An international audit of the management of dyslipidaemia and hypertension in patients with rheumatoid arthritis: results from 19 countries

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.

POS0596 SERUM CHOLESTEROL LOADING CAPACITY ON MACROPHAGES IS LINKED TO OXIDIZED LOW-DENSITY LIPOPROTEIN AND REGULATED BY SEROPOSITIVITY AND C-REACTIVE PROTEIN IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Excessive cholesterol accumulation in macrophages underlies foam cell formation, initiation and progression of atherosclerosis. LDL oxidation and unregulated uptake of oxidized LDL by macrophages are critical in foam cell development. Cholesterol loading capacity (CLC) is the ability of serum to deliver cholesterol to cells and is related to foam cell formation. Rheumatoid arthritis (RA) serum increased cholesterol content in macrophages and promoted foam cell formation significantly more than control serum1. Although inflammation, LDL oxidation and antibodies to oxidized LDL (anti-oxLDL) may be higher in RA, their relationships and their individual and synergistic contributions to CLC in RA are unknown.

Objectives

To explore determinants and moderators of serum CLC in patients with RA. We also investigated whether oxidized LDL influences CLC directly or indirectly through anti-oxLDL IgG and proprotein convertase subtilisin/Kexin type-9 (PCSK9), independently or conditionally on RA-related autoantibodies such as rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) or level of inflammation.

Methods

In an observational study of 104 patients, CLC was measured fluorimetrically as intracellular cholesterol content in human THP-1-derived macrophages after incubation with patient serum. Oxidized LDL was measured as oxidized phospholipids on apoB100 particles (oxPL-apoB100). Anti-oxLDL, PCSK9 and C-reactive protein (CRP) were also quantified. Associations of oxPL-apoB100, anti-oxLDL IgG and PCSK9 with CLC were examined with multivariable linear regression. A two-stage dual moderated mediation model explored whether an indirect association of oxPL-apoB100 with CLC through parallel mediators anti-oxLDL IgG and PCSK9 varied as a function of moderators CRP and RF/ACPA positivity.

Results

OxPL-apoB100, anti-oxLDL IgG and PCSK9 positively associated with CLC (all adjusted p<0.020). In the final dual moderated mediation model oxPL-apoB100 was directly linked to CLC only in dual seropositive patients (unstandardized b [95% bootstrap confidence interval]=2.08 [0.38-3.79], Figure 1). An indirect effect of oxPL-apoB100 on CLC through anti-oxLDL IgG was present and increased along with level of CRP (index of moderated mediation=0.55 [0.05-1.17]). CRP also moderated the other indirect effect of oxPL-apoB100 on CLC through PCSK9, but only in dual seropositive patients (conditional indirect effect=0.64 [0.13-1.30]).

Conclusion

Oxidized LDL can directly influence CLC in dual seropositive RA patients, regardless of CRP. This suggests that targeting LDL oxidation in addition to inflammation may enable a more comprehensive reduction of atherosclerotic risk in these patients. Depending on CRP level, oxidized LDL also affected CLC indirectly via anti-oxLDL IgG and via PCSK9 in dual seropositive patients. If externally validated, our findings may have clinical implications for cardiovascular risk stratification and prevention.

References

[1]Voloshyna I et al. Plasma from rheumatoid arthritis patients promotes pro-atherogenic cholesterol transport gene expression in THP-1 human macrophages. Exp Biol Med (Maywood) 2013;238:1192–7.

Disclosure of Interests

George Karpouzas Speakers bureau: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Grant/research support from: Pfizer, Bianca Papotti: None declared, Sarah Ormseth: None declared, Marcella Palumbo: None declared, Elizabeth Hernandez: None declared, Cinzia Marchi: None declared, Francesca Zimetti: None declared, Matthew Budoff Consultant of: Pfizer, Nicoletta Ronda: None declared

POS0519 RELATIONSHIP BETWEEN DISEASE ACTIVITY AND MAJOR ADVERSE EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS ON TOFACITINIB OR TNF INHIBITORS: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

Uncontrolled rheumatoid arthritis (RA) activity and acute disease flares are associated with higher risk of adverse outcomes such as cardiovascular (CV) disease, venous thromboembolism (VTE), malignancy and infection.1-4

Objectives

To evaluate associations of acute and cumulative Clinical Disease Activity Index (CDAI) measurements with major CV, malignancy, or infectious adverse events (AEs) of special interest in ORAL Surveillance.

Methods

ORAL Surveillance (NCT02092467) was a post-authorisation safety study of tofacitinib vs TNF inhibitors (TNFi) in patients (pts) aged ≥50 yrs with active RA despite methotrexate (MTX), and ≥1 additional CV risk factor. Pts were randomised 1:1:1 to tofacitinib 5 or 10 mg twice daily (BID) or subcutaneous TNFi. Two post hoc analyses were performed: (1) a time-varying multivariate Cox model examined risks of major AEs when pts were in CDAI-defined low (>2.8–≤10; LDA), moderate (>10–≤22; MDA) or high (>22; HDA) disease activity vs remission (≤2.8). The Cox model also included pt demographics, medical history, RA characteristics, prior treatments, baseline (BL) medications and treatment arm, pre-selected using backward selection; (2) area under the curve (AUC) per yr for CDAI prior to event or to study end (pts without event) was calculated and compared using an analysis of variance model with treatment arm, event status and interaction (supportive). Nominal p values <0.10 were considered evidence of associations.

Results

4362 pts were included. Mean RA duration at BL was approximately 10 yrs. All pts were on MTX at BL, and 28% had previously been on one other synthetic disease-modifying antirheumatic drug (DMARD). Overall, 10% of pts had been on one biologic DMARD. Hazard ratios suggested that when pts had LDA, MDA or HDA vs remission, they were potentially at higher risk of developing major adverse CV events (MACE), VTE and non-serious infections (NSIs) excluding herpes zoster (HZ), but not malignancies, serious infections or HZ (Figure 1). Similarly, mean CDAI AUC trended higher for MACE, VTE and NSIs (Table 1).

Table 1.

Cumulative CDAI (from BL to event) for pts with vs without events (AUC/yr)

Major AEPts with eventsPts without eventsLS mean difference in pts with vs without eventsp valueTreatmentnLS mean AUC/yrnLS mean AUC/yrMACETofacitinib 5 mg BID426275.413364607.31668.10.0018*Tofacitinib 10 mg BID505237.413064482.6754.80.1253TNFi365234.513124851.5383.00.5069VTETofacitinib 5 mg BID156546.713634614.41932.30.0293*Tofacitinib 10 mg BID316688.213234458.52229.70.0003*TNFi86423.613394839.41584.10.1907Malignancy excl. NMSCTofacitinib 5 mg BID595249.313194618.9630.40.1655Tofacitinib 10 mg BID554793.713014482.2311.50.5077TNFi395561.413084826.3735.10.1854Serious infectionsTofacitinib 5 mg BID1275710.212424577.51132.70.0004*Tofacitinib 10 mg BID1505425.211974476.4948.80.0013*TNFi1056058.412404807.71250.70.0003*HZTofacitinib 5 mg BID1755184.511994738.1446.40.1101Tofacitinib 10 mg BID1635549.111864481.31067.80.0002*TNFi565667.212914875.5791.80.0930*NSIs excl. HZTofacitinib 5 mg BID7606608.34635122.51485.8<0.0001*Tofacitinib 10 mg BID7506587.84265009.61578.2<0.0001*TNFi7226737.65215217.51520.1<0.0001*

*p<0.10. Data collected after pts who were randomised to tofacitinib 10 mg BID had their dose reduced to 5 mg BID were included in the tofacitinib 10 mg BID group LS, least squares; n, number of pts in analysis of variance model

Conclusion

In ORAL Surveillance, the risk of MACE, VTE and NSIs excluding HZ appeared higher when pts had active disease than when in remission. Greater cumulative RA disease activity was seen in pts who suffered these AEs vs those who did not. Our findings support treat-to-target recommendations for RA.

References

[1]Molander et al. Ann Rheum Dis 2021; 80: 169-175.

[2]Maradit-Kremers et al. Arthritis Rheum 2005; 52: 722-732.

[3]Au et al. Ann Rheum Dis 2011; 70: 785-791.

