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Wahlin B, Innala L, Magnusson S, Möller B, Smedby T, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Performance of the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis Is Not Superior to the ACC/AHA Risk Calculator. J Rheumatol 2018; 46:130-137. [PMID: 30275258 DOI: 10.3899/jrheum.171008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cardiovascular (CV) risk estimation calculators for the general population do not perform well in patients with rheumatoid arthritis (RA). An RA-specific risk calculator has been developed, but did not perform better than a risk calculator for the general population when validated in a heterogeneous multinational cohort. METHODS In a cohort of patients with new-onset RA from northern Sweden (n = 665), the risk of CV disease was estimated by the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA) and the American College of Cardiology/American Heart Association algorithm (ACC/AHA). The ACC/AHA estimation was analyzed, both as crude data and when adjusted according to the recommendations by the European League Against Rheumatism (ACC/AHA × 1.5). ERS-RA was calculated using 2 variants: 1 from patient and physician reports of hypertension (HTN) and hyperlipidemia [ERS-RA (reported)] and 1 from assessments of blood pressure (BP) and blood lipids [ERS-RA (measured)]. The estimations were compared with observed CV events. RESULTS All variants of risk calculators underestimated the CV risk. Discrimination was good for all risk calculators studied. Performance of all risk calculators was poorer in patients with a high grade of inflammation, whereas ACC/AHA × 1.5 performed best in the high-inflammatory patients. In those patients with an estimated risk of 5-15%, no risk calculator performed well. CONCLUSION ERS-RA underestimated the risk of a CV event in our cohort of patients, especially when risk estimations were based on patient or physician reports of HTN and hyperlipidemia instead of assessment of BP and blood lipids. The performance of ERS-RA was no better than that of ACC/AHA × 1.5, and neither performed well in high-inflammatory patients.
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Affiliation(s)
- Bengt Wahlin
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden. .,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University.
| | - Lena Innala
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Staffan Magnusson
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Bozena Möller
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Torgny Smedby
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Solbritt Rantapää-Dahlqvist
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
| | - Solveig Wållberg-Jonsson
- From the Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå; Department of Rheumatology, Sundsvall Hospital, Sundsvall; Department of Rheumatology, Sunderby Hospital, Luleå; Department of Rheumatology, Östersund Hospital, Östersund, Sweden.,B. Wahlin, MD, PhD student, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; L. Innala, MD, PhD, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University; S. Magnusson, MD, Department of Rheumatology, Sundsvall Hospital; B. Möller, MD, Department of Rheumatology, Sunderby Hospital; T. Smedby, MD, Department of Rheumatology, Östersund Hospital; S. Rantapää-Dahlqvist, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå; S. Wållberg-Jonsson, MD, PhD, Professor, Department of Public Health and Clinical Medicine/Rheumatology, Umeå University
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Hörnberg K, Sundström B, Innala L, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Aerobic capacity over 16 years in patients with rheumatoid arthritis: Relationship to disease activity and risk factors for cardiovascular disease. PLoS One 2017; 12:e0190211. [PMID: 29272303 PMCID: PMC5741242 DOI: 10.1371/journal.pone.0190211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to analyse the change in aerobic capacity from disease onset of rheumatoid arthritis (RA) over 16.2 years, and its associations with disease activity and cardiovascular risk factors. Twenty-five patients (20 f/5 m), diagnosed with RA 1995-2002 were tested at disease onset and after mean 16.2 years. Parameters measured were: sub-maximal ergometer test for aerobic capacity, functional ability, self-efficacy, ESR, CRP and DAS28. At follow-up, cardiovascular risk factors were assessed as blood lipids, glucose concentrations, waist circumference, body mass index (BMI), body composition, pulse wave analysis and carotid intima-media thickness. Aerobic capacity [median (IQR)] was 32.3 (27.9-42.1) ml O2/kg x min at disease onset, and 33.2 (28.4-38.9) at follow-up (p>0.05). Baseline aerobic capacity was associated with follow-up values of: BMI (rs = -.401, p = .047), waist circumference (rs = -.498, p = .011), peripheral pulse pressure (rs = -.415, p = .039) self-efficacy (rs = .420, p = .037) and aerobic capacity (rs = .557, p = .004). In multiple regression models adjusted for baseline aerobic capacity, disease activity at baseline and over time predicted aerobic capacity at follow-up (AUC DAS28, 0-24 months; β = -.14, p = .004). At follow-up, aerobic capacity was inversely associated with blood glucose levels (rs = -.508, p = .016), BMI (rs = -.434, p = .030), body fat% (rs = -.419, p = .037), aortic pulse pressure (rs = -.405, p = .044), resting heart rate (rs = -.424, p = .034) and self-efficacy (rs = .464, p = .020) at follow-up. We conclude that the aerobic capacity was maintained over 16 years. High baseline aerobic capacity associated with favourable measures of cardiovascular risk factors at follow-up. Higher disease activity in early stages of RA predicted lower aerobic capacity after 16.2 years.
