was about 50% and 20% higher, respectively, in RA patients. The association between RA and CVD was prominent in females after adjusting for confounding variables. The association between RA and risk of MI was significant in individuals without DM. Therefore, appropriate screening for CVD is important in all RA patients including females and younger patients.
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Affiliation(s)
- Seonyoung Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Republic of Korea
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yeonghee Eun
- Division of Rheumatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Republic of Korea
| | - In Young Kim
- Department of Medicine, National Police Hospital, Seoul 05715, Republic of Korea
| | - Jiwon Hwang
- Division of Rheumatology, Department of Internal Medicine, Sungkyunkwan University Samsung Changwon Hospital, Changwon 51353, Republic of Korea
| | - Eun-Mi Koh
- Korean Health Insurance Review and Assessment Service, Seoul 06653, Republic of Korea
| | - Seulkee Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hoon-Suk Cha
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hyungjin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Medical Humanities, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Correspondence: (H.K.); (J.L.); Tel.: +82-2-3410-1879 (H.K.); +82-2-3410-3439 (J.L.); Fax: +82-2-3410-6983 (H.K.); +82-2-3410-0231 (J.L.)
| | - Jaejoon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Correspondence: (H.K.); (J.L.); Tel.: +82-2-3410-1879 (H.K.); +82-2-3410-3439 (J.L.); Fax: +82-2-3410-6983 (H.K.); +82-2-3410-0231 (J.L.)
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12
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Giachi A, Cugno M, Gualtierotti R. Disease-modifying anti-rheumatic drugs improve the cardiovascular profile in patients with rheumatoid arthritis. Front Cardiovasc Med 2022; 9:1012661. [PMID: 36352850 PMCID: PMC9637771 DOI: 10.3389/fcvm.2022.1012661] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting about 0. 5–1% of the adult population and manifesting as persistent synovitis, systemic inflammation and production of autoantibodies. Patients affected by RA not only experience chronic disease progression, but are also burdened by a 1.5-fold increased cardiovascular (CV) risk, which is comparable to the risk experienced by patients with type 2 diabetes mellitus. RA patients also have a higher incidence and prevalence of coronary artery disease (CAD). Although RA patients frequently present traditional CV risk factors such as insulin resistance and active smoking, previous studies have clarified the pivotal role of chronic inflammation–driven by proinflammatory cytokines such as interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha)–in accelerating the process of atherosclerosis and impairing the coagulation system. Over the last years, a number of studies have shown that disease-modifying anti-rheumatic drugs (DMARDs) reducing the inflammatory state in general improve the CV risk, however some drugs may carry some apparent negative effects. Thus, RA is a model of disease in which targeting inflammation may counteract the progression of atherosclerosis and reduce CV risk. Clinical and experimental evidence indicates that the management of RA patients should be tailored based on the positive and negative effects of DMARDs on CV risk together with the individual traditional CV risk profile. The identification of genetic, biochemical and clinical biomarkers, predictive of evolution and response to treatment, will be the next challenge for a precision approach to reduce the burden of the disease.
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Affiliation(s)
- Andrea Giachi
- UOC Medicina Generale Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- UOC Medicina Generale Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
- *Correspondence: Massimo Cugno
| | - Roberta Gualtierotti
- UOC Medicina Generale Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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13
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Jain K, Laila D, Nandagudi A, Bharadwaj A. Long-term outcomes in Rheumatoid Arthritis: Review of data from the ‘Basildon Inflammatory Arthritis Cohort’. Rheumatol Adv Pract 2022; 6:rkac075. [PMID: 36176320 PMCID: PMC9514795 DOI: 10.1093/rap/rkac075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/17/2022] [Indexed: 11/24/2022] Open
Abstract
Objective The aim was to determine outcomes in RA with long-term analysis of a real-world inception cohort. Methods We carried out a retrospective cohort analysis of 184 patients with a new diagnosis of RA (ACR/EULAR 2010 criteria) between 2009 and 2013. Measured parameters included patient demographics, serological markers, disease activity (DAS28-CRP), treatment regimen, development of new co-morbidities and all-cause mortality. Results Complete data were available for analysis in 171 patients, 60 men and 111 women, with a median age of 57 years and median follow-up time of 7.5 years. DAS-28 remission was achieved in 73%, with the majority continuing to require pharmacological therapy. Drug-free remission was achieved in 11.7%, whereas 3.5% remained refractory to treatment. Analysis of new co-morbidities revealed malignancy in 12.9% (n = 22), with lung cancer having the highest incidence (n = 9). Cardiovascular, pulmonary and cerebrovascular disease developed in 11.1% (n = 19), 5.8% (n = 10) and 5.3% (n = 9), respectively. The crude mortality rate was 19.3% (33 of 171), incidence mortality rate 174 per 10 000 person-years of follow-up and standardized mortality ratio 1.57 (95% CI 1.10, 2.17). More deaths were recorded from underlying malignancy [7.6% (n = 13)] than with cardiovascular disease [4.7% (n = 8)]. The majority of deaths occurred ≥5 years after initial diagnosis (67%). Conclusion Long-term analysis reveals that mortality in RA remains significantly elevated compared with the general population. Additionally, this real-world study underlines malignancy as the predominant cause of morbidity and mortality in RA.
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Affiliation(s)
- Kanishk Jain
- Department of Rheumatology, Mid & South Essex Foundation Trust, Basildon University Hospital , Basildon, UK
| | - Deena Laila
- Department of Rheumatology, Mid & South Essex Foundation Trust, Basildon University Hospital , Basildon, UK
| | - Anupama Nandagudi
- Department of Rheumatology, Mid & South Essex Foundation Trust, Basildon University Hospital , Basildon, UK
| | - Anurag Bharadwaj
- Department of Rheumatology, Mid & South Essex Foundation Trust, Basildon University Hospital , Basildon, UK
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Rollefstad S, Ikdahl E, Wibetoe G, Sexton J, Crowson CS, van Riel P, Kitas GD, Graham I, Dahlqvist SR, Karpouzas G, Myasoedova E, Gonzalez-Gay MA, Sfikakis PP, Tektonidou MG, Lazarini A, Vassilopoulos D, Kuriya B, Hitchon CA, Stoenoiu MS, Durez P, Pascual-Ramos V, Galarza-Delgado DA, Faggiano P, Misra DP, Borg A, Mu R, Mirrakhimov EM, Gheta D, Myasoedova S, Krougly L, Popkova T, Tuchyňová A, Tomcik M, Vrablik M, Lastuvka J, Horák P, Medková H, Semb AG. An international audit of the management of dyslipidaemia and hypertension in patients with rheumatoid arthritis: results from 19 countries. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:539-548. [PMID: 34232315 DOI: 10.1093/ehjcvp/pvab052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 07/05/2021] [Indexed: 01/05/2023]
Abstract
AIMS To assess differences in estimated cardiovascular disease (CVD) risk among rheumatoid arthritis (RA) patients from different world regions and to evaluate the management and goal attainment of lipids and blood pressure (BP). METHODS AND RESULTS The survey of CVD risk factors in patients with RA was conducted in 14 503 patients from 19 countries during 2014-19. The treatment goal for BP was <140/90 mmHg. CVD risk prediction and lipid goals were according to the 2016 European guidelines. Overall, 21% had a very high estimated risk of CVD, ranging from 5% in Mexico, 15% in Asia, 19% in Northern Europe, to 31% in Central and Eastern Europe and 30% in North America. Of the 52% with indication for lipid-lowering treatment (LLT), 44% were using LLT. The lipid goal attainment was 45% and 18% in the high and very high risk groups, respectively. Use of statins in monotherapy was 24%, while 1% used statins in combination with other LLT. Sixty-two per cent had hypertension and approximately half of these patients were at BP goal. The majority of the patients used antihypertensive treatment in monotherapy (24%), while 10% and 5% as a two- or three-drug combination. CONCLUSION We revealed considerable geographical differences in estimated CVD risk and preventive treatment. Low goal attainment for LLT was observed, and only half the patients obtained BP goal. Despite a high focus on the increased CVD risk in RA patients over the last decade, there is still substantial potential for improvement in CVD preventive measures.
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Affiliation(s)
- Silvia Rollefstad
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
| | - Eirik Ikdahl
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
| | - Grunde Wibetoe
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
| | - Joe Sexton
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
| | - Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - George D Kitas
- Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
| | | | | | - George Karpouzas
- The Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Elena Myasoedova
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Petros P Sfikakis
- Joint Rheumatology Program, First Department of Propaedeutic Internal Medicine, Laiko Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- Joint Rheumatology Program, First Department of Propaedeutic Internal Medicine, Laiko Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Argyro Lazarini
- Joint Rheumatology Program, 2nd Department of Medicine and Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, 2nd Department of Medicine and Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Bindee Kuriya
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Carol A Hitchon
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maria Simona Stoenoiu
- Rheumatology Department, Cliniques Universitaires Saint Luc, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Brussels, Belgium
| | - Patrick Durez
- Rheumatology Department, Cliniques Universitaires Saint Luc, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Brussels, Belgium
| | - Virginia Pascual-Ramos
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | | | | | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
| | | | - Rong Mu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | | | - Diane Gheta
- Tallagh University Hospital, Dublin, Ireland
| | | | - Lev Krougly
- Center of Cardiology of Russian Ministry of Healthcare, Moscow, Russia
| | - Tatiana Popkova
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - Alena Tuchyňová
- National Institute of Rheumatic Diseases, 92101 Piešťany, Slovensko, Slovakia
| | - Michal Tomcik
- Institute of Rheumatology, Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Vrablik
- Third Department of Internal Medicine, Department of Endocrinology and Metabolism, First Medical Faculty, Charles University and General Faculty Hospital, Prague, Czech Republic
| | - Jiri Lastuvka
- Third Department of Internal Medicine, Department of Endocrinology and Metabolism, First Medical Faculty, Charles University and General Faculty Hospital, Prague, Czech Republic
- First Medical Faculty, Charles University, Prague, Czech Republic
| | - Pavel Horák
- Iii Interna klinika fn Olomouc, Olomouc, Czech Republic
| | - Helena Medková
- Division of Rheumatology, 2nd Department of Internal Medicine-Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Anne Grete Semb
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
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15
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Suwal A, Shrestha B, Setyono D, Poudel B, Donato A. Outcomes of the First Episode of STEMI in Rheumatoid Arthritis Patients from the National Inpatient Sample Database, 2016-2019. Curr Probl Cardiol 2022; 47:101310. [PMID: 35810846 DOI: 10.1016/j.cpcardiol.2022.101310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 12/06/2022]
Abstract
BACKGROUND Patients with Rheumatoid arthritis (RA) have a higher burden of cardiovascular diseases (CVDs), but conflicting results were seen regarding in-hospital outcomes of STEMI in patients with RA compared to patients without RA. OBJECTIVES To compare in-hospital outcomes of the first episode of STEMI between patients with and without RA. METHODS The NIS database was used to conduct a retrospective study of U.S. hospitalizations with a primary diagnosis of first-time STEMI from 2016 to 2019. We divided our study population into two cohorts, with diagnosis codes for RA and those without RA and compared baseline demographics, comorbidities, and in-hospital outcomes and finally performed a multivariate logistic regression analysis after adjusting for baseline factors. RESULTS Our analysis revealed that patients with RA were statistically more likely to be older, white, and female and had more hypertension, cardiomyopathy, CKD stage 3 or greater and heart failure. However, after adjusting for potential confounders, we found lower inpatient mortality in the first STEMI with RA cohort (adjusted OR: 0.70, 95% CI of 0.56-0.87, p <0.002) compared to the patients without RA. However, there was no statistically significant difference between the two groups in rates of in-hospital complications, including repeat MI, acute heart failure, arrhythmias, cardiac arrest, cardiogenic shock, and stroke. CONCLUSION In this study, patients with RA with first STEMI had lower inpatient mortality than those without RA. However, further patient-level studies are needed to understand better the impact of newer biologics and the effect of risk factor modification on this patient subset.