[4]Baecklund et al. Arthritis Rheum 2006; 54: 692-701.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Karen Thompson, PhD, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

George Karpouzas Speakers bureau: Sanofi-Genzyme-Regeneron, Consultant of: Janssen and Sanofi-Genzyme-Regeneron, Grant/research support from: Pfizer Inc, Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Eva Baecklund: None declared, Ted Mikuls Paid instructor for: Pfizer Inc, Consultant of: Gilead Sciences, Horizon and Sanofi, Grant/research support from: Bristol-Myers Squibb and Horizon, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Eli Lilly, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company, Harry Shi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Gosford Sawyerr Consultant of: Pfizer Inc, Employee of: Syneos Health Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Mahta Mortezavi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc.

OP0136 SERUM CHOLESTEROL LOADING CAPACITY ON MACROPHAGES AND INTERACTIONS WITH TREATMENTS ON CORONARY ATHEROSCLEROSIS BURDEN AND EVENT RISK IN RHEUMATOID ARTHRITIS

Background

Cholesterol loading capacity (CLC) describes the ability of serum to deliver cholesterol to cells. It is linked to foam cell formation, a pivotal step in atherosclerotic plaque development. Rheumatoid arthritis (RA) serum promoted foam cell formation significantly more than control serum. Likewise, RA patients display greater plaque burden and higher-risk features than non-RA controls. bDMARDs and statins lower cardiovascular risk by reducing new coronary plaque formation, promoting regression, altering the composition and stabilizing prevalent atherosclerotic lesions.

Objectives

To evaluate the associations between CLC, coronary plaque burden and cardiovascular event risk in patients with RA. We further explored the conditioning effects of RA treatments on these relationships.

Methods

140 patients underwent coronary CT angiography for atherosclerosis evaluation and were prospectively followed for cardiovascular events over 6.0±2.4 years. Coronary artery calcium score (CAC), number of segments with plaque (segment involvement score [SIS]) and plaque composition were assessed. CLC was the macrophage cholesterol content, measured by fluorometric assay, after a 24-hour incubation with whole serum. Robust linear regression examined the effects of CLC and the interaction between CLC and bDMARD use on SIS and CAC. Negative binomial regression evaluated CLC and CLC × bDMARD interaction effects on number of high-risk (low-attenuation) plaques. With data discretized into 1-month intervals, weighted pooled logistic regression models with robust variance estimation evaluated CLC and time-varying bDMARD use as predictors of event risk, and the effect of CLC × time-varying bDMARD use on risk. Stabilized inverse probability of treatment and censoring weights were estimated as a function of ASCVD risk, SIS, RA duration, and baseline and time-varying CRP and statin use.

Results

Mean (SD) CLC was 12.67 (2.83) μg/mg protein. In analyses adjusting for ASCVD score, HDL, prednisone and statin use, CLC (per 1-SD unit) was not related to SIS (β -0.05 [95%CI -1.19,0.09]), number of high-risk plaques (rate ratio [RR] 1.20 [95%CI 0.80-1.80]) or ln-transformed CAC (β 0.017 [95%CI -0.133,0.147]). However, in analyses stratified by baseline bDMARD use, CLC (per 1-SD unit) was positively related to number of high-risk plaques (RR 2.14 [95%CI 1.04-4.40]) and ln-transformed CAC (β 0.21 [95%CI 0.01-0.41]) among bDMARD-naïve individuals (Figure 1). In addition, CLC inversely associated with SIS (per SD increment; β -0.16 [95%CI -0.32, -0.01]) only in bDMARD-treated patients. Baseline statin use did not significantly modify the effect of CLC on coronary plaque (not shown). CLC associated with cardiovascular event risk (per SD increment; adjusted odds ratio 2.02 [95%CI 1.27-3.50], p=0.011) covarying for ASCVD score and time-varying bDMARD use. The CLC × time-varying bDMARD use interaction also predicted event risk (p =0.010); current bDMARD use associated with lower event risk at higher (1 SD above the mean) CLC levels (p=0.037) but not average or lower (1 SD below the mean) CLC levels (p=0.064 and 0.756, respectively).

Conclusion

CLC associated with greater CAC score and high-risk plaque burden in bDMARD-naïve RA patients and lower total plaque burden in bDMARD-treated patients at baseline. CLC also predicted long-term cardiovascular risk and its effect was mitigated by bDMARD use.

Disclosure of Interests

George Karpouzas Speakers bureau: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Grant/research support from: Pfizer, Bianca Papotti: None declared, Sarah Ormseth: None declared, Marcella Palumbo: None declared, Elizabeth Hernandez: None declared, Cinzia Marchi: None declared, Francesca Zimetti: None declared, Matthew Budoff Consultant of: Pfizer, Nicoletta Ronda: None declared

OP0137 ABDOMINAL OBESITY MAY CONFOUND THE ACCURACY OF CARDIOVASCULAR RISK PREDICTION IN RHEUMATOID ARTHRITIS; CAN CORONARY ATHEROSCLEROSIS IMAGING AND BIOMARKERS HELP?

Background

Accurate cardiovascular risk stratification is essential in rheumatoid arthritis (RA) care. RA patients who are underweight incur greater total and cardiovascular mortality compared to those who are overweight or obese.

Objectives

We explored whether abdominal obesity impaired the accuracy of risk prediction estimates in RA patients without known cardiovascular disease (CVD). We further interrogated the potential utility of coronary atherosclerosis assessment and serum levels of related cardiac damage biomarkers to optimize risk prediction in obese RA patients.

Methods

In a single center observational study, 150 participants with coronary CT angiography for atherosclerosis evaluation and prospective follow-up for cardiovascular events over 6.0±2.4 years were assessed. Framingham cardiovascular risk score was computed at baseline. Obesity was defined as waist circumference >88 cm in females and >102 cm in males. Segment involvement score (SIS) described the number of coronary segments with plaque. Serum highly-sensitive cardiac troponin I (hscTnI)-related both to coronary plaque burden and event risk in RA- was measured with Erenna immunoassay. Serum leptin, which is closely related to obesity, was measured with radioimmunoassay. CVD risk estimates were contrasted in non-obese vs. obese patients and those with low vs. high leptin correspondingly using area under the curve (AUC) comparisons. Improvements in risk estimate accuracy in obese patients were explored by sequentially adding hscTnI information and coronary plaque burden estimates to a baseline model of Framingham score and evaluating sequential change in AUC, net reclassification index (NRI) and integrated discrimination improvement (IDI).

Results

A significant interaction between Framingham cardiovascular risk score and obesity was observed (p=0.032). Lower estimates were seen in obese [AUC 0.660, 95%CI 0.487-0.832] vs. non-obese RA patients [AUC 0.952, 95%CI 0.897-1.007, p=0.002, Figure 1A]. Likewise, risk estimates were lower in patients with higher (>22.1 ng/ml) vs. lower (<22.1 ng/ml) leptin [AUC 0.618, 95%CI 0.393-0.842 vs. 0.874, 95%CI 0.772-0.976 respectively, p=0.042, Figure 1B]. In obese patients, sequential addition of the highest hscTnI tertile values and extensive atherosclerotic plaque presence (SIS>5) to a base model including Framingham risk score, significantly improved risk prediction estimates based on changes in NRI [1.093 95%CI 0.517-1.574], IDI [0.188, 95%CI 0.060-0.526], as well as AUC [0.179, 95%CI 0.058-0.378, p=0.02]. The final, combined model accurately predicted 83.9% of incident cardiovascular events (Figure 1C).

Figure 1.

A and B. Obesity attenuates accuracy of clinical cardiovascular risk estimates in RA. C. Addition of information from hs-cTnI measurements and coronary atherosclerosis assessment significantly improve risk prediction

Conclusion

Obesity significantly reduced cardiovascular risk estimate accuracy in patients with RA. The optimization of cardiac risk stratification with the help of non-invasive assessment of coronary atherosclerosis burden and related cardiac damage biomarkers in the serum may warrant further study.

Disclosure of Interests

George Karpouzas Speakers bureau: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Bristol-Meyer-Squibb, Grant/research support from: Pfizer, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff Consultant of: Pfizer

Doppler ultrasound impacts response to intravenous tocilizumab in rheumatoid arthritis patients

OBJECTIVE

Within rheumatoid arthritis (RA) patients treated with intravenous tocilizumab (IV-TCZ), it is unclear if power Doppler ultrasonography (PDUS) can predict future clinical response. This study sought to determine if baseline PDUS or its early changes can predict 12-week and 24-week disease activity outcomes, and quantify the need for dose escalation (4 to 8 mg/kg).

