Risk factors for cardiovascular disease in rheumatoid arthritis

Cardiovascular disease risk factors in newly diagnosed rheumatoid arthritis: A retrospective cohort study

Background and objectives

Patients with rheumatoid arthritis (RA) face an increased risk of cardiovascular disease (CVD) that traditional risk factors alone cannot fully explain. Chronic inflammation may influence lipid profiles and contribute to this risk. This study evaluates predictors of incident CVD in RA and explores how erythrocyte sedimentation rate (ESR) modifies the relationship between lipid levels and CVD outcomes.

Design settings participants and measurements

This retrospective cohort study included 1,802 RA patients aged 40-79 years, diagnosed between 2015 and 2022, and free of CVD at diagnosis. We evaluated the association between traditional cardiovascular risk factors-including current smoking, diabetes mellitus, systolic blood pressure, body mass index (BMI), HDL cholesterol, and LDL cholesterol-and RA-specific inflammatory markers, including ESR and C-reactive protein (CRP), with the incidence of CVD. Cox proportional hazards models adjusted for age, sex, race/ethnicity, antihypertensive medications, lipid-lowering medications, and antiplatelet medications.

Results

During a median follow-up of 3.5 years, 187 patients (10.4 %) developed CVD. The mean BMI was 32 kg/m² (standard deviation [SD] 10), HDL cholesterol was 53 mg/dL (SD 17), and LDL cholesterol was 104 mg/dL (SD 37). The median ESR was 21 mm/hr (interquartile range [IQR] 11-42) and CRP was 6 mg/L (IQR 3-12). Higher LDL cholesterol was inversely associated with CVD risk (HR 0.77 per SD increase, 95 % CI 0.63-0.94), with this association weakening with increasing ESR levels (interaction term HR 0.84, 95 % CI 0.71-0.99). Elevated HDL cholesterol also showed significantly decreased CVD risk (HR 0.82 per SD increase, 95 % CI 0.68-0.97). Smoking and diabetes were associated with increased risks (HR 1.52, 95 % CI 1.07-2.17 and HR 2.08, 95 % CI 1.39-3.10, respectively).

Conclusion

This study highlights the complex interplay between lipid levels and inflammation in RA, highlighting the nuances of CVD risk assessment in RA.

DXA and cardiovascular disease in rheumatoid arthritis: A scoping review

DXA technology is widely available today in many regions of the world. There is a growing realization of the value of DXA not only for osteoporosis management but also for sports medicine, sarcopenia, and the assessment of cardiovascular disease and mortality. Such features may be of particular interest for populations with a greater risk of these outcomes such as those with diabetes mellitus or rheumatoid arthritis. Recent systematic reviews and meta-analyses show DXA can robustly predict fractures, cardiovascular disease, dementia and mortality. Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting multiple organs including synovial joints, bone and other tissues. People suffering from RA have a greater propensity to osteoporotic fracture, cardiovascular disease, infection and premature death, which is well recognised. RA is the only unique disease included in some fracture risk algorithms such as FRAX, and so RA patients are often referred for a DXA scan to evaluate their risk of osteoporosis. We have previously shown vertebral fractures, aortic calcification and cardiovascular disease are prevalent in our RA population, with strong association. In this paper we performed a scoping review of published literature in Medline and Embase to better understand the current status of DXA and cardiovascular disease in RA populations. 822 papers were identified in an initial search of which 7 papers reflecting 2,038 RA patients from 7 different countries were included. Study design included 4 cross-sectional, 2 longitudinal and 1 case-control. All included associations with various cardiovascular measures, while only 1 included clinical events as an outcome. Our results suggest this is an area which remains relatively unexplored but has substantial important clinical potential.

A study of lipid profile peculiarities and atherogenic index of plasma in patients younger than fifty years of age with newly diagnosed rheumatoid arthritis

Context

Cardiovascular disease (CVD) is an important cause of mortality in rheumatoid arthritis (RA).

Aims

Evaluation of lipid profile and atherogenic index of plasma (AIP) in newly diagnosed DMARD naïve patients of RA younger than 50 years of age, and its comparison with age- and sex-matched healthy controls.