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Affiliation(s)
- Amar Suwal
- Department of Medicine, Reading Hospital, Tower Health, Reading, PA.
| | - Biraj Shrestha
- Department of Medicine, Reading Hospital, Tower Health, Reading, PA
| | | | - Bidhya Poudel
- Department of Medicine, AMITA Health Saint Francis Hospital, Evanston, IL, United States of America
| | - Anthony Donato
- Department of Medicine, Reading Hospital, Tower Health, Reading, PA
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Yoshida K, Harrold LR, Middaugh N, Guan H, Stryker S, Karis E, Solomon DH. Time-Varying Association of Rheumatoid Arthritis Disease Activity to Subsequent Cardiovascular Risk. ACR Open Rheumatol 2022; 4:587-595. [PMID: 35403370 PMCID: PMC9274374 DOI: 10.1002/acr2.11432] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 12/12/2022] Open
Abstract
Objective It is unknown how the relationship between disease activity in rheumatoid arthritis (RA) and cardiovascular (CV) events may change over time. We examined the potentially time‐varying association of RA disease activity to CV events. Methods We used the CorEvitas prevalent RA registry. The Clinical Disease Activity Index (CDAI) score category, averaged within each 6‐month window since enrollment, was the exposure, and the outcome was major adverse CV events (MACEs). We used marginal structural models to estimate the hazard ratio (HR), comparing each CDAI score category with remission, allowing for differential association over time. We predicted MACE‐free survival under several CDAI score scenarios. Results We found 44,816 eligible patients (77% female; mean age 58 years) with a crude event rate of 5.3/1000 person‐years (median follow‐up 3.4 years). The strongest association between higher CDAI score and MACEs was observed during the first 6 months of enrollment (HR for CDAI score low 2.29 [95% CI: 1.21‐4.36], moderate 2.81 [95% CI: 1.46‐5.43], and high 2.99 [95% CI: 1.48‐6.02]). These estimates gradually diminished; by year 5, the HRs were 1.00 (95% CI: 0.49‐2.05) for low, 1.18 (95% CI: 0.51‐2.71) for moderate, and 1.04 (95% CI: 0.45‐2.40) for high CDAI score. Predicted MACE‐free survival suggested a potential decrease in MACEs with a hypothetical earlier transition to remission. Conclusion The association of higher disease activity with CV events may be stronger earlier in the disease course of RA. Interventional studies may be warranted to precisely determine the effect of disease activity suppression on CV events in RA.
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Affiliation(s)
- Kazuki Yoshida
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester, and CorEvitas, LLC, Waltham, Massachusetts
| | | | - Hongshu Guan
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Daniel H Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Kerola AM, Kazemi A, Rollefstad S, Lillegraven S, Sexton J, Wibetoe G, Haavardsholm EA, Kvien TK, Semb AG. All-cause and cause-specific mortality in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: a nationwide registry study. Rheumatology (Oxford) 2022; 61:4656-4666. [PMID: 35377442 PMCID: PMC9707036 DOI: 10.1093/rheumatology/keac210] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/24/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To explore mortality and causes of death among Norwegian patients with RA, PsA and axial spondyloarthritis (axSpA) compared with the general population by conducting a nationwide registry-based cohort study. METHODS Patients with RA, PsA and axSpA were identified from the Norwegian Patient Registry based on ICD-10 codes between 2008 and 2017. Using age as the time variable, all-cause and cause-specific mortality were estimated between 2010 and 2017 with the Kaplan-Meier estimator and the cumulative incidence competing risk method, respectively. Sex-, education level-, health region- and age group-adjusted hazard ratios (HRs) for mortality were estimated using Cox regression models. RESULTS We identified 36 095 RA, 18 700 PsA and 16 524 axSpA patients (70%, 53% and 45% women, respectively). RA and axSpA were associated with increased all-cause mortality (HR 1.45 [95% CI: 1.41, 1.48] and HR 1.38 [95% CI: 1.28, 1.38], respectively). Women but not men with PsA had a slightly increased mortality rate (HR 1.10 [95% CI: 1.00, 1.21] among women and 1.02 [95% CI: 0.93, 1.11] among men). For all patient groups as well as for the general population, the three leading causes of death were cardiovascular diseases, neoplasms and respiratory diseases. RA patients had increased mortality from all of these causes, while axSpA patients had increased mortality from cardiovascular and respiratory diseases. CONCLUSION Even in the era of modern treatments for IJDs, patients with RA and axSpA still have shortened life expectancy. Our findings warrant further attention to the prevention and management of comorbidities.
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Affiliation(s)
- Anne M Kerola
- Correspondence to: Anne Kerola, Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway. E-mail:
| | | | - Silvia Rollefstad
- Preventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Joseph Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital
| | - Grunde Wibetoe
- Preventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen A Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital
| | - Anne Grete Semb
- Preventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
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18
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Dehlin M, Sandström TZ, Jacobsson LT. Incident Gout: Risk of Death and Cause-Specific Mortality in Western Sweden: A Prospective, Controlled Inception Cohort Study. Front Med (Lausanne) 2022; 9:802856. [PMID: 35280894 PMCID: PMC8907510 DOI: 10.3389/fmed.2022.802856] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Excess mortality in gout has been attributed to cardiovascular diseases (CVD). Considering the decline in CVD mortality in the general population, we wanted to evaluate overall mortality in gout and cause-specific contributions to mortality beyond CVD and temporal trends. Methods All incident cases of gout between 2006 and 2015 in western Sweden and 5 population controls per case matched for age, sex, and county were identified. Comorbidities were identified for 5 years preceding the index date. Follow-up ended at death, migration, or end of study on December 2017. Effect of gout on death risk was calculated using COX regression on the whole population and stratified by sex, adjusted for demographics, and comorbidities. Death incidence rates were compared between the two time periods, 2006-2010 and 2011-2015. Results We identified 22,055 cases of incident gout and 98,946 controls, median age (Q1, Q3) 69-68 (57, 79/56, 78) years and 67.6-66.5% males. Except for dementia, all comorbidities were significantly more common at baseline among gout cases. Overall, the risk for death in incident gout was neither increased overall nor in men, but women had a 10% elevated risk. In adjusted models for cause-specific mortality, death from CVD, renal disease, and digestive system diseases were significantly increased in the total gout population while death from dementia, cancer, and lung diseases were significantly decreased. There were no significant differences in overall incident death rate ratios between cases and controls in the two time periods examined. Conclusions An increased risk for CVD, renal disease, and diseases of the digestive system in patients with gout highlights the importance of addressing CVD risk factors in gout management. Gout was associated with reduced mortality from dementia, which may have implications on urate lowering therapy and possible effects on dementia risk.
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Affiliation(s)
- Mats Dehlin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tatiana Zverkova Sandström
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lennart Th Jacobsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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The association between rheumatoid arthritis and cardiovascular disease among adults in the United States during 1999-2018, and age-related effect modification in relative and absolute scales. Ann Epidemiol 2022; 71:23-30. [PMID: 35301105 DOI: 10.1016/j.annepidem.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To explore the rheumatoid arthritis (RA)-cardiovascular diseases (CVD) association in relative and absolute risk scales among US adults aged ≥20 years over time and the effect modification of the association by age. METHODS We analyzed aggregated data from all ten continuous National Health and Nutrition Examination Survey cycles. A sample of 43,184 complete-case subjects was considered. The design-based regressions were used to investigate the associations in relative and absolute scales. RESULTS In relative scale, the CVD odds ratio was 2.32, 2.19, and 1.97 among adults with RA than no arthritis in 1999-2006, 2007-2012, and 2013-2018 cycles, respectively. This time trend was not statistically significant. The absolute risk estimates were 11, 10, and 9 per 100 CVD events. We also observed a significant effect modification by age; the higher relative risk among younger adults (<50 years) with RA and higher absolute risk in older adults (≥80 years) with RA were consistent across survey cycles. CONCLUSIONS There is a significant association between RA and CVD among US adults in both relative and absolute risks. Moreover, age is a significant effect modifier for this association; but with opposing age-related trends in relative and absolute scales.