METHODS

Fifty-four RA patients starting IV-TCZ were evaluated at baseline, 4, 6, 12, 16, and 24 weeks using 34-joint PDUS (US34-PDUS), clinical disease activity index (CDAI), 28-joint disease activity score using erythrocyte sedimentation rate (DAS28-ESR), ACR 20/50/70, health assessment questionnaire-disability index (HAQ-DI), and PDUS 20/50/70, a novel measure. Logistic regression models evaluated the predictive utility of US34-PDUS of DAS28-ESR response after adjusting for covariates.

RESULTS

Ninety-four percent of patients required dose escalation to 8 mg/kg. US34-PDUS, CDAI, and DAS28-ESR improved significantly over 24 weeks (p < 0.001). Baseline PDUS and 12-week PDUS change correlated with CDAI at 24 weeks (p < 0.05). Logistic regression demonstrated baseline US34-PDUS was independently associated with DAS28-ESR ≥ 1.2 response, even after adjusting for baseline DAS28-ESR (p = 0.03). CDAI, DAS28-ESR, and their components increased across PDUS 20/50/70 categories; however, HAQ-DI did not.

CONCLUSION

RA patients treated with IV-TCZ for 24 weeks demonstrated significant improvement, and baseline/early changes in PDUS were predictive of later clinical response. The PDUS 20/50/70 measure is a novel metric of response. This study suggests that IV-TCZ 4 mg/kg may not be sufficient to attain low RA disease activity at 12 weeks, in RA patients with moderate to severe disease (DAS28 ≥ 4.4 and US34-PDUS ≥ 10).

TRIAL REGISTRATION

ClinicalTrials.gov NCT01717859 Key Points • Over 90% of RA patients with baseline DAS28-ESR ≥ 4.4 and PDUS34 ≥ 10 required intravenous tocilizumab dose escalation from 4 to 8 mg/kg at 12 weeks. • Reduction in power Doppler ultrasonography (US34-PDUS) scores correlate with DAS28-ESR and CDAI over 24 weeks in rheumatoid arthritis patients with moderate to severe disease activity. • Baseline US34-PDUS predicts future improvements in clinical disease activity outcomes, independent of baseline DAS28-ESR. • Clinical response measures, DAS28-ESR and CDAI, improved across US34-PDUS 20/50/70 categories, while patient-reported outcomes did not.

POS0215 DIRECT AND CONDITIONAL EFFECTS OF EPICARDIAL ADIPOSE TISSUE VOLUME ON CORONARY PLAQUE PROGRESSION IN RHEUMATOID ARTHRITIS

Background:

Epicardial adipose tissue volume (EATv) predicts coronary atherosclerosis presence, progression and cardiovascular event risk in general patients1,2. Our group recently reported that EATv associated with greater subclinical coronary plaque burden, non-calcified plaque presence and vulnerable plaque characteristics in patients with rheumatoid arthritis (RA). The relationship was stronger in RA patients with lower disease duration, no traditional cardiac risk factors, and who were not obese.

Objectives:

To evaluate the predictive value of EATv on long-term coronary atherosclerosis development, and moderators of the association between EATv and plaque formation.

Methods:

This single-center observational cohort study included 100 patients without symptoms or diagnosis of cardiovascular disease who underwent computed tomography angiography for evaluation of EATv and coronary atherosclerosis at baseline and repeat assessments 6.9±0.3 years later to evaluate plaque progression. New plaque formation in segments without plaque at baseline was the main outcome. Robust multivariable logistic regression evaluated the effect of high versus low EATv (based on median) on likelihood of new plaque formation, accounting for clustering of segments within patients. Potential moderator effects of prespecified predictors were also assessed.

Results:

High EATv (>107 cm3) predicted new plaque formation in segments without baseline plaque (OR 2.77 [95% CI 1.43-5.37], p= 0.003); however, significance was lost in the multivariable model. Importantly, high EATv associated with formation of higher-risk non- and partially calcified plaque after adjusting for Framingham D’Agostino risk score, obesity, segment location, time-averaged CRP, duration of bDMARD and statin treatment and cumulative prednisone dose (adjusted OR 2.57 [95% CI 1.02-6.48], p= 0.045). RA duration (<10 versus >10 years), cardiac risk factor burden (≤1 versus >1), presence of mixed/calcified plaque in other coronary segments at baseline, and statin exposure (≤1 versus >1 year, based on median) moderated the effect of EATv on all new plaque formation (all p for interaction ≤ 0.021). Specifically, high EATv predicted new plaque formation in patients with RA duration <10 years (adjusted OR 5.75 [95% CI 1.77-18.67]), those with ≤1 cardiac risk factors (adjusted OR 3.40 [95% CI 1.46-7.90]), those without calcification at baseline (adjusted OR 2.65 [95% CI 1.11-6.31]) and those with statin treatment <1 year (adjusted OR 3.33 [95% CI 1.13-9.77]). This was not the case for patients with RA >10 years, ≥ 2 cardiac risk factors, calcification at baseline and statin treatment >1 year (figure 1).

Conclusion:

High baseline EATv independently predicted future higher-risk non-calcified and mixed coronary plaque in RA. Moreover, it conditionally promoted new plaque formation overall in patients with earlier disease, low cardiac risk factor burden, who had little or no atherosclerosis at baseline and who had limited exposure to statin therapy. These findings indicate the need for a larger prospective evaluation of the role of EATv as a biomarker of coronary atherosclerosis development in RA.

References:

[1]Hwang I-C et al. J Atheroscler Thromb 2017;24:262–74. 2. Ding J et al. Am J Clin Nutr 2009;90:499–504.

Figure 1.

Moderators of influence of EATv on new coronary plaque formation

Disclosure of Interests:

George Karpouzas Speakers bureau: Sanofi/ Genzyme/ Regeneron, Consultant of: Sanofi/ Genzyme/ Regeneron, Grant/research support from: Pfizer, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff Consultant of: Pfizer

OP0104 DIFFERENCES IN LOW-DENSITY LIPOPROTEIN (LDL) PARTICLE COMPOSITION AND OXIDATION MAY UNDERLIE THE PARADOXICAL ASSOCIATION OF LOW LDL WITH HIGHER CORONARY ATHEROSCLEROSIS BURDEN IN RHEUMATOID ARTHRITIS

Background:

The association between cholesterol and cardiovascular disease (CVD) risk is attenuated in Rheumatoid arthritis (RA). In fact, RA patients in the lowest low-density lipoprotein (LDL) group (<70mg/dl) may experience unexpectedly high CVD risk.

Objectives:

We here explored whether patients with LDL<70mg/dl (Group 1) had higher coronary atherosclerosis burden compared to other LDL groups (Group 2: 70≤LDL≤130 and Group 3: LDL>130), as a reason for this risk. We further evaluated whether low LDL in group 1 associated with differences in inflammation, LDL particle composition or oxidation.

Methods:

One hundred fifty RA patients without symptoms or history of CVD underwent coronary atherosclerosis evaluation with computed tomography angiography. Coronary artery calcium (CAC), number of segments with plaque (segment involvement score), stenotic severity (segment stenosis score), and extensive (>4 segments with plaque) or obstructive disease (>50% stenosis) were assessed. Lipoprotein classes and subclasses were directly measured. Oxidized LDL (oxLDL) was measured with monoclonal antibody E06. Chemiluminescence Elisa quantified IgG and IgM antibodies to oxLDL (anti-oxLDL) and apoB100 immune complexes (IC). Proinflammatory cytokines were measured with Erenna Immunoassay. Robust linear and logistic regression models- adjusted for Framingham D’Agostino score, obesity, disease activity, bDMARD and statin treatment- evaluated associations between LDL groups and plaque outcomes. Similar models evaluated adjusted differences in LDL subclasses, oxLDL, anti-oxLDL, anti-ApoB100 IC, and cytokines across LDL groups.