Settings and Design

Cross-sectional comparative study.

Methods and Material

48 patients aged 18 to 50 years fulfilling the ACR/EULAR criteria for RA, not yet on DMARD or steroids and 51 healthy controls were included. Disease activity was assessed, and lipid profile was estimated: total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG) and very low-density lipoprotein (VLDL). Atherogenic index of plasma (AIP) was calculated using a standard formula.

Statistical Analysis Used

Independent sample t-tests were used to determine the statistical significance of mean values between the case and control groups. Pearson's correlation test was used to correlate various components of the lipid profile and the atherogenic index with DAS28-ESR.

Results

Significantly reduced levels of HDL (39.31 ± 6.52 mg/dl) were found in patients with RA as compared to the healthy controls. Serum TG was significantly higher in the cases (138.35 ± 39.23 mg/dl). TC level was significantly elevated in the cases. Mean atherogenic index in cases was significantly higher (0.17 + 0.14) in some cases. Only a weak correlation was found between lipid profile components and DAS28-ESR.

Conclusions

Serum HDL level was significantly lower, and TC, TG levels and AIP were significantly higher in younger patients of early DMARD naïve RA pointing to a higher CV risk.

Safety outcomes of tocilizumab and tofacitinib treatment for rheumatoid arthritis: Target trial emulation

OBJECTIVES

Biological disease-modifying antirheumatic drugs have been the primary treatment option for moderate to severe rheumatoid arthritis (RA) in Taiwan since 2010. Tocilizumab is an interleukin-6 receptor inhibitor, whereas tofacitinib is a Janus kinase inhibitor. The two medications were indicated to treat RA by direct and indirect inhibition of interleukin-6 cytokine. We compared the safety outcomes of tocilizumab and tofacitinib in patients with RA in real-world clinical settings, following the 7 key components of target trial emulation (TTE).

METHODS

The data source was the Taiwan National Health Insurance Research Database. Patients with RA between 2010 and 2018 were eligible and assigned to either tocilizumab or tofacitinib based on their first prescription of these two medications. The index date was set as the first prescription date of either study medication. Propensity score stabilized weighting (PSSW) was used to balance the characteristics between the two medication groups. The incidences of safety outcomes were all-cause mortality, cancer, coronary heart disease, stroke, venous thrombosis events, tuberculosis, joint replacement events, and herpes zoster infection. The intention-to-treat (ITT) effect was commenced from the index date until the study outcomes, independently, 3 years, withdrawal, or December 31, 2021, whichever occurred first. For the per-protocol (PP) effect, patients were required to maintain the same medical group during the entire follow-up period.

RESULTS

A total of 2125 patients with RA who were prescribed tocilizumab (n = 844) or tofacitinib (n = 1281) were included in this study. The mean follow-up duration was 2.78 years in the tocilizumab group and 2.83 years in the tofacitinib group. For ITT, the sample sizes were 721 and 1196 for the tocilizumab and tofacitinib, respectively, after PSSW. A substantially lower incidence rate of herpes zoster infection (per 100 patient-years) was observed in the tocilizumab group (3.67) than in the tofacitinib group (7.61), with a hazard ratio of 0.48 (95%CI =0.37-0.63; p < .0001). All-cause mortality, cancer, coronary heart disease, stroke, total hip replacement, and tuberculosis were similar between the two medication groups. For PP, the sample sizes were 619 and 1085 for the tocilizumab and tofacitinib, respectively, after PSSW. The results of the PP analysis were similar to those of the ITT analysis.

CONCLUSIONS

Tocilizumab and tofacitinib act along the same inflammatory pathway. A lower herpes zoster incident rate was observed in the tocilizumab group than in the tofacitinib group. The incidence rates of other safety concerns and mortality rates were comparable in both groups of patients with RA treated in real-world settings.

Cardiovascular Events, Malignancies, and Efficacy Outcomes in Latin American Patients With Rheumatoid Arthritis Receiving Tofacitinib or Tumor Necrosis Factor Inhibitors: A Post Hoc Analysis of the ORAL Surveillance Study

BACKGROUND/OBJECTIVE

To assess safety/efficacy of tofacitinib and tumor necrosis factor inhibitors (TNFi) in patients from Latin America (LATAM) in ORAL Surveillance.