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Alsing CL, Nystad TW, Igland J, Gjesdal CG, Midtbø H, Tell GS, Fevang BT. Trends in the occurrence of ischaemic heart disease over time in rheumatoid arthritis: 1821 patients from 1972 to 2017. Scand J Rheumatol 2022; 52:233-242. [PMID: 35272584 DOI: 10.1080/03009742.2022.2040116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate trends of acute myocardial infarction (AMI) and ischaemic heart disease (IHD) in rheumatoid arthritis (RA) patients compared with the general population over time. METHOD We performed a retrospective cohort study of 1821 RA patients diagnosed from 1972 to 2013. Aggregated counts of the total population of the same county (Hordaland, Norway) and period were used for comparison. Information on AMI and IHD events was obtained from hospital patient administrative systems or cardiovascular registries. We estimated incidence rates and excess of events [standardized event ratio (SER) with 95% confidence interval (CI)] compared with the general population by Poisson regression. RESULTS There was an average annual decline of 1.6% in age- and gender-adjusted AMI incidence rates from 1972 to 2017 (p < 0.035). The difference in events (excess events) in RA patients compared with the general population declined on average by 1.3% per year for AMI and by 2.3% for IHD from 1972 to 2014. There were no significant excess AMI (SER 1.05, 95% CI 0.82-1.35) or IHD events (SER 1.02, 95% CI 0.89-1.16) for RA patients diagnosed after 1998 compared with the general population. CONCLUSION Incidence rates and excess events of AMI and IHD in RA patients declined from 1972 to 2017. There were no excess AMI or IHD events in RA patients diagnosed after 1998 compared with the general population.
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Affiliation(s)
- C L Alsing
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - T W Nystad
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - J Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Health and Social Science, Centre for Evidence-Based Practice, Western Norway University of Applied Science, Bergen, Norway
| | - C G Gjesdal
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - H Midtbø
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - G S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - B T Fevang
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
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21
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Park E, Griffin J, Bathon JM. Myocardial Dysfunction and Heart Failure in Rheumatoid Arthritis. Arthritis Rheumatol 2022; 74:184-199. [PMID: 34523821 PMCID: PMC8795468 DOI: 10.1002/art.41979] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/24/2021] [Accepted: 09/09/2021] [Indexed: 02/03/2023]
Abstract
Rheumatoid arthritis (RA) patients have almost twice the risk of heart failure (HF) as individuals without RA, even with adjustment for the presence of ischemic heart disease. Moreover, RA patients remain at a 2-fold higher risk of mortality from HF compared to non-RA patients. These observations suggest that RA-specific inflammatory pathways are significant contributors to this increased risk of HF. Herein we summarize the epidemiology of HF in RA patients, the differences in myocardial structure or function between RA patients and non-RA patients without clinical signs of HF, and data on the role of systemic and local inflammation in RA HF pathophysiology. We also discuss the impact of subduing inflammation through the use of RA disease-modifying therapies on HF and myocardial structure and function, emphasizing gaps in the literature and areas needing further research.
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Affiliation(s)
- Elizabeth Park
- Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
| | - Jan Griffin
- Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
| | - Joan M Bathon
- Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, New York
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22
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Gunderson TM, Myasoedova E, Davis JM, Crowson CS. Multimorbidity Burden in Rheumatoid Arthritis: A Population-based Cohort Study. J Rheumatol 2021; 48:1648-1654. [PMID: 33589552 PMCID: PMC8364559 DOI: 10.3899/jrheum.200971] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To estimate the prevalence and incidence of multimorbidity (MM) in a population-based cohort of patients with rheumatoid arthritis (RA) compared to subjects without RA. METHODS Between 1999-2013, residents of Olmsted County, Minnesota with incident RA who met the 1987 American College of Rheumatology criteria were compared to age- and sex-matched non-RA subjects from the same population. Twenty-five chronic comorbidities from a combination of the Charlson, Elixhauser, and Rheumatic Disease Comorbidity Indices were included, excluding rheumatic comorbidities. The Aalen-Johansen method was used to estimate the cumulative incidence of MM (MM2+; ≥ 2 chronic comorbidities) or substantial MM (MM5+; ≥ 5), adjusting for the competing risk of death. RESULTS The study included 597 patients with RA and 594 non-RA subjects (70% female, 90% White, mean age 55.5 yrs). At incidence/index date, the prevalence of MM2+ was higher in RA than non-RA subjects (38% RA vs 32% non-RA, P = 0.02), whereas prevalence of MM5+ was similar (5% RA vs. 4% non-RA, P = 0.68). During follow-up (median 11.6 yrs RA, 11.3 yrs non-RA), more patients with RA developed MM2+ (214 RA vs 188 non-RA; adjusted HR 1.39, 95% CI 1.14-1.69). By 10 years after RA incidence/index, the cumulative incidence of MM2+ was 56.5% among the patients with RA (95% CI 56.5-62.3%) compared with 47.9% among the non-RA (95% CI 42.8-53.7%). Patients with RA showed no evidence of increase in incidence of MM5+ (adjusted HR 1.17, 95% CI 0.93-1.47). CONCLUSION Patients with RA have both a higher prevalence of MM at the time of RA incidence as well as increased incidence thereafter.
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Affiliation(s)
- Tina M Gunderson
- T.M. Gunderson, MS, Department of Health Sciences Research, Mayo Clinic, Rochester
| | - Elena Myasoedova
- E. Myasoedova, MD, PhD, C.S. Crowson, PhD, Department of Health Sciences Research, and Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester
| | - John M Davis
- J.M. Davis III, MD, MS, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia S Crowson
- E. Myasoedova, MD, PhD, C.S. Crowson, PhD, Department of Health Sciences Research, and Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester;
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23
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Autoimmune Rheumatic Diseases and Vascular Function: The Concept of Autoimmune Atherosclerosis. J Clin Med 2021; 10:jcm10194427. [PMID: 34640445 PMCID: PMC8509415 DOI: 10.3390/jcm10194427] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/18/2022] Open
Abstract
Autoimmune rheumatic diseases (AIRDs) with unknown etiology are increasing in incidence and prevalence. Up to 5% of the population is affected. AIRDs include rheumatoid arthritis, system lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. In patients with autoimmune diseases, the immune system attacks structures of its own body, leading to widespread tissue and organ damage, which, in turn, is associated with increased morbidity and mortality. One third of the mortality associated with autoimmune diseases is due to cardiovascular diseases. Atherosclerosis is considered the main underlying cause of cardiovascular diseases. Currently, because of finding macrophages and lymphocytes at the atheroma, atherosclerosis is considered a chronic immune-inflammatory disease. In active inflammation, the liberation of inflammatory mediators such as tumor necrotic factor alpha (TNFa), interleukine-6 (IL-6), IL-1 and other factors like T and B cells, play a major role in the atheroma formation. In addition, antioxidized, low-density lipoprotein (LDL) antibodies, antinuclear antibodies (ANA), and rheumatoid factor (RF) are higher in the atherosclerotic patients. Traditional risk factors like gender, age, hypercholesterolemia, smoking, diabetes mellitus, and hypertension, however, do not alone explain the risk of atherosclerosis present in autoimmune diseases. This review examines the role of chronic inflammation in the etiology-and progression-of atherosclerosis in autoimmune rheumatic diseases. In addition, discussed here in detail are the possible effects of autoimmune rheumatic diseases that can affect vascular function. We present here the current findings from studies that assessed vascular function changes using state-of-the-art techniques and innovative endothelial function biomarkers.
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24
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Myasoedova E, Davis JM, Roger VL, Achenbach SJ, Crowson CS. Improved Incidence of Cardiovascular Disease in Patients With Incident Rheumatoid Arthritis in the 2000s: A Population-based Cohort Study. J Rheumatol 2021; 48:1379-1387. [PMID: 33589553 PMCID: PMC8364571 DOI: 10.3899/jrheum.200842] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess trends in incidence of cardiovascular disease (CVD) and mortality following incident CVD events in patients with rheumatoid arthritis (RA) onset in 1980-2009 vs non-RA subjects. METHODS We studied Olmsted County, Minnesota residents with incident RA (aged > 18 yrs, 1987 American College of Rheumatology criteria met in 1980-2009) and non-RA subjects from the same source population with similar age, sex, and calendar year of index. All subjects were followed until death, migration, or December 31, 2016. Incident CVD events included myocardial infarction and stroke. Patients with CVD before RA incidence/index date were excluded. Cox models were used to compare incident CVD events by decade, adjusting for age, sex, and CVD risk factors. RESULTS The study included 905 patients with RA and 904 non-RA subjects. Cumulative incidence of any CVD event was lower in patients with incident RA in the 2000s vs the 1980s. The HR for any incident CVD in the 2000s vs 1980s was 0.53 (95% CI 0.31-0.93). The strength of association attenuated after adjustment for anti-rheumatic medication use (HR 0.64, 95% CI 0.34-1.22). Patients with RA in the 2000s had no excess in CVD over non-RA subjects (HR 0.71, 95% CI 0.42-1.19). Risk of death after a CVD event was somewhat lower in patients with RA after the 1980s with an HR of 0.54 (95% CI 0.33-0.90) in the 1990s vs 1980s and 0.68 (95% CI 0.33-1.41) in the 2000s vs 1980s. CONCLUSION The incidence of major CVD events in RA has declined in recent decades. The gap in CVD occurrence between patients with RA and the general population is closing. Mortality after CVD events in RA may be improving.