Results:

Group 1 patients had higher coronary plaque burden (Figure 1A) and 2.8 times greater risk of extensive or obstructive disease (adjusted OR 2.82 [95% CI 1.12-7.17], P = 0.031) compared to LDL>70 groups. Among statin naïve patients, those with LDL<70 also had higher oxLDL (log-transformed adjusted mean 2.55 [95% CI 2.34-2.77] versus 2.27 [95% CI 2.19-2.36], P = 0.018 for LDL>70). Notably, Group 1 patients also had higher anti-oxLDL IgG and anti-ApoB100 IgG IC levels compared to other groups (Figure 1B). LDL subclass relative content in the LDL particle differed across groups (Figure 1C). Lp(a) was higher in LDL particles in Group 1 (adjusted mean 16.04% [95% CI 11.75-20.33], versus 10.48% [95% CI 8.20-12.75] in Group 2, P = 0.026 and 7.41% [95% CI 0.77-14.04] in Group 3, P = 0.033). Notably, Lp(a) content strongly associated with oxLDL overall (r = 0.83, P < 0.0001). This association was stronger for Group 1 compared to others (P < 0.005, Figure 1D). No differences in RA activity, CRP, TNF-α, IL-17A, or IL-17F were seen across groups. However, Group 1 had higher IL-6 (log-transformed adjusted mean 1.98 [95% CI 1.64- 2.32] versus 1.57 [95% CI 1.45-1.70], P = 0.028 in Group 2 and 1.32 [95% CI 0.84-1.80], P = 0.031 in Group 3). IL-6 associated with both IgG anti-oxLDL (P = 0.015) and anti-apoB100 IC (P = 0.016). Log-transformed IL-6 further associated with higher log-transformed CAC (adjusted B 0.41 [95% CI 0.01-0.81], P = 0.049).

Conclusion:

RA patients with LDL<70 mg/dl had higher coronary atherosclerosis burden. Low circulating LDL in that group may reflect higher oxidation; this was mostly linked to the larger Lp(a) relative content of LDL and its significantly higher oxidation potential in that group. OxLDL immune recognition was linked to higher IgG anti-oxLDL Ab and anti-ApoB100 IC levels in the LDL<70 group, which further associated with higher IL-6 elaboration and atherosclerosis burden.

Disclosure of Interests:

George Karpouzas Speakers bureau: Sanofi/ Genzyme/ Regeneron, Consultant of: Sanofi/ Genzyme/ Regeneron, Grant/research support from: Pfizer, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff Consultant of: Pfizer

POS0216 GREATER HIGH-DENSITY LIPOPROTEIN LEVELS OVER TIME ARE LINKED TO DECREASED CORONARY PLAQUE FORMATION AND REGRESSION AND STABILIZATION OF HIGH-RISK LESIONS IN RHEUMATOID ARTHRITIS

Background:

The relationship between serum lipoproteins and cardiovascular disease risk in rheumatoid arthritis (RA) is complex1. Their levels and function may vary based on disease activity and medication use. Beneficial effects on high-density lipoprotein (HDL-C) levels, structure and behavior, in response to treatment have been described. However, the impact of HDL-C levels over time on coronary atherosclerosis progression in RA is unknown.

Objectives:

We here evaluated the influence of HDL-C levels over time on long-term coronary plaque formation and progression in patients with RA.

Methods:

One hundred one RA patients without symptoms or history of cardiovascular disease who participated in a computed tomography angiography study of coronary atherosclerosis had repeat assessments after 6.9±0.3 years to evaluate plaque progression. Clinical, laboratory and medication data were recorded at baseline and regular outpatient follow-up visits thereafter. Time-averaged HDL-C was calculated for each patient using available consecutive HDL measurements between baseline and follow-up. Robust logistic regression assessed the association between time-averaged HDL-C and likelihood of new plaque formation in segments without plaque at baseline, and transition of prevalent mixed plaque to calcified plaque. Robust multinomial logistic regression evaluated the effect of time-averaged HDL-C on likelihood of new non-calcified, mixed or calcified plaque formation in segments without plaque (compared to remaining without plaque), and non-calcified plaque regression or transition to mixed or calcified plaque at follow-up (compared to remaining non-calcified). All models accounted for clustering of coronary segments within patients and adjusted for Framingham D’Agostino risk score, proximal segment location, time-averaged CRP, cumulative prednisone dose, bDMARD duration, statin duration, waist-to-height ratio, and time-averaged triglycerides.

Results:

Participants were mostly female (n=87, 86.1%), with a mean ± standard deviation (SD) age of 51.5±10.3 years and time-averaged HDL-C of 51.7±13.9. Ninety-seven new plaques formed in segments without plaque at baseline; 20 were noncalcified, 21 were mixed, and 56 were calcified. Time-averaged HDL-C had no effect on new total plaque formation (adjusted odds ratio-OR 0.88 [95% CI 0.64-1.21]). However, each 1-SD increase in time-averaged HDL-C associated with a 44% reduced likelihood of new non-calcified plaque formation at follow-up (adjusted OR 0.56 [95% CI 0.35-0.92], Figure 1). In contrast, there was no effect of time-averaged HDL-C on new mixed or calcified plaque formation. Of 98 non-calcified plaques at baseline, 42 did not change at follow-up, 32 regressed (disappeared), 16 transitioned to mixed and 8 to calcified plaques. Each SD increase in time-averaged HDL-C yielded a 2.2-fold greater likelihood of non-calcified plaque regression (adjusted OR 2.21 [95% CI 1.02-4.83]). Sixteen of 52 mixed plaques present at baseline transitioned to more stable calcified lesions, and time-averaged HDL-C (per 1-SD increment) predicted a 3.5-fold increased likelihood of transition of mixed to fully calcified plaque (adjusted OR 3.56 [95% CI 1.25-10.17]).

Conclusion:

Higher HDL-C over time predicted regression of existing and decreased formation of new higher-risk non-calcified plaque. It also associated with transition of vulnerable mixed plaque to more stable fully calcified plaque. These effects were independent of RA treatment duration, prednisone dose and statin exposure.

References:

[1]Toms TE et al. Curr Vasc Pharmacol. 2010;8:301–326.

Figure 1.

Impact of HDL-C over time on coronary plaque progression in RA

Disclosure of Interests:

George Karpouzas Speakers bureau: Sanofi/Genzyme/Regeneron, Consultant of: Sanofi/Genzyme/Regeneron, Grant/research support from: Pfizer, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff: None declared

POS0571 NON-OBESE RHEUMATOID ARTHRITIS PATIENTS WITH LOW LOW-DENSITY LIPOPROTEIN HAVE GREATER CORONARY ATHEROSCLEROSIS BURDEN, PLAQUE PROGRESSION AND CARDIOVASCULAR EVENT RISK

Background:

Rheumatoid arthritis (RA) patients with low body weight incur higher mortality than obese patients. Paradoxically, RA patients in the lowest low-density lipoprotein group (LDL <70 mg/dl) may also experience higher cardiovascular disease (CVD) risk.

Objectives:

We here explored whether abdominal obesity (waist-to-height ratio >0.58 in females and >0.63 in males) might moderate the effect of low LDL (<70mg/dl) on coronary atherosclerosis burden, progression and long-term CVD risk in RA.

Methods:

One hundred fifty patients without symptoms or diagnosis of CVD underwent coronary computed tomography angiography. Plaque progression was evaluated 6.9±0.3 years later in 101 patients. Coronary artery calcium, number of segments with plaque (segment involvement score), and extensive (>4 segments with plaque) or obstructive disease (>50% stenosis) were assessed. CVD events were prospectively recorded, including cardiac death, myocardial infarction, unstable angina, revascularization, stroke, claudication, and heart failure hospitalization over 6.0±2.4 years of follow-up. Lipoprotein classes were directly measured. Oxidized LDL (oxLDL) was assessed with monoclonal antibody E06. Adjusted robust linear regression evaluated interactions between abdominal obesity and LDL groups on plaque outcomes. Per segment, adjusted robust logistic regression models explored obesity x LDL group interactions on new plaque formation and stenotic progression of prevalent plaques. Robust Cox regression models stratified by abdominal obesity evaluated the effect of LDL group (<70 vs. >70 mg/dl) on CVD events.

Results:

Non-obese patients with low LDL had the highest plaque burden (Figure 1A, all p < 0.02). Obesity moderated the effect of LDL on likelihood of extensive/obstructive disease (P for interaction = 0.061); specifically, LDL<70 associated with an increased likelihood of extensive/obstructive plaque in non-obese (adjusted OR 4.75 [95% CI 1.18-19.07], P = 0.028) but not obese patients (adjusted OR 1.55 [95% CI 0.39-6.08], P = 0.532). No differences in disease activity or inflammatory markers were seen across groups. Compared to LDL>70 mg/dl, low LDL predicted an increased likelihood of high oxLDL (>median) in non-obese patients (adjusted OR 5.10 [95% CI 1.46-17.75], P = 0.011) but not obese patients (adjusted OR 0.50 [95% CI 0.11-2.21], P = 0.36, Figure 1B). Obesity further moderated the effect of LDL on likelihood of future development of plaque (P for interaction = 0.002) and increased stenotic severity of existing plaques (P for interaction = 0.040); in non-obese patients, low LDL associated with a greater likelihood of new plaque forming in segments without baseline plaque (adjusted OR 4.68 [95% CI 2.26-9.66]) and worsening stenotic severity in segments with prevalent plaque (OR 5.35 [95% CI 1.62-17.67]). This was not observed in obese patients (Figure 1C). Notably, in non-obese patients, low LDL associated with higher CVD event risk compared to those with LDL>70 mg/dl (HR 7.94 [95% CI 1.52-41.36], P = 0.015). This was not the case in obese patients (HR 0.32 [95% CI 0.04-2.40], P = 0.27, Figure 1D).