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Affiliation(s)
- Kristina Hörnberg
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
- * E-mail:
| | - Björn Sundström
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
| | - Lena Innala
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
| | | | - Solveig Wållberg-Jonsson
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
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Crowson CS, Rollefstad S, Ikdahl E, Kitas GD, van Riel PLCM, Gabriel SE, Matteson EL, Kvien TK, Douglas K, Sandoo A, Arts E, Wållberg-Jonsson S, Innala L, Karpouzas G, Dessein PH, Tsang L, El-Gabalawy H, Hitchon C, Ramos VP, Yáñez IC, Sfikakis PP, Zampeli E, Gonzalez-Gay MA, Corrales A, Laar MVD, Vonkeman HE, Meek I, Semb AG. Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis. Ann Rheum Dis 2017; 77:48-54. [PMID: 28877868 DOI: 10.1136/annrheumdis-2017-211735] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/30/2017] [Accepted: 08/04/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Patients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD). We aimed to assess the impact of CVD risk factors, including potential sex differences, and RA-specific variables on CVD outcome in a large, international cohort of patients with RA. METHODS In 13 rheumatology centres, data on CVD risk factors and RA characteristics were collected at baseline. CVD outcomes (myocardial infarction, angina, revascularisation, stroke, peripheral vascular disease and CVD death) were collected using standardised definitions. RESULTS 5638 patients with RA and no prior CVD were included (mean age: 55.3 (SD: 14.0) years, 76% women). During mean follow-up of 5.8 (SD: 4.4) years, 148 men and 241 women developed a CVD event (10-year cumulative incidence 20.9% and 11.1%, respectively). Men had a higher burden of CVD risk factors, including increased blood pressure, higher total cholesterol and smoking prevalence than women (all p<0.001). Among the traditional CVD risk factors, smoking and hypertension had the highest population attributable risk (PAR) overall and among both sexes, followed by total cholesterol. The PAR for Disease Activity Score and for seropositivity were comparable in magnitude to the PAR for lipids. A total of 70% of CVD events were attributable to all CVD risk factors and RA characteristics combined (separately 49% CVD risk factors and 30% RA characteristics). CONCLUSIONS In a large, international cohort of patients with RA, 30% of CVD events were attributable to RA characteristics. This finding indicates that RA characteristics play an important role in efforts to reduce CVD risk among patients with RA.