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Affiliation(s)
- Elena Myasoedova
- E. Myasoedova, MD, PhD, Division of Rheumatology, Department of Internal Medicine, and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic;
| | - John M Davis
- J.M. Davis III, MD, MS, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic
| | - Veronique L Roger
- V.L. Roger, MD, MPH, Division of Epidemiology, Department of Health Sciences Research, and Division of Circulatory Failure, Department of Cardiovascular Disease, Mayo Clinic
| | - Sara J Achenbach
- S.J. Achenbach, MS, Division of Medical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic
| | - Cynthia S Crowson
- C.S. Crowson, PhD, Division of Rheumatology, Department of Internal Medicine, and Division of Medical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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25
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Baviera M, Cioffi G, Colacioppo P, Tettamanti M, Fortino I, Roncaglioni MC. Temporal trends from 2005 to 2018 in deaths and cardiovascular events in subjects with newly diagnosed rheumatoid arthritis. Intern Emerg Med 2021; 16:1467-1475. [PMID: 33386606 DOI: 10.1007/s11739-020-02581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
Although rheumatoid arthritis (RA) is associated with an increased risk of death and cardiovascular (CV) disease, the excess of these risks is expected to have diminished over time, in more recent incident cohorts with RA. We analysed the risk of all-cause death, stroke, and myocardial infarction as primary outcomes and all CV events as secondary outcomes in RA subjects compared to the general population, from 2005 to 2018. The risk outcomes were also evaluated in relation to the time since RA diagnosis. We conducted a cohort study using linkable administrative healthcare databases of the Lombardy Region, Northern Italy. Analyses included subjects newly diagnosed RA subjects and a random sample of No-RA subjects. An adjusted Cox proportional hazard regression model was used to calculate hazard ratios and 95% CIs for all outcomes. The study population comprised 16,047 RA subjects and 500,000 without RA. The risks of dying (HR 1.22, 95% CI 1.15-1.30), stroke (HR 1.39, 95% CI 1.22-1.58), myocardial infarction (HR 2.00, 95% CI 1.78-2.26) were significantly higher in the RA cohort, as were those that for secondary outcomes. Differences between RA and No-RA already emerged during the first five years after diagnosis. Risk patterns remained statistically significant during the next 5 years or more. Subjects with RA still have a higher risk of death and worse CV outcomes than the general population, appearing early and not decreasing with time. Preventive interventions are urgently needed.
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Affiliation(s)
- Marta Baviera
- Laboratory of Cardiovascular Prevention, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy.
| | - Giovanni Cioffi
- Rheumatology Section, Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
- Division of Cardiac Rehabilitation, S. Pancrazio Hospital, Arco, Trento, Italy
| | - Pierluca Colacioppo
- Laboratory of Cardiovascular Prevention, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Mauro Tettamanti
- Laboratory of Geriatric Neuropsychiatry, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Maria Carla Roncaglioni
- Laboratory of Cardiovascular Prevention, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
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26
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Vicente GNS, Pereira IA, de Castro GRW, da Mota LMH, Carnieletto AP, de Souza DGS, da Gama FO, Santos ABV, de Albuquerque CP, Bértolo MB, Júnior PL, Giorgi RDN, Radominski SC, Guimarães MFBR, Bonfiglioli KR, Sauma MDFLDC, Brenol CV, da Rocha Castelar Pinheiro G. Cardiovascular risk comorbidities in rheumatoid arthritis patients and the use of anti-rheumatic drugs: a cross-sectional real-life study. Adv Rheumatol 2021; 61:38. [PMID: 34172097 DOI: 10.1186/s42358-021-00186-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/17/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a common autoimmune systemic inflammatory disease. In addition to joint involvement, RA patients frequently have other comorbidities, such as cardiovascular diseases. Drugs used for RA treatment may increase or decrease the risk of a cardiovascular event. This study aims to analyze cardiovascular risk comorbidities in patients with RA and the correlation with the use of anti-rheumatic drugs. METHODS Cross-sectional study conducted based on the real-life rheumatoid arthritis study database - REAL, a prospective observational cohort study. Associations between the use of anti-rheumatic drugs and the presence of comorbidities were represented by their prevalence ratio and evaluated using the Chi-square or Fisher's Exact tests. RESULTS We assessed 1116 patients, 89.4% women, mean age of 55.15 years and predominance of seropositive disease. 63.3% had some cardiovascular comorbidity, predominantly hypertension (49.9%). The use of glucocorticoids was observed in 47.4% of patients and there was a significant tendency of lower use of these drugs in the presence of dyslipidemia (PR: 0.790; p = 0.007). We observed that the presence of cardiovascular comorbidities was associated with higher use of bDMARDs (PR:1.147; p = 0.003). CONCLUSIONS The presence of cardiovascular risk comorbidities was confirmed to be higher in RA patients. Different treatment strategies using less glucocorticoids in the presence of dyslipidemia and more common use of bDMARDs in patients with cardiovascular comorbidities suggest that rheumatologists are aware of the potential influence of the DMARDs in the risk of cardiovascular event. Reinforcing these results, we highlight the need for a better baseline assessment to guide the choice of anti-rheumatic drugs in RA patients who have comorbidities.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Manoel Barros Bértolo
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Rina Dalva Neubarth Giorgi
- Instituto de Assistência Médica ao Servidor Público Estadual, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
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27
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Bathon JM. Is the Gap in Incidence of Cardiovascular Events in Rheumatoid Arthritis Really Closing? J Rheumatol 2021; 48:1351-1353. [PMID: 34329190 DOI: 10.3899/jrheum.210366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Joan M Bathon
- J.M. Bathon, MD, Professor of Medicine, Division of Rheumatology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA.
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Long-Term Outcomes of Surgical Aortic Valve Replacement in Patients with Rheumatoid Arthritis. J Clin Med 2021; 10:jcm10112492. [PMID: 34199991 PMCID: PMC8200235 DOI: 10.3390/jcm10112492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Patients with rheumatoid arthritis (RA) have increased risk of developing cardiovascular disease and events. Little is, however, known about the influence of RA to the outcomes after surgical aortic valve replacement (SAVR). Methods: In a retrospective, nationwide, multicenter cohort study, RA patients (n = 109) were compared to patients without RA (n = 1090) treated with isolated SAVR for aortic valve stenosis. Propensity score-matching adjustment for baseline features was used to study the outcome differences in a median follow-up of 5.6 years. Results: Patients with RA had higher all-cause mortality (HR 1.76; CI 1.21–2.57; p = 0.003), higher incidence of major adverse cardiovascular events (HR 1.63; CI 1.06–2.49; p = 0.025), and they needed more often coronary artery revascularization for coronary artery disease (HR 3.96; CI 1.21–12.90; p = 0.027) in long-term follow-up after SAVR. As well, cardiovascular mortality rate was higher in patients with RA (35.7% vs. 23.4%, p = 0.023). There was no difference in 30-day mortality (2.8% vs. 1.8%, p = 0.518) or in the need for aortic valve reoperations (3.7% vs. 4.0%, p = 0.532). Conclusions: Patients with rheumatoid arthritis had impaired long-term results and increased cardiovascular mortality after SAVR for aortic valve stenosis. Special attention is needed to improve outcomes of aortic valve stenosis patients with RA after SAVR.
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29
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Yazdani K, Xie H, Avina-Zubieta JA, Zheng Y, Abrahamowicz M, Lacaille D. Ten-year risk of cerebrovascular accidents in incident rheumatoid arthritis: a population-based study of trends over time. Rheumatology (Oxford) 2021; 60:2267-2276. [PMID: 33246339 DOI: 10.1093/rheumatology/keaa579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/22/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate secular trends in 10-year risk of incident cerebrovascular accidents (CVA), in incident RA relative to the general population. METHODS We conducted a retrospective study of a population-based incident cohort with RA onset from 1997 to 2004 in British Columbia, Canada, with matched general population controls (2:1), using administrative health data. RA and general population cohorts were divided according to year of RA onset, defined according to the first RA visit of the case definition. Incident CVA was defined as the first CVA occurring within 10 years from the first RA visit. Secular trend was assessed using delayed-entry Cox models with a two-way interaction term between the year of RA onset and indicator of RA vs general population. Linear, quadratic and spline functions of year of RA onset were compared with assess non-linear effects. The model with the lowest Akaike Information Criterion was selected. RESULTS Overall, 23 545 RA and 47 090 general population experienced 658 and 1220 incident CVAs, respectively. A spline Cox model with a knot at year of onset 1999 was selected. A significant decline in risk of CVA was observed in individuals with RA onset after 1999 [0.90 (0.86, 0.95); P = 0.0001]. The change in CVA risk over time differed significantly in RA with onset from 1999 onwards compared with the general population (P-value of interaction term = 0.03), but not before 1999 (P = 0.06). CONCLUSION Our findings suggest that people with RA onset from 1999 onwards, had a significantly greater decline in 10-year risk of CVA compared with the general population.
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Affiliation(s)
- Kiana Yazdani
- Arthritis Research Canada, Richmond.,Department of Medicine, Faculty of Medicine, Experimental Medicine Program, University of British Columbia, Vancouver
| | - Hui Xie
- Arthritis Research Canada, Richmond.,Faculty of Health Sciences, Simon Fraser University, Vancouver
| | - J Antonio Avina-Zubieta
- Arthritis Research Canada, Richmond.,Department of Medicine, Faculty of Medicine, Experimental Medicine Program, University of British Columbia, Vancouver.,Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC
| | | | - Michal Abrahamowicz
- Arthritis Research Canada, Richmond.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Richmond.,Department of Medicine, Faculty of Medicine, Experimental Medicine Program, University of British Columbia, Vancouver.,Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC
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30
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Karpouzas GA, Bui VL, Ronda N, Hollan I, Ormseth SR. Biologics and atherosclerotic cardiovascular risk in rheumatoid arthritis: a review of evidence and mechanistic insights. Expert Rev Clin Immunol 2021; 17:355-374. [PMID: 33673792 DOI: 10.1080/1744666x.2021.1899809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Cardiovascular disease is a leading comorbidity in rheumatoid arthritis. Timely introduction of biologic therapies in a treat-to-target approach has optimized disease-related outcomes and attenuated accrual of comorbidities, including cardiovascular risk.Areas covered: A literature search in MEDLINE (via PubMed) was performed between January 2009 and November 2020. This manuscript explores recent developments in atherosclerotic cardiovascular risk in RA compared with non-RA individuals; it synopsizes differences in vascular function and inflammation, prevalence, burden, vulnerability, and progression of atherosclerotic plaque and their underlying cellular and molecular mechanisms. Finally, it reviews the recent literature on cardioprotective benefits of biologics and draws mechanistic links with inhibition of new plaque formation, stabilization of high-risk lesions and improvement in endothelial function, arterial stiffness, lipid metabolism, and traditional cardiac risk factors.Expert opinion: Increasing evidence points to a solid cardioprotective influence of earlier, longer, and ongoing use of biologic treatments in RA. Nevertheless, the precise mechanistic effects of plaque progression and remodeling, vascular stiffness, endothelial dysfunction, lipid metabolism, and traditional cardiac risk factors are less rigorously characterized.