METHODS

In ORAL Surveillance, 4362 patients with rheumatoid arthritis aged ≥50 years with ≥1 additional cardiovascular risk factor received tofacitinib 5 or 10 mg twice daily or TNFi. This post hoc analysis stratified patients by geographical location (LATAM, n = 1202; non-LATAM, n = 3160). Incidence rates (IRs; patients with first event/100 patient-years) and hazard ratios for adverse events of special interest were reported. Efficacy outcomes included Clinical Disease Activity Index and American College of Rheumatology 20/50/70 responses.

RESULTS

Risk factors associated with cardiovascular disease and malignancies were less prevalent in the LATAM cohort compared with the non-LATAM cohort. IRs for patients receiving tofacitinib (combined doses) versus TNFi were 0.54 versus 0.28 (LATAM) and 1.14 versus 0.92 (non-LATAM) for major adverse cardiovascular events; 0.58 versus 0.27 (LATAM) and 1.33 versus 0.95 (non-LATAM) for malignancies excluding nonmelanoma skin cancer; and 0.69 versus 0.35 (LATAM) and 0.63 versus 0.33 (non-LATAM) for all-cause death. IRs for nonmelanoma skin cancer and venous thromboembolism were also numerically higher with tofacitinib versus TNFi and in the non-LATAM cohort versus LATAM. Efficacy was similar across treatment groups within each cohort.

CONCLUSIONS

Adverse events of special interest were generally less frequent in LATAM versus non-LATAM patients, reflecting differences in baseline characteristics, and higher with tofacitinib versus TNFi in both cohorts, consistent with the overall findings of ORAL Surveillance. Our findings emphasize the importance of assessing individual risk factors to guide benefit/risk assessment and treatment decisions.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02092467.

Increased epicardial adipose tissue thickness as a sign of subclinical atherosclerosis in patients with rheumatoid arthritis and ıts relationship with disease activity ındices

Epicardial adipose tissue is a novel cardiometabolic risk factor and indicator of subclinical atherosclerosis. We aimed to evaluate the epicardial adipose tissue thickness in rheumatoid arthritis (RA) patients and its association with disease activity scores. A total of 81 rheumatoid arthritis patients and 70 age- and sex-matched healthy individuals were recruited for this cross-sectional study. Epicardial adipose tissue thickness (EATT) was measured by transthoracic two-dimensional echocardiography. Tender and swollen joint counts were recorded at the time of inclusion. The laboratory tests included erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, anti-citrullinated protein antibodies, and serum lipid levels. Disease activity was calculated based on Disease Activity Scores for 28 joints (DAS-28) ESR and CRP, the Simple Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI). Epicardial adipose tissue thickness was significantly higher in the RA patients compared to the healthy controls (p < 0.001). We found statistically significant correlations of EATT with all disease activity indices (p < 0.001) and CRP (p = 0.002). According to a cut-off value of 6.4 mm determined for epicardial adipose tissue thickness, the RA patients with thickness ≥ 6.4 mm had higher disease activity scores and CRP levels. In the multivariable regression analysis, only SDAI score was found as an independent risk factor for increased EATT (OR, (95%CI), 13.70 (3.88-48.43), p < 0.001). Epicardial adipose tissue thickness measurement by echocardiography is a reliable method for assessing subclinical atherosclerosis in rheumatoid arthritis patients, and a higher disease activity score is an independent risk factor for coronary artery disease.

Cardiovascular complications of rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) patients remain at higher cardiovascular (CV) risk compared to non-RA patients, driven by accelerated atherosclerosis, leading to plaque rupture and acute CV events (CVE), including heart failure (HF). It has been hypothesized that chronic inflammation is the main driving force behind such outcomes. We summarize the current evidence supporting this hypothesis, focusing on arterial disease and myocardial disease.