Conclusion:

In non-obese RA patients, LDL<70 mg/dl may reflect higher LDL oxidation and was associated with higher baseline coronary atherosclerosis burden, new plaque formation, stenotic plaque progression and greater CVD risk than LDL>70 mg/dl.

Disclosure of Interests:

George Karpouzas Speakers bureau: Sanofi/ Genzyme/ Regeneron, Consultant of: Sanofi/ Genzyme/ Regeneron, Grant/research support from: Pfizer, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff Consultant of: Pfizer

Smoking cessation is associated with lower disease activity and predicts cardiovascular risk reduction in rheumatoid arthritis patients

Objectives

Smoking is a major risk factor for the development of both cardiovascular disease (CVD) and RA and may cause attenuated responses to anti-rheumatic treatments. Our aim was to compare disease activity, CVD risk factors and CVD event rates across smoking status in RA patients.

Methods

Disease characteristics, CVD risk factors and relevant medications were recorded in RA patients without prior CVD from 10 countries (Norway, UK, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico). Information on CVD events was collected. Adjusted analysis of variance, logistic regression and Cox models were applied to compare RA disease activity (DAS28), CVD risk factors and event rates across categories of smoking status.

Results

Of the 3311 RA patients (1012 former, 887 current and 1412 never smokers), 235 experienced CVD events during a median follow-up of 3.5 years (interquartile range 2.5–6.1). At enrolment, current smokers were more likely to have moderate or high disease activity compared with former and never smokers (P < 0.001 for both). There was a gradient of worsening CVD risk factor profiles (lipoproteins and blood pressure) from never to former to current smokers. Furthermore, former and never smokers had significantly lower CVD event rates compared with current smokers [hazard ratio 0.70 (95% CI 0.51, 0.95), P = 0.02 and 0.48 (0.34, 0.69), P < 0.001, respectively]. The CVD event rates for former and never smokers were comparable.

Conclusion

Smoking cessation in patients with RA was associated with lower disease activity and improved lipid profiles and was a predictor of reduced rates of CVD events.

THU0530 HIGHLY-SENSITIVE CARDIAC TROPONIN I AND BETA-2-GLYCOPROTEIN-I IGA ANTIBODIES INFORM THE UTILITY OF SCREENING AND FOLLOW-UP NON-INVASIVE CORONARY ATHEROSCLEROSIS EVALUATION AND OPTIMIZE CARDIOVASCULAR RISK ASSESSMENT IN RHEUMATOID ARTHRITIS

Background:

Occult coronary atherosclerosis burden predicts mid-term cardiovascular disease (CVD) events in rheumatoid arthritis (RA) above and beyond Framingham D’Agostino cardiac risk score (FRS-DA). Highly-sensitive cardiac troponin I (hs-cTnI) levels in blood associate with coronary plaque burden and event risk in RA. Moreover, IgA antibodies against beta2-glycoprotein-1 (a-b2GPI-IgA)- an atherosclerotic plaque antigen- in RA promote coronary plaque progression and moderate the effect of inflammation on CVD events. It is currently unclear when to recommend a screening, non-invasive coronary atherosclerosis evaluation in asymptomatic RA patients and whether such an assessment should be repeated.

Objectives:

To explore whether either biomarker alone or their combination improved prediction of plaque presence on an initial coronary CT angiogram (CCTA) beyond FRS-DA score; to evaluate whether either biomarker predicted progression to extensive or obstructive plaque on a follow-up evaluation.

Methods:

One hundred fifty RA patients underwent a baseline CCTA; 101 had repeat evaluation within 6.9±0.3 years. Hs-cTnI and a-b2GPI-IgA were assessed at baseline; the latter were confirmed 12 weeks later, if positive. Lesions rendering greater than 50% luminal stenosis were considered obstructive. Extensive plaque was defined as >5 coronary segments with plaque, or stenosis score>5, or coronary artery calcium score (CAC)>100. The diagnostic accuracy of FRS-DA alone vs. with hs-cTnI or a-b2GPI-IgA individually or combined for plaque or CAC at baseline was evaluated as area under the curve (AUC). Improvement in prediction accuracy between constructs was further assessed as integrated discrimination improvement (IDI). Similar AUC and IDI constructs evaluated the transition to obstructive or extensive atherosclerosis at follow-up in patients with baseline non-extensive or non-obstructive disease.

Results:

High hs-cTnI (>1.5pg/ml) added to FRS-DA increased AUC from 0.717 to 0.731 (Figure 1A) and improved prediction accuracy for baseline plaque [IDI=0.041 (SE)=0.017, p=0.015]. In contrast, a-b2GPI-IgA did not [IDI=0.005 (0.006), p=0.47] and the combination offered no added benefit to the hs-cTnI model alone. Similar observations were made for CAC. Presence of a-b2GPI-IgA independently associated with coronary plaque progression (IRR=1.67 [95%CI 1.04-2.67]), whereas hs-cTnI did not. Likewise, a-b2GPI-IgA associated with transition to extensive or obstructive disease independently of FRS-DA (OR=13.48 [95%CI 2.09-86.99]). Notably, 71.4% of a-b2GPI-IgA positive patients with high hs-cTnI progressed to extensive or obstructive disease compared to 7.7% of a-b2GPI-IgA negative subjects with high hs-cTnI (p=0.008). Addition of a-b2GPI-IgA to FRS-DA in patients with prevalent non-extensive non-obstructive plaque increased AUC from 0.785 to 0.900 (Figure 1B) and significantly improved the prediction for development of obstructive or extensive atherosclerosis at follow-up [0.387, (0.13), p=0.003].

Figure 1.

(A) Diagnostic accuracy for prediction of occult coronary atherosclerosis at baseline. FRS-DA alone is the base model followed by addition of hs-cTnI or a-b2GPI-IgA individually or combined.(B) Diagnostic accuracy for progression from non-obstructive and non-extensive plaque at baseline to obstructive or extensive atherosclerosis at follow-up.

Conclusion:

High hs-cTnI improved the risk of baseline plaque presence beyond clinical risk score and may trigger an initial non-invasive coronary atherosclerosis evaluation. A-b2GPI-IgA presence may justify a follow-up evaluation in patients with non-extensive, non-obstructive plaque at baseline.

Disclosure of Interests:

George Karpouzas Grant/research support from: Pfizer, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Speakers bureau: Sanofi-Genzyme-Regeneron, BMS, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff: None declared

OP0120 BIOLOGICS MAY PREVENT CARDIOVASCULAR EVENTS IN RHEUMATOID ARTHRITIS BY INHIBITING CORONARY PLAQUE FORMATION AND STABILIZING HIGH-RISK LESIONS

Background:

Biologic disease-modifying antirheumatic drugs (bDMARDs) effectively control inflammation and may improve cardiovascular outcomes in Rheumatoid arthritis.

Objectives:

To evaluate if bDMARDs decrease long-term cardiovascular disease (CVD) risk in rheumatoid arthritis and whether potential benefits might be rendered by impacting coronary plaque formation or progression.

Methods:

In this single-center observational cohort study, 150 patients underwent computed tomography angiography for evaluation of coronary atherosclerosis (total, non-calcified, mixed/calcified and low-attenuation or high-risk plaque); 101 had repeat assessments within 6.9±0.3 years to evaluate plaque progression. All CVD events were prospectively recorded, including cardiac death, myocardial infarction, unstable angina, revascularization, stroke, claudication, and heart failure hospitalization. The Framingham-D’Agostino score assessed clinical risk. Segment stenosis score (cumulative stenosis) measured plaque burden. The effect of bDMARD treatment on CVD events was assessed using marginal structural models. The inverse probability of treatment and censoring weights were used in a weighted pooled logistic regression with current bDMARD use and time since study entry included in the model to approximate a Cox proportional hazards model allowing for time-varying weights. Robust logistic regression evaluated the effect of bDMARD exposure (>50 percent of follow-up period) on likelihood of new plaque formation or change in plaque composition in per-segment models adjusted for Framingham-D’Agostino score, time between scans, statin duration, cumulative prednisone dose and time-averaged CRP.