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Affiliation(s)
- George A Karpouzas
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Viet L Bui
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nicoletta Ronda
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Ivana Hollan
- The Norwegian University of Science and Technology, Gjøvik, Norway.,Beitostølen Sport and Health Centre, Beitostølen, Norway
| | - Sarah R Ormseth
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
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31
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Myasoedova E. Defeating the Hydra of Excess Cardiovascular Disease Risk in Rheumatoid Arthritis - How Close Are We to Completing the Task? J Rheumatol 2021; 48:629-632. [PMID: 33649065 DOI: 10.3899/jrheum.201110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Elena Myasoedova
- E. Myasoedova, MD, PhD, Associate Professor of Internal Medicine, Senior Associate Consultant, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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32
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Yazdani K, Xie H, Avina-Zubieta JA, Zheng Y, Abrahamowicz M, Lacaille D. Has the excess risk of acute myocardial infarction in rheumatoid arthritis relative to the general population declined? A population study of trends over time. Semin Arthritis Rheum 2021; 51:442-449. [PMID: 33735663 DOI: 10.1016/j.semarthrit.2021.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/03/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate secular trend in ten-year risk of incident acute myocardial infarction (AMI) in incident rheumatoid arthritis (RA) relative to the general population. METHODS We conducted a retrospective study of population-based incident RA cohorts with RA incidence from 1997 to 2004 in British Columbia, Canada, with matched general population comparators, using administrative health data. RA and their matched cohorts were divided according to the year of RA incidence, defined according to the first RA visit of the case definition. Incident AMI was defined as the first event occurring within 10 years from RA incidence. Secular trend was assessed using delayed-entry Cox models with an interaction term between the year of RA onset and indicator of RA vs. general population. Linear, quadratic and spline functions of year of RA onset were compared to assess possibility of nonlinear trends. The model with the lowest AIC was selected to interpret the results. Sensitivity analyses were conducted to account for potential effect of unmeasured (e.g. smoking) or partially measured (e.g. obesity) confounders in administrative data, on the interaction term. RESULTS Overall, 23,237 RA and 46,474 general population controls experienced 1,133 and 1,606 incident AMIs, respectively. A linear Cox model was selected as the model best fitting the AMI events. Overall, RA patients were found to have a 21% higher risk of AMI than the matched general population controls [1.21 (1.10, 1.32); p < 0.001]. A significant linear decline in risk of AMI was observed in RA patients [0.94 (95% CI 0.91, 0.97) p = <0.0001], and in the general population [0.93 (0.91, 0.95); p = <0.0001]. The change in AMI risk over time did not differ in RA compared to the general population [p-value of interaction term=0.49]. Our results remained similar after adjusting for the potential effect of confounders on the interaction term, and no difference in the change in risk of AMI over time was observed between RA and the general population. CONCLUSION Our findings suggest a decline in 10-year risk of AMI in RA, and in the general population. The decline in the risk of AMI over time did not differ between RA and the general population, such that the excess risk of AMI in RA relative to the general population, has remained the same.
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Affiliation(s)
- Kiana Yazdani
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada; Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Hui Xie
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada; Faculty of Health Science, Simon Fraser University, Vancouver, Canada
| | - J Antonio Avina-Zubieta
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada; Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Canada; Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Yufei Zheng
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada
| | - Michal Abrahamowicz
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada; Department of Epidemiology, Biostatistics and Occupational Health McGill University, Montreal, Quebec, Canada
| | - Diane Lacaille
- Arthritis Research Canada, 5591 Number 3 Rd, Richmond V6X 2C7, British Columbia, Canada; Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of British Columbia, Canada; Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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Skeletal muscle disease in rheumatoid arthritis: the center of cardiometabolic comorbidities? Curr Opin Rheumatol 2021; 32:297-306. [PMID: 32141950 DOI: 10.1097/bor.0000000000000697] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Despite its critical roles in body movement, structure, and metabolism, skeletal muscle remains underappreciated in the context of rheumatoid arthritis. In rheumatoid arthritis, chronic inflammation, physical inactivity, and medication toxicities impair skeletal muscle. These skeletal muscle alterations contribute to continued rheumatoid arthritis disparities in physical function and cardiometabolic health. RECENT FINDINGS In the prebiologic disease-modifying antirheumatic drug era, rheumatoid arthritis skeletal muscle atrophy was the central feature of 'rheumatoid cachexia,' a hypermetabolic state driven by chronic systemic inflammation and muscle protein degradation. In the current era, rheumatoid arthritis muscle deficits are less visible, yet persist as a key component of 'sarcopenic obesity.' In rheumatoid arthritis sarcopenic obesity, chronic inflammation, physical inactivity, and medication toxicities contribute to muscle contractile deficits, inflammation, altered metabolism, and intramuscular adiposity, a key predictor of rheumatoid arthritis disability and insulin resistance. SUMMARY Rheumatoid arthritis skeletal muscle disease in the current era is defined by impaired contractile function (poor strength and endurance) and sarcopenic obesity (decreased muscle mass, increased fat mass, and intramuscular adiposity). These muscle impairments contribute to disability and cardiometabolic disease in rheumatoid arthritis. Management should focus on monitoring of rheumatoid arthritis muscle function and body composition, limiting potentially myotoxic drugs, and prescription of exercise training.
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Sorour AA, Kurmann RD, Shahin YE, Crowson CS, Achenbach SJ, Mankad R, Myasoedova E. Use of Hydroxychloroquine and Risk of Heart Failure in Patients With Rheumatoid Arthritis. J Rheumatol 2021; 48:1508-1511. [PMID: 33452171 DOI: 10.3899/jrheum.201180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the relationship between the use of hydroxychloroquine (HCQ) and risk of developing heart failure (HF) in rheumatoid arthritis (RA). METHODS In this nested case-control study, cases were Olmsted County, Minnesota residents with incident RA (based on 1987 American College of Rheumatology criteria) from 1980 to 2013 who developed HF after RA incidence. Each case was matched on year of birth, sex, and year of RA incidence with an RA control who did not develop HF. Data on HCQ use including start and stop dates, as well as dose changes, were reviewed and used to calculate HCQ duration and cumulative dose. Age-adjusted logistic regression models were used to examine the association between HCQ and HF. RESULTS The study identified 143 RA cases diagnosed with HF (mean age 65.8 yrs, 62% females) and 143 non-HF RA controls (mean age 64.5, 62% female). HCQ cumulative dose was not associated with HF (OR 0.96 per 100-g increase in cumulative dose, 95% CI 0.90-1.03). Likewise, no association was found for patients with a cumulative dose ≥ 300 g (OR 0.92, 95% CI 0.41-2.08). The HCQ duration of intake in years prior to index was not associated with HF (OR 0.98, 95% CI 0.91-1.05). CONCLUSION Use of HCQ was not associated with development of HF in patients with RA in this study. Further studies are needed to understand the effect of higher doses of HCQ on the development of HF in RA.
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Affiliation(s)
- Ahmed A Sorour
- A.A. Sorour, MD, R.D. Kurmann, MD, Y.E. Shahin, R. Mankad, MD, Department of Cardiovascular Medicine, Mayo Clinic
| | - Reto D Kurmann
- A.A. Sorour, MD, R.D. Kurmann, MD, Y.E. Shahin, R. Mankad, MD, Department of Cardiovascular Medicine, Mayo Clinic
| | - Youssef E Shahin
- A.A. Sorour, MD, R.D. Kurmann, MD, Y.E. Shahin, R. Mankad, MD, Department of Cardiovascular Medicine, Mayo Clinic
| | - Cynthia S Crowson
- C.S. Crowson, PhD, Division of Biomedical Statistics and Informatics, and Department of Rheumatology, Mayo Clinic
| | - Sara J Achenbach
- S.J. Achenbach, MS, Division of Biomedical Statistics and Informatics, Mayo Clinic
| | - Rekha Mankad
- A.A. Sorour, MD, R.D. Kurmann, MD, Y.E. Shahin, R. Mankad, MD, Department of Cardiovascular Medicine, Mayo Clinic
| | - Elena Myasoedova
- E. Myasoedova, MD, PhD, Department of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA.
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Hansildaar R, Vedder D, Baniaamam M, Tausche AK, Gerritsen M, Nurmohamed MT. Cardiovascular risk in inflammatory arthritis: rheumatoid arthritis and gout. THE LANCET. RHEUMATOLOGY 2021; 3:e58-e70. [PMID: 32904897 PMCID: PMC7462628 DOI: 10.1016/s2665-9913(20)30221-6] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The increased risk of cardiovascular morbidity and mortality in rheumatoid arthritis and gout has been increasingly acknowledged in past decades, with accumulating evidence that gout, just as with rheumatoid arthritis, is an independent cardiovascular risk factor. Although both diseases have a completely different pathogenesis, the underlying pathophysiological mechanisms in systemic inflammation overlap to some extent. Following the recognition that systemic inflammation has an important causative role in cardiovascular disease, anti-inflammatory therapy in both conditions and urate-lowering therapies in gout are expected to lower the cardiovascular burden of patients. Unfortunately, much of the existing data showing that urate-lowering therapy has consistent beneficial effects on cardiovascular outcomes in patients with gout are of low quality and contradictory. We will discuss the latest evidence in this respect. Cardiovascular disease risk management for patients with rheumatoid arthritis and gout is essential. Clinical guidelines and implementation of cardiovascular risk management in daily clinical practice, as well as unmet needs and areas for further investigation, will be discussed.