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Affiliation(s)
- Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Silvia Rollefstad
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Eirik Ikdahl
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Piet L C M van Riel
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sherine E Gabriel
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tore K Kvien
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karen Douglas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Aamer Sandoo
- Department of Rheumatology, Dudley Group NHS Foundation Trust, West Midlands, UK.,School of Sport, Health and Exercise Sciences, Bangor University, Bangor, Wales, UK
| | - Elke Arts
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Solveig Wållberg-Jonsson
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
| | - Lena Innala
- Department of Public Health and Clinical Medicine/Rheumatology, University of Umeå, Umeå, Sweden
| | - George Karpouzas
- Division of Rheumatology, Harbor UCLA Medical Center RHU, Torrance, California, USA
| | - Patrick H Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Rheumatology Division, UniversitairZiekenhuis and Vrije Universiteit, Brussel, Belgium
| | - Linda Tsang
- Rheumatology Division, UniversitairZiekenhuis and Vrije Universiteit, Brussel, Belgium
| | - Hani El-Gabalawy
- Institute of Musculoskeletal Health and Arthritis, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carol Hitchon
- Institute of Musculoskeletal Health and Arthritis, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Virginia Pascual Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Irazú Contreras Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Petros P Sfikakis
- First Department of Propedeutic Medicine, University of Athens, Athens, Greece
| | - Evangelia Zampeli
- First Department of Propedeutic Medicine, University of Athens, Athens, Greece
| | - Miguel A Gonzalez-Gay
- Division of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander (Cantabria), Spain
| | - Alfonso Corrales
- Division of Rheumatology, Hospital Universitario Marques de Valdecilla, Santander (Cantabria), Spain
| | - Mart van de Laar
- Department of Rheumatology and Clinical Immunology, Hospital Medisch Spectrum Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- Department of Rheumatology and Clinical Immunology, Hospital Medisch Spectrum Twente, Enschede, The Netherlands
| | - Inger Meek
- Department of Rheumatology and Clinical Immunology, Hospital Medisch Spectrum Twente, Enschede, The Netherlands
| | - Anne Grete Semb
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Innala L, Sjöberg C, Möller B, Ljung L, Smedby T, Södergren A, Magnusson S, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Co-morbidity in patients with early rheumatoid arthritis - inflammation matters. Arthritis Res Ther 2016; 18:33. [PMID: 26818851 PMCID: PMC4730785 DOI: 10.1186/s13075-016-0928-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 01/07/2016] [Indexed: 01/10/2023] Open
Abstract
Background Patients with rheumatoid arthritis (RA) suffer from co-morbidities that contribute to a shortened lifespan. Inflammation is important for the development of cardiovascular disease, but little is known on its relationship with other co-morbidities. We investigated the role of inflammation for the development of new comorbidities in early RA. Methods Since 1995, all patients with early RA in Northern Sweden are included in a prospective study on co-morbidities, with a total of 950 patients being included. At the time for this study, 726 had been ill for ≥5 years. Data on co-morbidities, clinical and laboratory disease activity and pharmacological therapy were collected from patient records and further validated using a questionnaire at RA onset (T0) and after 5 years (T5). Results Of the patients, 53.2 % of the patients had one or more co-morbidity at onset, the commonest being: hypertension (27.3 %), obstructive pulmonary disease (13.9 %), diabetes (8.0 %), hypothyroidism (6.3 %) and malignancy (5.0 %). After 5 years, 41.0 % had developed at least one new co-morbidity, the most common being: hypertension (15.1 %), malignancy (7.6 %), stroke/transient ischemic accident (5.1 %), myocardial infarction (4.3 %) and osteoporosis (3.7 %). Age at disease onset, a raised erythrocyte sedimentation rate (ESR) at inclusion, previous treatment with glucocorticoids (GC; p < 0.001 for all), extra-articular RA (Ex-RA; p < 0.01), DAS28 (area under the curve) at 24 months (p < 0.05), previous smoking at inclusion (p = 0.058) and male gender (p < 0.01) were associated with a new co-morbidity overall at T5. Treatment with biologics (p < 0.05) reduced the risk. In multiple logistic regression modelling, ESR (p = 0.036) at inclusion was associated with a new co-morbidity after 5 years, adjusted for age, sex, smoking and GC treatment. In a similar model, Ex-RA (p < 0.05) was associated with a new co-morbidity at T5. In a third model, adjusted for age and sex, a new pulmonary co-morbidity was associated with a smoking history at inclusion (p < 0.01), but not with ESR. Conclusion There was substantial co-morbidity among early RA patients already at disease onset, with considerable new co-morbidity being added during the first five years. Measures of disease activity were associated with the occurrence of a new co-morbidity indicating that the inflammation is of importance in this context.