Results:

Sixteen patients incurred 19 CVD events. Current bDMARD use associated with lower CVD risk (OR=0.20 [95%CI=0.05-0.75], p=0.018, Figure 1). However, the effect of bDMARDs was no longer significant when a 6-month exposure extension was applied (OR=0.42 [95% CI 0.13-1.38], p=0.15). The effect of bDMARD use on CVD risk was moderated by non-calcified plaque and low-attenuation plaque presence (Figure 1); specifically, bDMARDs were associated with lower CVD risk only in patients with non-calcified plaque (p=.048) or low-attenuation plaque (p=0.036) at baseline. Per-segment plaque progression analyses showed no main effect of bDMARD exposure on likelihood of new plaque formation (Figure 2). However, bDMARD exposure predicted lower likelihood of new plaque forming in segments without plaque among patients without mixed/calcified plaque in other coronary segments (OR=0.40 [95%CI=0.17-0.93]), but not among those with mixed/calcified plaque elsewhere in their arteries (OR=1.60 [95%CI=0.71-3.62]). Moreover, transition of non-calcified to mixed/calcified plaque associated with bDMARD exposure (OR=4.00 [95%CI=1.05-15.32]). bDMARD use also predicted low-attenuation plaque loss (p=0.042).

Figure 1.

Effect of bDMARD use on cardiovascular disease risk stratified by coronary plaque presence

Figure 2.

Effect of bDMARD exposure on plaque formation and transition from baseline to follow-up

Conclusion:

In rheumatoid arthritis, bDMARD use associated with reduced long-term CVD risk, lower likelihood of new plaque formation in patients with early atherosclerosis, stabilization of high-risk plaque and protective calcification of non-calcified lesions.

Disclosure of Interests:

George Karpouzas Grant/research support from: Pfizer, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Speakers bureau: Sanofi-Genzyme-Regeneron, BMS, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff: None declared

FRI0066 SUBCLINICAL CORONARY CALCIFICATION ASSOCIATED WITH LONG-TERM CARDIOVASCULAR OUTCOMES IN RHEUMATOID ARTHRITIS

Background:

Large, multicenter studies established the strong prognostic value of coronary artery calcium (CAC) scoring in asymptomatic individuals. Increasing CAC score is an independent predictor of worsening cardiovascular disease event risk in general patients. The prognostic significance of higher CAC score strata in the long-term cardiovascular risk in rheumatoid arthritis (RA) is unknown.

Objectives:

To evaluate the long-term cardiovascular event risk across CAC strata in a prospective, single center cohort of established RA patients without symptoms or prior diagnosis of cardiovascular disease.

Methods:

One hundred-fifty patients underwent computed tomography angiography for coronary atherosclerosis evaluation. CAC score was measured according to Agatston. CVD events were prospectively recorded, including cardiac death, myocardial infarction, unstable angina, revascularization, stroke, claudication, and heart failure hospitalization over 6.0±2.4 years of follow-up. Unadjusted, robust Cox proportional hazards regression models evaluated CVD event risk across higher CAC strata (CAC=1-99, CAC=100-399 and CAC≥400) compared to CAC=0. Additional multivariable robust Cox regression models with time-varying covariates evaluated the impact of log transformed CAC or different CAC thresholds (CAC>0 vs. CAC=0, CAC≥100 vs. CAC<100 and CAC≥400 vs. CAC<400) on future CVD events. Models were controlled for Framingham-D’Agostino clinical risk score, time-varying current bDMARD use and time-varying CRP.

Results:

Sixteen patients incurred 19 events, for a total of 2.1 (95% CI 1.3-3.3) events/100 patient-years. Increasing HR for cardiovascular events was observed for ascending CAC strata; 3.87 (1.03-14.48), 6.31 (1.38-28.91) and 16.98 (4.50-64.10) for CAC=1-99, CAC=100-399 and CAC≥400 respectively compared to CAC=0 (figure 1). In fully adjusted models, CAC score associated with future event risk independently of Framingham D’Agostino score, time-varying bDMARD use and time-varying CRP (HR=1.31 [95%CI 1.04-1.66]). CAC thresholds ≥100 (vs. <100) and CAC≥400 (vs. <400) in fully adjusted models similarly constituted independent predictors of long-term cardiovascular events (Figure 2).

Figure 1.

Increasing CAC scores associated with higher cardiovascular event risk in RA

Figure 2.

Impact of different CAC thresholds on cardiovascular event risk in RA

Conclusion:

Increasing CAC scores are strong, independent predictors of long-term cardiovascular events in RA patients without symptoms or prior diagnosis of cardiovascular disease.

Disclosure of Interests:

George Karpouzas Grant/research support from: Pfizer, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Speakers bureau: Sanofi-Genzyme-Regeneron, BMS, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff: None declared

THU0139 STATINS MODERATE THE EFFECT OF INFLAMMATION ON CORONARY PLAQUE PROGRESSION AND CARDIOVASCULAR DISEASE RISK IN RHEUMATOID ARTHRITIS

Background:

Cumulative inflammation correlates with coronary plaque increase and cardiovascular disease (CVD) events in rheumatoid arthritis (RA). Coronary plaque progression predicts CVD risk beyond baseline burden in general patients. Statins inhibit plaque progression and are effective for CVD prevention in general patients. Nevertheless, their impact on coronary plaque trajectory and CVD risk in RA are less clear.

Objectives:

To explore if statin treatment may reduce CVD event risk, inhibit new plaque formation or promote the regression or protective calcification of prevalent atherosclerotic lesions in RA. We also evaluated whether statins moderate the effects of inflammation (CRP) on CVD risk and on coronary plaque progression.

Methods:

One hundred-fifty patients underwent computed tomography angiography for coronary atherosclerosis evaluation (total, non-calcified, mixed/calcified plaque); 101 had repeat assessments within 6.9±0.3 years to evaluate plaque progression. CVD events were prospectively recorded, including cardiac death, myocardial infarction, unstable angina, revascularization, stroke, claudication, and heart failure hospitalization. Framingham-D’Agostino score assessed clinical risk. Plaque burden was measured as segment stenosis score (cumulative stenosis). Robust cox proportional hazards regression models evaluated the effects of time-varying statin use, log-transformed time-varying CRP (mg/dL) and their interaction on CVD risk controlling for Framingham-D’Agostino score, plaque burden and time-varying bDMARD use. Per-segment robust logistic regression assessed the effect of statin duration (years), log-transformed time-averaged CRP, and their interaction on likelihood of plaque formation in segments without plaque, and plaque regression or calcification in segments with non-calcified lesions. Models accounted for clustering of coronary segments within patients and controlled for Framingham-D’Agostino score, total prednisone dose, bDMARD duration, and time between scans.

Results:

Sixteen patients incurred 19 CVD events. There was no main effect of current statin use on CVD risk (adjusted HR 1.10, 95% CI 0.33-3.67). However, there was an interaction between current statin use and time-varying CRP (p-interaction=0.030); higher time-varying CRP predicted greater CVD risk in patients not receiving statins (adjusted HR 2.78, 95% CI 1.01-7.65), but not current statin users (Figure 1A). Likewise, current statin use associated with lower CVD risk when patients had higher time-varying CRP (>0.5 mg/dL) but not when CRP was lower (<0.5 mg/dL, Figure 1B). Statin duration had no main effect on new plaque formation in segments without plaque at baseline (adjusted OR 1.13, 95% CI 0.95-1.05); however, statin use moderated the effect of time-averaged CRP on new plaque formation (p-interaction=0.030, Figure 2A). Time-averaged CRP associated with a higher likelihood of new plaque in patients receiving statins less than one year (adjusted OR 1.75, 95% CI 1.38-2.20) but not those treated for longer (adjusted OR 1.26, 95% CI 0.78-2.02). In segments with non-calcified plaque, longer statin duration predicted protective calcification (adjusted OR 1.28, 95% CI 1.07-1.53, Figure 2B).

Conclusion:

In RA, statins moderated the effect of CRP on CVD event risk and new plaque formation in coronary segments without plaque. Longer statin duration was also associated with an increased likelihood of protective calcification of non-calcified plaque.

Disclosure of Interests:

George Karpouzas Grant/research support from: Pfizer, Consultant of: Sanofi-Genzyme-Regeneron, Janssen, Speakers bureau: Sanofi-Genzyme-Regeneron, BMS, Sarah Ormseth: None declared, Elizabeth Hernandez: None declared, Matthew Budoff: None declared

Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models

BACKGROUND

In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics.