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Affiliation(s)
- Romy Hansildaar
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam and Reade, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Daisy Vedder
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam and Reade, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Milad Baniaamam
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam and Reade, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Anne-Kathrin Tausche
- Department of Rheumatology, University Clinic Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Martijn Gerritsen
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam and Reade, Amsterdam, Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam and Reade, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
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Fragoulis GE, Panayotidis I, Nikiphorou E. Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment. Curr Vasc Pharmacol 2020; 18:431-446. [PMID: 31258091 DOI: 10.2174/1570161117666190619143842] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Ismini Panayotidis
- Faculty of Medical Sciences, Medical School, University College London, London, United Kingdom
| | - Elena Nikiphorou
- Department of Inflammation Biology, King's College London, London, UK and Department of Rheumatology, King's College Hospital, London, United Kingdom
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Nakajima A, Sakai R, Inoue E, Harigai M. Prevalence of patients with rheumatoid arthritis and age-stratified trends in clinical characteristics and treatment, based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Int J Rheum Dis 2020; 23:1676-1684. [PMID: 33016574 DOI: 10.1111/1756-185x.13974] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/18/2020] [Accepted: 09/03/2020] [Indexed: 01/06/2023]
Abstract
AIM To estimate the prevalence and age-stratified treatment trends and clinical characteristics of rheumatoid arthritis (RA) in Japan. METHOD Using 7 RA definitions, the prevalence of RA in those aged ≥16 years was estimated using the National Database of Health Insurance Claims and Specific Health Checkups of Japan in the fiscal year 2017. We analyzed age-stratified trends in characteristics and treatments. RESULTS Of 1 116 122 patients aged ≥16 years with at least 1 RA-related International Classification of Diseases-10 code, 825.7 thousand patients (women, 76.3%) were assessed as having RA with an estimated prevalence of 0.65%. The highest age-stratified prevalence was 1.63% in patients aged 70-79 years. Overall, 60.8% and 7.0% of patients with RA were aged ≥65 years and ≥85 years, respectively. Methotrexate use was most frequent in patients aged 50-59 years (73.0%) and least frequent in patients aged ≥85 years (38.2%). Biologic disease-modifying antirheumatic drugs use was 50.9% in patients aged 16-19 years and decreased to 13.7% in those aged ≥85 years. Preference for the use of tumor necrosis factor inhibitors versus abatacept decreased from 24.0:1 to 1.7:1 in patients aged 16-19 years and ≥85 years, respectively. The prevalence of cardiovascular disease was 3.5% in patients aged 60-69 years and 12.1% in those aged ≥85 years. Overall RA-related orthopedic surgeries were most prevalent in patients aged 70-79 years. CONCLUSION The estimated prevalence of patients with RA in Japan was 0.65%. Age-stratified treatment trends and clinical characteristics have been described in a super-aged society for the first time.
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Affiliation(s)
- Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Tsu, Japan.,Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Ryoko Sakai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Division of Multidisciplinary Management of Rheumatic Diseases, Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eisuke Inoue
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Research Administration Center, Showa University, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Elbadawi A, Ahmed HMA, Elgendy IY, Omer MA, Ogunbayo GO, Abohamad S, Paniagua D, Jneid H. Outcomes of Acute Myocardial Infarction in Patients with Rheumatoid Arthritis. Am J Med 2020; 133:1168-1179.e4. [PMID: 32278845 DOI: 10.1016/j.amjmed.2020.02.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a paucity of data on the outcomes of acute myocardial infarction in patients with rheumatoid arthritis in the contemporary era. METHODS We queried the National Inpatient Sample database (2002-2016) for hospitalizations with acute myocardial infarction. We described the trends and outcomes of acute myocardial infarction-rheumatoid arthritis compared with acute myocardial infarction-no rheumatoid arthritis. RESULTS The analysis included 9,359,546 hospitalizations with acute myocardial infarction, of whom 123,783 (1.3%) had rheumatoid arthritis. There was an increase in the number of hospitalizations with acute myocardial infarction-rheumatoid arthritis (Ptrend < .001). There was an observed downtrend in mortality rates for acute myocardial infarction-rheumatoid arthritis (5.8% in 2002 vs 5.2% in 2016, Ptrend = .01) corresponding to an increase in the utilization of percutaneous coronary intervention (Ptrend < .001). In the overall cohort of acute myocardial infarction, rheumatoid arthritis was independently associated with lower rate of in-hospital mortality (adjusted odds ratio 0.90; 95% confidence interval, 0.81-0.99, P = .03). Compared with ST-elevation myocardial infarction (STEMI)-no rheumatoid arthritis, STEMI-rheumatoid arthritis was associated with lower in-hospital mortality and cardiac arrest, while it was associated with higher discharges to nursing facilities. No difference in mortality was observed among non-ST-elevation myocardial infarction (NSTEMI)-rheumatoid arthritis and NSTEMI-no rheumatoid arthritis, while NSTEMI-rheumatoid arthritis was associated with lower cardiac arrest, cardiogenic shock, and hemodialysis, at the expense of higher bleeding events and discharges to nursing facilities. CONCLUSION In this nationwide analysis, we found an increase in hospitalizations for acute myocardial infarction-rheumatoid arthritis. Among patients with acute myocardial infarction, rheumatoid arthritis was independently associated with lower in-hospital mortality, particularly in cases of STEMI.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston
| | - Hamdy M A Ahmed
- Division of Rheumatology and Clinial Immunology, University of Alabama at Birmingham, Birmingham.
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mohmed A Omer
- Division of Cardiovascular Medicine, University of Missouri-Kansas City
| | | | - Samar Abohamad
- Department of Internal Medicine, Cairo University, Cairo, Egypt.
| | - David Paniagua
- Division of Cardiology, Baylor School of Medicine, Houston, Texas
| | - Hani Jneid
- Division of Cardiology, Baylor School of Medicine, Houston, Texas.
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Daniel CM, Davila L, Makris UE, Mayo H, Caplan L, Davis L, Solow EB. Ethnic Disparities in Atherosclerotic Cardiovascular Disease Incidence and Prevalence Among Rheumatoid Arthritis Patients in the United States: a Systematic Review. ACR Open Rheumatol 2020; 2:525-532. [PMID: 32869533 PMCID: PMC7504478 DOI: 10.1002/acr2.11170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 07/17/2020] [Indexed: 12/16/2022] Open
Abstract
Objective Rheumatoid arthritis (RA) is associated with increased atherosclerotic cardiovascular disease (ASCVD). General population cohorts have shown African American individuals to have greater and Hispanic Americans to have lower cardiovascular disease prevalence when compared with non‐Hispanic white individuals; however, the reasons for these findings are not clear. This systematic review seeks to describe the incidence and prevalence of ASCVD stratified by race/ethnicity within the US RA population. Methods MEDLINE, Embase, and Cochrane databases were searched for studies that reported incidence or prevalence of ASCVD (including, but not limited to, fatal and nonfatal stroke, myocardial infarction, and cardiovascular death) in those with RA. Abstracts and full texts were screened separately for inclusion by two reviewers, with a third reviewer to resolve discrepancies. Results We screened 2625 abstracts and fully reviewed 138 manuscripts. Twenty‐one were included that cited at a minimum the percentage of non‐Hispanic whites in their population. No publication meeting entry criteria initially stratified ASCVD by race/ethnicity. The average prevalent ASCVD in RA is 46.9% (95% CI: 46.8–47) (range of prevalent ASCVD: 30%‐47%). The average incident ASCVD is 8.2% (95% CI: 8.14–8.25) (range of incident ASCVD 1%–46%). Conclusion In this systematic review, we found a paucity of data on racially/ethnically diverse RA patients and ASCVD outcomes. Future studies should report the prevalence of ASCVD in various races/ethnicities with RA in the United States. These data would help inform clinicians on how best to manage cardiovascular disease risk in RA.
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Affiliation(s)
| | - Lesley Davila
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Una E Makris
- University of Texas Southwestern Medical Center, Dallas, Texas and Medical Service VA North Texas Health Care System, Dallas, Texas
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, UT Southwestern Medical Center, Dallas, Texas
| | - Liron Caplan
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado and University of Colorado, Aurora
| | | | - E Blair Solow
- University of Texas Southwestern Medical Center, Dallas, Texas
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Solomon A, Stanwix AE, Castañeda S, Llorca J, Gonzalez-Juanatey C, Hodkinson B, Romela B, Ally MMTM, Maharaj AB, Van Duuren EM, Ziki JJ, Seboka M, Mohapi M, Jansen Van Rensburg BJ, Tarr GS, Makan K, Balton C, Gogakis A, González-Gay MA, Dessein PH. Points to consider in cardiovascular disease risk management among patients with rheumatoid arthritis living in South Africa, an unequal middle income country. BMC Rheumatol 2020; 4:42. [PMID: 32550295 PMCID: PMC7296622 DOI: 10.1186/s41927-020-00139-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND It is plausible that optimal cardiovascular disease (CVD) risk management differs in patients with rheumatoid arthritis (RA) from low or middle income compared to high income populations. This study aimed at producing evidence-based points to consider for CVD prevention in South African RA patients. METHODS Five rheumatologists, one cardiologist and one epidemiologist with experience in CVD risk management in RA patients, as well as two patient representatives, two health professionals and one radiologist, one rheumatology fellow and 11 rheumatologists that treat RA patients regularly contributed. Systematic literature searches were performed and the level of evidence was determined according to standard guidelines. RESULTS Eighteen points to consider were formulated. These were grouped into 6 categories that comprised overall CVD risk assessment and management (n = 4), and specific interventions aimed at reducing CVD risk including RA control with disease modifying anti-rheumatic drugs, glucocorticoids and non-steroidal anti-inflammatory drugs (n = 3), lipid lowering agents (n = 8), antihypertensive drugs (n = 1), low dose aspirin (n = 1) and lifestyle modification (n = 1). Each point to consider differs partially or completely from recommendations previously reported for CVD risk management in RA patients from high income populations. Currently recommended CVD risk calculators do not reliably identify South African black RA patients with very high-risk atherosclerosis as represented by carotid artery plaque presence on ultrasound. CONCLUSIONS Our findings indicate that optimal cardiovascular risk management likely differs substantially in RA patients from low or middle income compared to high income populations. There is an urgent need for future multicentre longitudinal studies on CVD risk in black African patients with RA.