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Affiliation(s)
- Lena Innala
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Clara Sjöberg
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Bozena Möller
- Department of Rheumatology, Sunderby Hospital, Luleå, 97180, Sweden.
| | - Lotta Ljung
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Torgny Smedby
- Department of Rheumatology, Östersund Hospital, Östersund, 83183, Sweden.
| | - Anna Södergren
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
| | - Staffan Magnusson
- Department of Rheumatology, Sundsvall Hospital, Sundsvall, 85186, Sweden.
| | | | - Solveig Wållberg-Jonsson
- Department of Public Health and Clinical Medicine, Rheumatology University Hospital, Umeå, 90185, Sweden.
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Innala L, Berglin E, Möller B, Ljung L, Smedby T, Södergren A, Magnusson S, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Age at onset determines severity and choice of treatment in early rheumatoid arthritis: a prospective study. Arthritis Res Ther 2014; 16:R94. [PMID: 24731866 PMCID: PMC4060263 DOI: 10.1186/ar4540] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 03/25/2014] [Indexed: 05/12/2023] Open
Abstract
Introduction Disease activity, severity and comorbidity contribute to increased mortality in patients with rheumatoid arthritis (RA). We evaluated the impact of age at disease onset on prognostic risk factors and treatment in patients with early disease. Methods In this study, 950 RA patients were followed regularly from the time of inclusion (<12 months from symptom onset) for disease activity (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), tender and/or swollen joints, Visual Analogue Scale pain and global scores, and Disease Activity Score in 28 joints (DAS28)) and function (Health Assessment Questionnaire (HAQ)). Disease severity, measured on the basis of radiographs of the hands and feet (erosions based on Larsen score), extraarticular disease, nodules, and comorbidities and treatment (disease-modifying antirheumatic drugs (DMARDs), corticosteroids, biologics and nonsteroidal anti-inflammatory drugs) were recorded at the time of inclusion and at 5 years. Autoantibodies (rheumatoid factor, antinuclear antibodies and antibodies against cyclic citrullinated peptides (ACPAs)) and genetic markers (human leucocyte antibody (HLA) shared epitope and protein tyrosine phosphatase nonreceptor type 22 (PTPN22)) were analysed at the time of inclusion. Data were stratified as young-onset RA (YORA) and late-onset RA (LORA), which were defined as being below or above the median age at the time of onset of RA (58 years). Results LORA was associated with lower frequency of ACPA (P < 0.05) and carriage of PTPN22-T variant (P < 0.01), but with greater disease activity at the time of inclusion measured on the basis of ESR (P < 0.001), CRP (P < 0.01) and accumulated disease activity (area under the curve for DAS28 score) at 6 months (P < 0.01), 12 months (P < 0.01) and 24 months (P < 0.05), as well as a higher HAQ score (P < 0.01) compared with YORA patients. At baseline and 24 months, LORA was more often associated with erosions (P < 0.01 for both) and higher Larsen scores (P < 0.001 for both). LORA was more often treated with corticosteroids (P < 0.01) and less often with methotrexate (P < 0.001) and biologics (P < 0.001). YORA was more often associated with early DMARD treatment (P < 0.001). The results of multiple regression analyses supported our findings regarding the impact of age on chosen treatment. Conclusion YORA patients were more frequently ACPA-positive than LORA patients. LORA was more often associated with erosions, higher Larsen scores, higher disease activity and higher HAQ scores at baseline. Nevertheless, YORA was treated earlier with DMARDs, whilst LORA was more often treated with corticosteroids and less often with DMARDs in early-stage disease. These findings could have implications for the development of comorbidities.