METHODS

RA patients aged 30-70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusion criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up.

RESULTS

A total of 1974 patients were included in the main analyses, and 144 events were observed during follow-up, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15-32% of patients. C-statistics ranged 0.68-0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results.

CONCLUSIONS

The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive.

Lipid management in rheumatoid arthritis: a position paper of the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology

Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity, partly due to alterations in lipoprotein quantity, quality and cell cholesterol trafficking. Although cardiovascular disease significantly contributes to mortality excess in RA, cardiovascular prevention has been largely insufficient. Because of limited evidence, optimal strategies for lipid management (LM) in RA have not been determined yet, and recommendations are largely based on expert opinions. In this position paper, we describe abnormalities in lipid metabolism and introduce a new algorithm for estimation of cardiovascular risk (CVR) and LM in RA. The algorithm stratifies patients according to RA-related factors impacting CVR (such as RA activity and severity and medication). We propose strategies for monitoring of lipid parameters and treatment of dyslipidaemia in RA (including lifestyle, statins and other lipid-modifying therapies, and disease modifying antirheumatic drugs). These opinion-based recommendations are meant to facilitate LM in RA until more evidence is available.

Rheumatoid arthritis-specific cardiovascular risk scores are not superior to general risk scores: a validation analysis of patients from seven countries

Objectives

Cardiovascular disease (CVD) risk calculators developed for the general population do not accurately predict CVD events in patients with RA. We sought to externally validate risk calculators recommended for use in patients with RA including the EULAR 1.5 multiplier, the Expanded Cardiovascular Risk Prediction Score for RA (ERS-RA) and QRISK2.

Methods

Seven RA cohorts from UK, Norway, Netherlands, USA, South Africa, Canada and Mexico were combined. Data on baseline CVD risk factors, RA characteristics and CVD outcomes (including myocardial infarction, ischaemic stroke and cardiovascular death) were collected using standardized definitions. Performance of QRISK2, EULAR multiplier and ERS-RA was compared with other risk calculators [American College of Cardiology/American Heart Association (ACC/AHA), Framingham Adult Treatment Panel III Framingham risk score-Adult Treatment Panel (FRS-ATP) and Reynolds Risk Score] using c-statistics and net reclassification index.

Results

Among 1796 RA patients without prior CVD [mean ( s . d .) age: 54.0 (14.0) years, 74% female], 100 developed CVD events during a mean follow-up of 6.9 years (12430 person-years). Estimated CVD risk by ERS-RA [mean ( s . d .) 8.8% (9.8%)] was comparable to FRS-ATP [mean ( s . d .) 9.1% (8.3%)] and Reynolds [mean ( s . d .) 9.2% (12.2%)], but lower than ACC/AHA [mean ( s . d .) 9.8% (12.1%)]. QRISK2 substantially overestimated risk [mean ( s . d .) 15.5% (13.9%)]. Discrimination was not improved for ERS-RA (c-statistic = 0.69), QRISK2 or EULAR multiplier applied to ACC/AHA compared with ACC/AHA (c-statistic = 0.72 for all) or for FRS-ATP (c-statistic = 0.75). The net reclassification index for ERS-RA was low (-0.8% vs ACC/AHA and 2.3% vs FRS-ATP).

Conclusion

The QRISK2, EULAR multiplier and ERS-RA algorithms did not predict CVD risk more accurately in patients with RA than CVD risk calculators developed for the general population.

Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis

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.

Sirukumab for rheumatoid arthritis: the phase III SIRROUND-D study

OBJECTIVES

Interleukin-6 (IL-6) is implicated in rheumatoid arthritis (RA) pathophysiology. Unlike IL-6 receptor inhibitors, sirukumab is a human monoclonal antibody that selectively binds to the IL-6 cytokine. The phase III, multicentre, randomised, double-blind, placebo-controlled, parallel-group SIRROUND-D study (ClinicalTrials.gov identifier NCT01604343) evaluated the efficacy and safety of sirukumab in patients with active RA refractory to disease-modifying antirheumatic drugs.

METHODS

Patients were randomised 1:1:1 to treatment with sirukumab 100 mg every 2 weeks, 50 mg every 4 weeks or placebo every 2 weeks subcutaneously. Results through week 52 are reported.

RESULTS

Of 1670 randomised patients, significantly more patients achieved American College of Rheumatology 20% (ACR20) response at week 16 (coprimary endpoint) with sirukumab 100 mg every 2 weeks (53.5%) or 50 mg every 4 weeks (54.8%) versus placebo (26.4%; both p<0.001). Mean (SD) change from baseline in modified Sharp/van der Heijde score at week 52 (coprimary endpoint) was significantly lower with sirukumab (100 mg every 2 weeks: 0.46 (3.26); 50 mg every 4 weeks: 0.50 (2.96)) versus placebo (3.69 (9.25); both p<0.001). All major secondary endpoints (week 24 Health Assessment Questionnaire-Disability Index change from baseline, ACR50 response, 28-joint Disease Activity Score based on C reactive protein and major clinical response (ACR70 for six continuous months by week 52)) were met. The most common adverse events with sirukumab were elevated liver enzymes, upper respiratory tract infection, injection site erythema and nasopharyngitis.

CONCLUSIONS

Sirukumab 100 mg every 2 weeks and 50 mg every 4 weeks led to significant reductions in RA symptoms, inhibition of structural damage progression and physical function and quality of life improvements, with an expected safety profile.

TRIAL REGISTRATION NUMBER

NCT01604343; Results.

Troxis necrosis, a novel mechanism for drug-induced hepatitis secondary to immunomodulatory therapy

OBJECTIVES

A case of drug-induced hepatitis mediated by troxis necrosis, a form of autoimmune hepatitis, is described.

METHODS

Clinical data, light and electron microscopy of an ultrasound-guided core needle liver biopsy specimen, were examined to investigate the cause of transaminitis in a 26year old male patient on Cellcept and Plaquenil for the treatment of lupus erythematosus. A systematic PUBMED review of troxis necrosis as the underlying mechanism for drug-induced hepatitis was performed.

RESULTS

Liver function tests (LFTs) were significant for elevated AST (305) and ALT (174); the autoimmune workup was significant for anti-ANA positivity and α-SMA negativity. On light microscopy, the liver biopsy shows focal areas of lymphocytic infiltrates surrounding and forming immunologic synapses with lobular hepatocytes, indicating lobular hepatitis of autoimmune nature. Electron microscopy confirmed the presence of immunologic synapses. Upon cessation of the offending medications, the LFTs returned to baseline with no further intervention. Literature search yielded 7 previously reported cases of drug-induced hepatitis mediated by troxis necrosis.

CONCLUSION

Troxis necrosis is a novel mechanism for drug-induced hepatitis, including immunomodulatory medications including a monoclonal anti-TWEAK antibody and Cellcept and Plaquenil, two widely used immunosuppression/anti-rejection medications.

Towards the identification of multi-parametric quantitative MRI biomarkers in lupus nephritis

PURPOSE

To identify potential biomarkers of the renal impairment in lupus nephritis using a multi-parametric renal quantitative MRI (qMRI) protocol including diffusion weighted imaging (DWI), blood oxygen level dependent (BOLD), arterial spin labeling (ASL) and T1rho MRI between a cohort of healthy volunteers and lupus nephritis (LN) patients.

MATERIALS AND METHODS

The renal qMRI protocol was performed twice with repositioning in between on 10 LN patients and 10 matched controls at 1.5 T. Navigator-gated and breath-hold acquisitions followed by non-rigid image registration were used to control respiratory motion. The repeatability of the 4 MRI modalities was evaluated with the intra-class correlation coefficient (ICC) and within-subject coefficient of variation (wsCV). Unpaired t-test and stepwise logistic regression were carried out to evaluate qMRI parameters between the LN and control groups.

RESULTS

The reproducibility of the 4 qMRI modalities ranged from moderate to good (ICC=0.4-0.91, wsCV≤12%) with a few exceptions. T1rho MRI and ASL renal blood flow (RBF) demonstrated significant differences between the LN and control groups. Stepwise logistic regression yielded only one significant parameter (medullar T1rho) in differentiating LN from control groups with 95% accuracy.

CONCLUSION

A reasonable degree of test-retest repeatability and accuracy of a multi-parametric renal qMRI protocol has been demonstrated in healthy volunteers and LN subjects. T1rho and ASL RBF are promising imaging biomarkers of LN.