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Affiliation(s)
- Ahmed Solomon
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | - Anne E. Stanwix
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | - Santos Castañeda
- Rheumatology Department, Hospital de la Princesa, IIS-Princesa, Cátedra UAM-ROCHE, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Javier Llorca
- Universidad de Cantabria – IDIVAL, CIBER Epidemiologia y Salud Pública (CIBERESP), Santander, Spain
| | | | - Bridget Hodkinson
- Rheumatology Department, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Benitha Romela
- Rheumatology Unit, Wilgeheuwel Hospital, Johannesburg, South Africa
| | - Mahmood M. T. M. Ally
- Rheumatology Department, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Ajesh B. Maharaj
- Rheumatology Unit, Westville Hospital and University of KwaZulu-Natal, Durban, South Africa
| | - Elsa M. Van Duuren
- Rheumatology Division, Department of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Joyce J. Ziki
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | - Mpoti Seboka
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | - Makgotso Mohapi
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | | | - Gareth S. Tarr
- Rheumatology Department, Tygerberg Hospital, Faculty of Health Sciences, Physiological Sciences Department, Stellenbosch University, Stellenbosch, Western Cape South Africa
| | - Kavita Makan
- Rheumatology Department, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Charlene Balton
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
| | - Aphrodite Gogakis
- Radiology Unit, Rivonia Road Medical Centre, Morningside, Johannesburg, South Africa
| | - Miguel A. González-Gay
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Spain; University of Cantabria, Santander, Spain
| | - Patrick H. Dessein
- Rheumatology Department, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, 80 Scholtz Road, Norwood, Johannesburg, 2190 South Africa
- School of Physiology and School of Clinical Medicine, Faculty Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Free University and University Hospital, Brussels, Belgium
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Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol 2020; 16:361-379. [PMID: 32494054 DOI: 10.1038/s41584-020-0428-y] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Patients with rheumatoid arthritis (RA) are at high risk of developing cardiovascular disease (CVD). Inflammation has a pivotal role in the pathogenesis of CVD. RA is an inflammatory joint disease and, compared with the general population, patients with RA have approximately double the risk of atherosclerotic CVD, stroke, heart failure and atrial fibrillation. Although this high risk of CVD has been known for decades, patients with RA receive poorer primary and secondary CVD preventive care than other high-risk patients, and an unmet need exists for improved CVD preventive measures for patients with RA. This Review summarizes the evidence for atherosclerotic CVD in patients with RA and provides a contemporary analysis of what is known and what needs to be further clarified about recommendations for CVD prevention in patients with RA compared with the general population. The management of traditional CVD risk factors, including blood pressure, lipids, diabetes mellitus and lifestyle-related risk factors, as well as the effects of inflammation and the use of antirheumatic medication on CVD risk and risk management in patients with RA are discussed. The main aim is to provide a roadmap of atherosclerotic CVD risk management and prevention for patients with RA.
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Cardiovascular Health in Patients With Rheumatoid Arthritis. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cardiovascular Disease Risk in Older Adults and Elderly Patients with Rheumatoid Arthritis: What Role Can Disease-Modifying Antirheumatic Drugs Play in Cardiovascular Risk Reduction? Drugs Aging 2019; 36:493-510. [PMID: 30953327 DOI: 10.1007/s40266-019-00653-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The prevalence of rheumatoid arthritis (RA), the most common autoimmune inflammatory arthritis, is increasing, partly due to the aging of the general population. RA is an independent risk factor for the development of cardiovascular disease (CVD). Older adults and elderly patients with RA develop CVD at a younger age compared with their general population peers. Both the traditional cardiovascular risk factors (age, sex, smoking, diabetes mellitus, hypertension), and systemic inflammation (i.e. high disease activity) are contributors to accelerated CVD in people with RA. Of the disease-modifying antirheumatic drugs (DMARDs) used for RA treatment, methotrexate, triple combination oral therapy (methotrexate, sulfasalazine, and hydroxychloroquine), tumor necrosis factor inhibitor biologicals, and abatacept have the strongest data in favor of the reduction of cardiovascular events in patients with RA. A treat-to-target strategy should be employed in older adults and elderly patients with RA to ensure appropriate reduction in cardiovascular risk, which can also prevent short- and long-term musculoskeletal disability. Our review findings are in line with the 2016 European League Against Rheumatism guideline recommendations, specifically: (1) RA disease activity should be controlled with an optimal DMARD regimen using a treat-to-target approach; (2) the lipid profile should be assessed and monitored in every older adult and elderly RA patient; (3) CVD risk factors, including smoking cessation, blood pressure, and blood glucose control, should be optimized; (4) RA treatment should be initiated as soon as possible; and (5) shared decision making regarding the treatment of patients with RA should include a discussion on the potential amelioration of increased cardiovascular risk.
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Kitas GD, Nightingale P, Armitage J, Sattar N, Belch JJF, Symmons DPM. A Multicenter, Randomized, Placebo-Controlled Trial of Atorvastatin for the Primary Prevention of Cardiovascular Events in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2019; 71:1437-1449. [PMID: 30983166 PMCID: PMC6771601 DOI: 10.1002/art.40892] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/12/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with increased cardiovascular event (CVE) risk. The impact of statins in RA is not established. We assessed whether atorvastatin is superior to placebo for the primary prevention of CVEs in RA patients. METHODS A randomized, double-blind, placebo-controlled trial was designed to detect a 32% CVE risk reduction based on an estimated 1.6% per annum event rate with 80% power at P < 0.05. RA patients age >50 years or with a disease duration of >10 years who did not have clinical atherosclerosis, diabetes, or myopathy received atorvastatin 40 mg daily or matching placebo. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, transient ischemic attack, or any arterial revascularization. Secondary and tertiary end points included plasma lipids and safety. RESULTS A total of 3,002 patients (mean age 61 years; 74% female) were followed up for a median of 2.51 years (interquartile range [IQR] 1.90, 3.49 years) (7,827 patient-years). The study was terminated early due to a lower than expected event rate (0.70% per annum). Of the 1,504 patients receiving atorvastatin, 24 (1.6%) experienced a primary end point, compared with 36 (2.4%) of the 1,498 receiving placebo (hazard ratio [HR] 0.66 [95% confidence interval (95% CI) 0.39, 1.11]; P = 0.115 and adjusted HR 0.60 [95% CI 0.32, 1.15]; P = 0.127). At trial end, patients receiving atorvastatin had a mean ± SD low-density lipoprotein (LDL) cholesterol level 0.77 ± 0.04 mmoles/liter lower than those receiving placebo (P < 0.0001). C-reactive protein level was also significantly lower in the atorvastatin group than the placebo group (median 2.59 mg/liter [IQR 0.94, 6.08] versus 3.60 mg/liter [IQR 1.47, 7.49]; P < 0.0001). CVE risk reduction per mmole/liter reduction in LDL cholesterol was 42% (95% CI -14%, 70%). The rates of adverse events in the atorvastatin group (n = 298 [19.8%]) and placebo group (n = 292 [19.5%]) were similar. CONCLUSION Atorvastatin 40 mg daily is safe and results in a significantly greater reduction of LDL cholesterol level than placebo in patients with RA. The 34% CVE risk reduction is consistent with the Cholesterol Treatment Trialists' Collaboration meta-analysis of statin effects in other populations.
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Affiliation(s)
- George D. Kitas
- Dudley Group NHS Foundation Trust, Russells Hall Hospital, Stourbridge, UKand Research UK Centre for EpidemiologyManchesterUK
| | | | | | - Naveed Sattar
- University of Glasgow, Glasgow, UKand Oxford Centre for Diabetes, Endocrinology and MetabolismOxfordUK
| | - Jill J. F. Belch
- University of Dundee and Ninewells Hospital and Medical SchoolDundeeUK
| | - Deborah P. M. Symmons
- Arthritis Research UK Centre for Epidemiology, University of Manchesterand NIHR Manchester Biomedical Research CenterManchester NHS Foundation TrustManchesterUK
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Imaging for screening cardiovascular involvement in patients with systemic rheumatologic diseases: more questions than answers. Eur Heart J Cardiovasc Imaging 2019; 20:967-978. [DOI: 10.1093/ehjci/jez171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Cardiovascular involvement due to systemic rheumatologic diseases (SRDs) remains largely underdiagnosed despite causing excess mortality and limiting the favourable effect of therapeutic developments on survival. Traditional risk scoring systems are poorly calibrated for SRD patients. There is an unmet need to develop a cardiovascular (CV) risk stratification tool and screening algorithm for CV involvement dedicated to asymptomatic patients with SRDs. Even though accelerated atherosclerosis is the most prominent cause of major CV events, a more comprehensive approach is crucial to detect different pathological processes associated with SRDs that are leading to CV complications. In that regard, incorporation of imaging parameters obtained from echocardiography and carotid ultrasound (CUS) might help to improve risk models, to detect and monitor subclinical CV involvement. These two imaging modalities should be an integral part of screening SRD patients with suspicion of CV involvement on top of electrocardiogram (ECG). Cardiac magnetic resonance and multi-slice computerized tomography angiography and nuclear imaging modalities seem very important to complement echocardiography and CUS for further evaluation. However, to answer the question ‘Should asymptomatic patients with SRDs undergo screening with echocardiography and CUS on top of ECG?’ necessitates large studies performing cardiac screening with a standard approach by using these imaging methods to obtain longitudinal data with hard CV outcomes.
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Agca R, Hopman LHGA, Laan KJC, van Halm VP, Peters MJL, Smulders YM, Dekker JM, Nijpels G, Stehouwer CDA, Voskuyl AE, Boers M, Lems WF, Nurmohamed MT. Cardiovascular Event Risk in Rheumatoid Arthritis Compared with Type 2 Diabetes: A 15-year Longitudinal Study. J Rheumatol 2019; 47:316-324. [PMID: 31092721 DOI: 10.3899/jrheum.180726] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Cardiovascular (CV) disease (CVD) risk is increased in rheumatoid arthritis (RA). However, longterm followup studies investigating this risk are scarce. METHODS The CARRÉ (CARdiovascular research and RhEumatoid arthritis) study is a prospective cohort study investigating CVD and its risk factors in 353 patients with longstanding RA. CV endpoints were assessed at baseline and 3, 10, and 15 years after the start of the study and are compared to a reference cohort (n = 2540), including a large number of patients with type 2 diabetes (DM). RESULTS Ninety-five patients with RA developed a CV event over 2973 person-years, resulting in an incidence rate of 3.20 per 100 person-years. Two hundred fifty-seven CV events were reported in the reference cohort during 18,874 person-years, resulting in an incidence rate of 1.36 per 100 person-years. Age- and sex-adjusted HR for CV events were increased for RA (HR 2.07, 95% CI 1.57-2.72, p < 0.01) and DM (HR 1.51, 95% CI 1.02-2.22, p = 0.04) compared to the nondiabetic participants. HR was still increased in RA (HR 1.82, 95% CI 1.32-2.50, p < 0.01) after additional adjustment for CV risk factors. Patients with both RA and DM or insulin resistance had the highest HR for developing CVD (2.21, 95% CI 1.01-4.80, p = 0.046 and 2.67, 95% CI 1.30-5.46, p < 0.01, respectively). CONCLUSION The incidence rate of CV events in established RA was more than double that of the general population. Patients with RA have an even higher risk of CVD than patients with DM. This risk remained after adjustment for traditional CV risk factors, suggesting that systemic inflammation is an independent contributor to CV risk.