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Innala L, Möller B, Ljung L, Magnusson S, Smedby T, Södergren A, Öhman ML, Rantapää-Dahlqvist S, Wållberg-Jonsson S. Cardiovascular events in early RA are a result of inflammatory burden and traditional risk factors: a five year prospective study. Arthritis Res Ther 2011; 13:R131. [PMID: 21843325 PMCID: PMC3239373 DOI: 10.1186/ar3442] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 05/18/2011] [Accepted: 08/15/2011] [Indexed: 11/15/2022] Open
Abstract
Introduction Co-morbidity and mortality due to cardiovascular disease (CVD) are increased in patients with rheumatoid arthritis (RA). Most published studies in this field are retrospective or cross sectional. We investigated the presence of traditional and disease related risk factors for CVD at the onset of RA and during the first five years following diagnosis. We also evaluated their potential for predicting a new cardiovascular event (CVE) during the five-year follow-up period and the modulatory effect of pharmacological treatment. Methods All patients from the four northern-most counties of Sweden with early RA are, since December 1995, consecutively recruited at diagnosis (T0) into a large survey on the progress of the disease. Information regarding cardiovascular co-morbidity and related predictors was collected from clinical records and supplemented with questionnaires. By April 2008, 700 patients had been included of whom 442 patients had reached the five-year follow-up (T5). Results Among the 442 patients who reached T5 during the follow-up period, treatment for hypertension increased from 24.5 to 37.4% (P < 0.001)), diagnosis of diabetes mellitus (DM) from 7.1 to 9.5% (P < 0.01) whilst smoking decreased from 29.8 to 22.4% (P < 0.001) and the BMI from 26.3 to 25.8 (P < 0.05), respectively. By T5, 48 patients had suffered a new CVE of which 12 were fatal. A total of 23 patients died during the follow-up period. Age at disease onset, male sex, a previous CVE, DM, treatment for hypertension, triglyceride level, cumulative disease activity (area under the curve (AUC) disease activity score (DAS28)), extra-articular disease, corticosteroid use, shorter duration of treatment with disease modifying anti-rheumatic drugs (DMARDs) and use of COX-2 inhibitors increased the hazard rate for a new CVE. A raised erythrocyte sedimentation rate (ESR) at inclusion and AUC DAS28 at six months increased the hazard rate of CVE independently whilst DMARD treatment was protective in multiple Cox extended models adjusted for sex and CV risk factors. The risk of a CVE due to inflammation was potentiated by traditional CV risk factors. Conclusions The occurrence of new CV events in very early RA was explained by traditional CV risk factors and was potentiated by high disease activity. Treatment with DMARDs decreased the risk. The results may have implications for cardio-protective strategies in RA.
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Affiliation(s)
- Lena Innala
- Institution of Public Health and Clinical Medicine/Rheumatology, University Hospital, Umeå, 901 85, Sweden
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Innala L, Kokkonen H, Eriksson C, Jidell E, Berglin E, Dahlqvst SR. Antibodies against mutated citrullinated vimentin are a better predictor of disease activity at 24 months in early rheumatoid arthritis than antibodies against cyclic citrullinated peptides. J Rheumatol 2008; 35:1002-1008. [PMID: 18398946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To evaluate the predictive values for disease progression of various antibodies against citrullinated peptide proteins (ACPA) and their relation to PTPN22 1858C/T polymorphism and HLA-DRB1 alleles in early rheumatoid arthritis (RA). METHODS The ACPA, e.g., antibodies against mutated citrullinated vimentin (MCV), cyclic citrullinated peptides (CCP) type 2 and 3 (both of IgG isotype) and 3.1 (of both IgG and IgA isotypes), were analyzed at baseline in patients with early RA (n = 210) and in population controls (n = 102) using an enzyme immunoassay. A receiver-operating characteristic curve was constructed for each antibody. Disease activity [swollen and tender joints, visual analog scale for global health, and erythrocyte sedimentation rate (ESR)] was evaluated at baseline and regularly for 24 months. Radiographs of hands and feet were graded using the Larsen score. RESULTS Patients with anti-MCV antibodies had significantly less reduction in Disease Activity Score (DAS28) over time (p < 0.01), and significantly increased area under the curve (AUC) for DAS28 (p < 0.05), ESR (p < 0.01), C-reactive protein (p < 0.01), and swollen joint count (p = 0.057) compared to those without. Corresponding differences were not found in patients with anti-CCP2, CCP3, and CCP3.1 antibodies. Radiological progression (p < 0.0001-0.01) and radiological outcome (p < 0.0001-0.01) at 24 months were significantly predicted by all ACPA after baseline adjustments. PTPN22 T variant and HLA-DRB1 alleles were not related to radiological progression or inflammatory activity over time. CONCLUSION Anti-MCV antibodies are associated with a more severe RA disease, as measured by DAS28, ESR, and swollen joint count over time, compared with anti-CCP2, CCP3, and CCP3.1 antibodies. Radiological progression was predicted equally by all 4 autoantibodies.