Developing pulmonary vasculopathy in systemic sclerosis, detected with non-invasive cardiopulmonary exercise testing

BACKGROUND

Patients with systemic sclerosis (SSc) may develop exercise intolerance due to musculoskeletal involvement, restrictive lung disease, left ventricular dysfunction, or pulmonary vasculopathy (PV). The latter is particularly important since it may lead to lethal pulmonary arterial hypertension (PAH). We hypothesized that abnormalities during cardiopulmonary exercise testing (CPET) in patients with SSc can identify PV leading to overt PAH.

METHODS

Thirty SSc patients from the Harbor-UCLA Rheumatology clinic, not clinically suspected of having significant pulmonary vascular disease, were referred for this prospective study. Resting pulmonary function and exercise gas exchange were assessed, including peakVO2, anaerobic threshold (AT), heart rate-VO2 relationship (O2-pulse), exercise breathing reserve and parameters of ventilation-perfusion mismatching, as evidenced by elevated ventilatory equivalent for CO2 (VE/VCO2) and reduced end-tidal pCO2 (PETCO2) at the AT.

RESULTS

Gas exchange patterns were abnormal in 16 pts with specific cardiopulmonary disease physiology: Eleven patients had findings consistent with PV, while five had findings consistent with left-ventricular dysfunction (LVD). Although both groups had low peak VO2 and AT, a higher VE/VCO2 at AT and decreasing PETCO2 during early exercise distinguished PV from LVD.

CONCLUSIONS

Previously undiagnosed exercise impairments due to LVD or PV were common in our SSc patients. Cardiopulmonary exercise testing may help to differentiate and detect these disorders early in patients with SSc.

Low physical activity is associated with proinflammatory high-density lipoprotein and increased subclinical atherosclerosis in women with systemic lupus erythematosus

OBJECTIVE

To investigate the association between physical activity, functional activity of high-density lipoprotein (HDL), and subclinical cardiovascular disease in patients with systemic lupus erythematosus (SLE).

METHODS

A total of 242 SLE patients (all women) participated in this cross-sectional study from February 2004 to February 2008. Carotid plaque and intima-media thickness (IMT), antioxidant function of HDL, and traditional cardiac risk factors were measured. Physical activity was assessed from self-reports by calculating the metabolic equivalents (METS) per week and by the physical function domain of the Medical Outcomes Study Short Form 36 (SF-36). Data were analyzed using bivariate and multivariate regression analyses.

RESULTS

Number of METS per week spent performing strenuous exercise was negatively correlated with IMT (r = -0.4, P = 0.002) and number of plaques (r = -0.30, P = 0.0001). Physical function as assessed by the SF-36 was also negatively correlated with IMT (r = -0.14, P = 0.03) and number of plaques (r = -0.14, P = 0.04). In multivariate analyses, number of strenuous exercise METS was significantly associated with IMT (t = -2.2, P = 0.028) and number of plaques (t = -2.5, P = 0.014) when controlling for markers of SLE disease activity and damage, but not after controlling for traditional cardiac risk factors. Low physical activity, defined as <225 total METS per week, was associated with the presence of proinflammatory HDL (P = 0.03).

CONCLUSION

Low physical activity is associated with increased subclinical atherosclerosis and proinflammatory HDL in patients with SLE. Increased strenuous exercise may reduce the risk of atherosclerosis in SLE.

Dysfunctional proinflammatory high-density lipoproteins confer increased risk of atherosclerosis in women with systemic lupus erythematosus

OBJECTIVE

Women with systemic lupus erythematosus (SLE) have an increased risk of atherosclerosis. Identification of at-risk patients and the etiology underlying atherosclerosis in SLE remain elusive. The antioxidant capacity of normal high-density lipoproteins (HDLs) is lost during inflammation, and these dysfunctional HDLs might predispose individuals to atherosclerosis. The aim of this study was to determine whether dysfunctional proinflammatory HDL (piHDL) is associated with subclinical atherosclerosis in SLE.

METHODS

Carotid artery ultrasound was performed in 276 women with SLE to identify carotid plaques and measure intima-media thickness (IMT). The antioxidant function of HDL was measured as the change in oxidation of low-density lipoprotein after the addition of HDL cholesterol. Two antiinflammatory HDL components, paraoxonase 1 and apolipoprotein A-I, were also measured.

RESULTS

Among the SLE patients, 48.2% were determined to have piHDL on carotid ultrasound, while 86.7% of patients with plaque had piHDL compared with 40.7% of those without plaque (P<0.001). Patients with piHDL also had a higher IMT (P<0.001). After multivariate analysis, the only factors found to be significantly associated with plaque were the presence of piHDL (odds ratio [OR] 16.1, P<0.001), older age (OR 1.2, P<0.001), hypertension (OR 3.0, P=0.04), dyslipidemia (OR 3.4, P=0.04), and mixed racial background (OR 8.3, P=0.04). Factors associated with IMT measurements in the highest quartile were the presence of piHDL (OR 2.5, P=0.02), older age (OR 1.1, P<0.001), a higher body mass index (OR 1.07, P=0.04), a cumulative lifetime prednisone dose>or=20 gm (OR 2.9, P=0.04), and African American race (OR 8.3, P=0.001).

CONCLUSION

Dysfunctional piHDL greatly increases the risk of developing subclinical atherosclerosis in SLE. The presence of piHDL was associated with an increased prevalence of carotid plaque and with a higher IMT. Therefore, determination of piHDL may help identify patients at risk for atherosclerosis.

Cellular and molecular mechanisms of regulation of autoantibody production in lupus

The hyperactive interaction between helper T cells and autoimmune B cells in individuals predisposed to systemic lupus erythematosus (SLE) can be interrupted by induction of regulatory and suppressor T cells. Using two strategies-high dose tolerance to an immunoglobulin-derived peptide, and minigene vaccination with DNA encoding T cell epitopes presented by MHC class I molecules-our group has induced at least three types of regulatory/suppressive T cells. They include CD8+ T cells that suppress helper T cells by cytokine secretion, CD8+ T suppressors that kill B cells making anti-DNA antibodies, and peptide-binding CD4+CD25+ regulatory T cells that suppress B cells by direct cell contact. Each of these lymphocyte subsets suppresses anti-DNA antibody production and delays the onset of nephritis in BWF1 lupus-prone mice. Patients with SLE have amino acid sequences similar to those from murine anti-DNA antibodies used in these studies, and at similar locations in the VH regions of anti-DNA immunoglobulins. Therefore, strategies described here might ultimately be useful in therapy of the human disease.

Identification and characterization of SmD183-119-reactive T cells that provide T cell help for pathogenic anti-double-stranded DNA antibodies

OBJECTIVE

The C-terminal peptide of amino acids 83-119 of the SmD1 protein is a target of the autoimmune response in human and murine lupus. This study was undertaken to test the hypothesis that SmD1(83-119)-reactive T cells play a crucial role in the generation of pathogenic anti-double-stranded DNA (anti-dsDNA) antibodies.

METHODS

Splenic or lymph node T cells derived from unmanipulated as well as SmD1(83-119)-immunized NZB/NZW mice were analyzed in vitro by enzyme-linked immunospot (ELISpot) assay to determine T cell help for anti-dsDNA generation induced by the SmD1(83-119) peptide. Cytokines expressed by these T cells were measured by ELISpot assay, enzyme-linked immunosorbent assay, and flow cytometry. SmD1(83-119)- and ovalbumin-specific T cell lines were generated and characterized.

RESULTS

The SmD1(83-119) peptide, but not the control peptides, significantly increased the in vitro generation of anti-dsDNA antibodies in cultures from unmanipulated NZB/NZW mice. Interferon-gamma (IFNgamma), interleukin-2 (IL-2), IL-4, transforming growth factor beta, and IL-10 production increased in response to the peptide in young mice; only IFNgamma and IL-2 were increased in older, diseased mice. Activation of SmD1(83-119)-reactive T cells by immunization of NZB/NZW mice resulted in elevated anti-dsDNA synthesis and, later, increased antibodies to SmD1(83-119). Most cells in SmD1(83-119)-specific CD4+ T cell lines helping both antibodies had increased intracellular expression of IFNgamma, and most expressed both IFNgamma and IL-4.

CONCLUSION

The SmD1(83-119) peptide plays an important role in generating T cell help for autoantibodies, including anti-dsDNA, and activates different subsets of T cells as defined by distinct cytokine expression. This peptide is an interesting target structure for the modulation of autoreactive T cells, and its characterization may contribute to our understanding of the role of autoantigen-reactive T cells in the pathogenesis of SLE.