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Affiliation(s)
- Rabia Agca
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands. .,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam.
| | - Luuk H G A Hopman
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Koen J C Laan
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Vokko P van Halm
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Mike J L Peters
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Yvo M Smulders
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Jacqueline M Dekker
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Giel Nijpels
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Coen D A Stehouwer
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Alexandre E Voskuyl
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Maarten Boers
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Willem F Lems
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
| | - Michael T Nurmohamed
- From the Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade; Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center; Department of Cardiology, and Department of Internal Medicine, and Department of Epidemiology and Biostatistics, and Department of General Practice, and EMGO Institute for Health and Care Research, Amsterdam UMC, VU University Medical Center; Amsterdam UMC, Academic Medical Center, Department of Cardiology; Department of Internal Medicine, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.,R. Agca, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; L.H. Hopman, PhD student, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology; K.J. Laan, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam; V.P. van Halm, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Cardiology, and Amsterdam UMC, Academic Medical Center, Department of Cardiology; M.J. Peters, MD, PhD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; Y.M. Smulders, MD, Amsterdam UMC, VU University Medical Center, Department of Internal Medicine; J.M. Dekker, Prof. Dr., Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; G. Nijpels, MD, Amsterdam UMC, VU University Medical Center, Department of General Practice, and Amsterdam UMC, VU University Medical Center, EMGO Institute for Health and Care Research; C.D. Stehouwer, MD, Maastricht University Medical Center, Department of Internal Medicine, and Maastricht University Medical Center, CARIM; A.E. Voskuyl, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M. Boers, MD, Amsterdam UMC, VU University Medical Center, Department of Epidemiology and Biostatistics; W.F. Lems, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center; M.T. Nurmohamed, MD, Amsterdam Rheumatology and Immunology Center, Department of Rheumatology in Reade, and Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, VU University Medical Center in Amsterdam
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Gender Differences in Cardiovascular Risk Profile in Rheumatoid Arthritis Patients with Low Disease Activity. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3265847. [PMID: 31032342 PMCID: PMC6458929 DOI: 10.1155/2019/3265847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 03/17/2019] [Indexed: 01/08/2023]
Abstract
Objective Patients with rheumatoid arthritis (RA) have an excess risk of cardiovascular (CV) disease (CVD). The objective of the study was to compare CV risk profile in female and male RA patients with low disease activity. Materials and Methods The study group consisted of 70 RA patients with continuous low disease activity and no CVD (54 women, 16 men) and 33 healthy controls of comparable age. The groups were assessed for blood pressure, serum amino-terminal pro-brain natriuretic peptide (NT-proBNP), carotid intima media thickness (cIMT), electrocardiography, ejection fraction (EF), and diastolic dysfunction (DD). Results Significantly higher burden of atherosclerosis, as revealed by higher cIMT, was found in males [0.93 (0.2) mm] vs females [0.80 (0.2) mm]. The risk of 10-year CVD was significantly higher in men than in women with RA. High/very high risk of fatal CVD was found in 62.5% of male patients. Males were significantly more often current/ex-smokers and had lower HDL-cholesterol and higher atherogenic index. There were no significant differences in NT-proBNP, QTc duration, and parameters of EF and DD. Conclusions In RA patients with continued low disease activity, a higher burden of atherosclerosis was found in males than in females. The data suggest a significant impact of traditional CV risk factors.
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Poppelaars PBM, van Tuyl LHD, Boers M. Normal mortality of the COBRA early rheumatoid arthritis trial cohort after 23 years of follow-up. Ann Rheum Dis 2019; 78:586-589. [PMID: 30808623 DOI: 10.1136/annrheumdis-2018-214618] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Mortality in patients with rheumatoid arthritis (RA) is higher than in the general population. We investigated mortality in the COBRA-trial cohort after 23 years follow-up, compared with a reference sample of the Dutch population. METHODS The COBRA-trial randomised patients with early RA to sulfasalazine monotherapy (SSZ, n=79) or a combination of SSZ, low-dose methotrexate and initially high, step-down prednisolone (COBRA, n=76). We compared the mortality in the COBRA-trial up to 2017 to a reference sample of the general population in the Netherlands (standardised mortality ratio, SMR), and its relation to early prognostic factors through stepwise Cox regression. RESULTS Duration of follow-up in patients alive was mean 23 (range 22-24) years. In total, 44 patients died (28%, SMR=0.80 [95% CI 0.59 to 1.06]); 20 of 75 COBRA patients (27%, SMR 0.75 [0.47 to 1.14]) and 24 of 79 SSZ patients (30%, SMR 0.85 [0.56 to 1.25]); p=0.61). In the reference sample of the general population, 55 people (36%) died. 5 factors were significantly associated with increased mortality hazard: damage progression at 28 weeks; high Health Assessment Questionnaire (HAQ) score and absence of HLA-DR 2 or 3; disease duration from start of complaints was also significant, but showed an uninterpretable pattern. CONCLUSIONS This prospective trial cohort study of early RA is one of the first to show similar mortality compared with the general population after 23 years of follow-up. It confirms that early, intensive treatment of RA has long-term benefits and suggests that treating to target is especially important for patients with poor prognosis.
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Affiliation(s)
- Pomme B M Poppelaars
- Amsterdam Rheumatology and immunology Centre, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lilian H D van Tuyl
- Amsterdam Rheumatology and immunology Centre, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maarten Boers
- Amsterdam Rheumatology and immunology Centre, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands .,Epidemiology & Biostatistics, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
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Giles JT. On Needles and Haystacks: The Perils of Cardiovascular Risk Screening in Rheumatoid Arthritis. J Rheumatol 2019; 46:121-123. [PMID: 30709999 DOI: 10.3899/jrheum.180933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Jon T Giles
- Division of Rheumatology, Columbia University, College of Physicians and Surgeons, 630 West 168th St., Physicians and Surgeons Building, Suite 3-450, New York, New York 10032, USA.
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England BR, Sayles H, Michaud K, Thiele GM, Poole JA, Caplan L, Sauer BC, Cannon GW, Reimold A, Kerr GS, Baker JF, Mikuls TR. Chronic lung disease in U.S. Veterans with rheumatoid arthritis and the impact on survival. Clin Rheumatol 2018; 37:2907-2915. [PMID: 30280369 PMCID: PMC6442481 DOI: 10.1007/s10067-018-4314-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 09/20/2018] [Accepted: 09/23/2018] [Indexed: 01/02/2023]
Abstract
Assess the impact of chronic lung diseases (CLD) on survival in rheumatoid arthritis (RA). Among participants in the Veterans Affairs Rheumatoid Arthritis (VARA) Registry, a prospective cohort of U.S. Veterans with RA, we identified CLD and cardiovascular disease (CVD) using administrative and registry data. Demographics, smoking status, RA characteristics including Disease Activity Score in 28 joints (DAS28), and disease-modifying anti-rheumatic drug (DMARD) use were obtained from registry data, which were linked to the National Death Index to obtain vital status. We evaluated associations of CLD with survival using the multivariable Cox regression models. Among a large (n = 2053), male-predominant (91%) RA cohort, 554 (27%) had CLD at enrollment. Mortality risk was increased 1.51-fold (95% CI 1.26-1.81) in RA patients with CLD after multivariable adjustment, a risk that was similar to that observed with CVD (HR CLD alone 1.46 [1.03-2.06]; CVD alone 1.62 [1.35-1.94]). Survival was significantly reduced in those with interstitial lung disease (ILD) as well as other forms of CLD. Mortality risk with methotrexate and biologic use was not different in those with CLD compared to those without (p interaction ≥ 0.15) using multiple exposure definitions and propensity score adjustment. Mortality risk is significantly increased in RA patients with CLD. This risk is attributable not only to ILD but also to other chronic lung conditions and does not appear to be substantially greater in those receiving methotrexate or biologic therapies. Comorbid lung disease should be targeted as a means of improving long-term outcomes in RA.
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Affiliation(s)
- Bryant R England
- VA Nebraska-Western IA Health Care System, Omaha, NE, USA.
- Division of Rheumatology and Immunology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Med Center, Omaha, Nebraska, United States.
| | - Harlan Sayles
- Division of Rheumatology and Immunology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Med Center, Omaha, Nebraska, United States
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kaleb Michaud
- Division of Rheumatology and Immunology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Med Center, Omaha, Nebraska, United States
- National Data Bank for Rheumatic Diseases, Wichita, KS, USA
| | - Geoffrey M Thiele
- VA Nebraska-Western IA Health Care System, Omaha, NE, USA
- Division of Rheumatology and Immunology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Med Center, Omaha, Nebraska, United States
| | - Jill A Poole
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Liron Caplan
- Denver VA and University of Colorado, Denver, CO, USA
| | - Brian C Sauer
- VA Salt Lake City and University of Utah, Salt Lake City, UT, USA
| | - Grant W Cannon
- VA Salt Lake City and University of Utah, Salt Lake City, UT, USA
| | - Andreas Reimold
- Dallas VA and University of Texas Southwestern, Dallas, TX, USA
| | - Gail S Kerr
- Washington DC VAMC, Georgetown and Howard University, Washington, DC, USA
| | - Joshua F Baker
- Corporal Michael J. Crescenz VA and University of Pennsylvania, Philadelphia, PA, USA
| | - Ted R Mikuls
- VA Nebraska-Western IA Health Care System, Omaha, NE, USA
- Division of Rheumatology and Immunology, Department of Internal Medicine, University of Nebraska Medical Center, 986270 Nebraska Med Center, Omaha, Nebraska, United States
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