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Affiliation(s)
- Lena Innala
- Department of Rheumatology, Department of Clinical Immunology, and Department of Transfusion Medicine, University Hospital, Umeå, Sweden
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Kokkonen H, Johansson M, Innala L, Jidell E, Rantapää-Dahlqvist S. The PTPN22 1858C/T polymorphism is associated with anti-cyclic citrullinated peptide antibody-positive early rheumatoid arthritis in northern Sweden. Arthritis Res Ther 2008; 9:R56. [PMID: 17553139 PMCID: PMC2206338 DOI: 10.1186/ar2214] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 05/10/2007] [Accepted: 06/06/2007] [Indexed: 11/10/2022] Open
Abstract
The PTPN22 1858C/T polymorphism has been associated with several autoimmune diseases including rheumatoid arthritis (RA). We have shown that carriage of the T variant (CT or TT) of PTPN22 in combination with anti-cyclic citrullinated peptide (anti-CCP) antibodies highly increases the odds ratio for developing RA. In the present study we analysed the association between the PTPN22 1858C/T polymorphism and early RA in patients from northern Sweden, related the polymorphism to autoantibodies and the HLA-DR shared epitope, and analysed their association with markers for disease activity and progression. The inception cohort includes individuals who also donated samples before disease onset. A case-control study was performed in patients (n = 505; 342 females and 163 males) with early RA (mean duration of symptoms = 6.3 months) and in population-based matched controls (n = 970) from northern Sweden. Genotyping of the PTPN22 1858C/T polymorphism was performed using a TaqMan instrument. HLA-shared epitope alleles were identified using PCR sequence-specific primers. Anti-CCP2 antibodies were determined using enzyme-linked immunoassays. Disease activity (that is, the number of swollen and tender joints, the global visual analogue scale, and the erythrocyte sedimentation rate) was followed on a regular basis (that is, at baseline and after 6, 12, 18 and 24 months). Both the 1858T allele and the carriage of T were associated with RA (chi2 = 23.84, P = 0.000001, odds ratio = 1.69, 95% confidence interval = 1.36-2.11; and chi2 = 22.68, P = 0.000002, odds ratio = 1.79, 95% confidence interval = 1.40-2.29, respectively). Association of the 1858T variant with RA was confined to seropositive disease. Carriage of 1858T and the presence of anti-CCP antibodies was independently associated with disease onset at an earlier age (P < 0.05 and P < 0.01, respectively), while the combination of both resulted in an even earlier age at onset. Smoking was identified as a risk factor independent of the 1858T variant and anti-CCP antibodies.
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Affiliation(s)
- Heidi Kokkonen
- Department of Rheumatology, University Hospital, SE-901 85 Umeå, Sweden
| | - Martin Johansson
- Department of Rheumatology, University Hospital, SE-901 85 Umeå, Sweden
| | - Lena Innala
- Department of Rheumatology, University Hospital, SE-901 85 Umeå, Sweden
| | - Erik Jidell
- Department of Transfusion Medicine, University Hospital, SE-901 85 Umeå, Sweden
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Kokkonen H, Johansson M, Innala L, Jidell E, Rantapää-Dahlqvist S. Correction: The PTPN22 1858C/T polymorphism is associated with anti-cyclic citrullinated peptide antibody-positive early rheumatoid arthritis in northern Sweden. Arthritis Res Ther 2007. [PMCID: PMC2212574 DOI: 10.1186/ar2312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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