RECENT FINDINGS

RA patients demonstrate higher prevalence of subclinical atherosclerosis (high risk plaque and arterial inflammation) compared to non-RA patients, with RA disease activity correlating independently with CVE and death. Nonischemic HF with preserved ejection fraction (HFpEF) is more common in RA compared to non-RA, with subclinical myocardial structural and functional alterations also more prevalent in RA. HFpEF and myocardial remodeling and dysfunction bear a strong and independent association with inflammatory correlates.

SUMMARY

All of this suggests that inflammation contributes to enhanced risk of CVE in RA. A more accurate and specific CV risk stratification tool for RA, incorporating biomarkers or imaging, is needed. Likewise, more prospective studies outlining the trajectory from preclinical to clinical HF, incorporating biomarkers and imaging, are also needed.

Faecalibacterium prausnitzii alleviates inflammatory arthritis and regulates IL-17 production, short chain fatty acids, and the intestinal microbial flora in experimental mouse model for rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease that leads to joint destruction and functional disability due to the targeting of self-antigens present in the synovium, cartilage, and bone. RA is caused by a number of complex factors, including genetics, environment, dietary habits, and altered intestinal microbial flora. Microorganisms in the gut bind to nod-like receptors and Toll-like receptors to regulate the immune system and produce various metabolites, such as short-chain fatty acids (SCFAs) that interact directly with the host. Faecalibacterium prausnitzii is a representative bacterium that produces butyrate, a well-known immunomodulatory agent in the body, and this microbe exerts anti-inflammatory effects in autoimmune diseases.

METHODS

In this study, F. prausnitzii was administered in a mouse model of RA, to investigate RA pathology and changes in the intestinal microbial flora. Using collagen-induced arthritic mice, which is a representative animal model of RA, we administered F. prausnitzii orally for 7 weeks.

RESULTS

The arthritis score and joint tissue damage were decreased in the mice administered F. prausnitzii compared with the vehicle-treated group. In addition, administration of F. prausnitzii reduced the abundance of systemic immune cells that secrete the pro-inflammatory cytokine IL-17 and induced changes in SCFA concentrations and the intestinal microbial flora composition. It also resulted in decreased lactate and acetate concentrations, an increased butyrate concentration, and altered compositions of bacteria known to exacerbate or improve RA.

CONCLUSION

These results suggest that F. prausnitzii exerts a therapeutic effect on RA by regulation of IL-17 producing cells. In addition, F. prausnitzii modify the microbial flora composition and short chain fatty acids in experimental RA mouse model.

Delay in diagnosis of rheumatoid arthritis: reasons and trends over a decade

INTRODUCTION

Delay in diagnosis and treatment initiation often lead to poorer outcomes in rheumatoid arthritis (RA). Most of the data on delay in diagnosis and management are from western population with no data from India. Additionally, with improved health care services, whether the delay has changed over years is not known. In this longitudinal observational study, we investigated delay to diagnosis and disease-modifying antirheumatic drugs (DMARDs) initiation over past 9 years.

METHODS

Patients aged ≥ 18 years having RA fulfilling 2010 ACR/EULAR criteria were enrolled from January to June in years 2012, 2017 and 2021. Diagnoses received before presenting to clinic, socioeconomic status, educational level and other demographic variables were recorded.

RESULTS

Each year, 323 patients (mean age 49.5-52.01 years) were enrolled. There was a significant reduction in delay in diagnosis from a median (IQR) of 36 (12-84, range 1-288) months in 2012 to 12 (4-36, range 1-180) months in 2017 and 10 (5-24, range 1-120) months) in 2021 (p < 0.0001). A significant improvement in time to initiating DMARDs from 2012 [48 (24-96) months] to 2017 [12 (6-36) months] (p < 0.0001) and from 2017 to 2021 [12 (5-24) months] (p = 0.03) was seen. Higher education, more patients opting for treatment from rheumatologists, and urbanisation contributed significantly to improvement in delay. There was no impact of age or gender on delay.

CONCLUSION

Delay in diagnosis has improved significantly between 2012 and 2021. However, delay still remains long as most patients miss the 3-month therapeutic window. Future work focussing on reasons for delays in the patient pathway could help improve consultation pathways in India.

Efficacy of Siwan Traditional Therapy on Erythrocyte Sedimentation Rate, Lipid Profile, and Atherogenic Index as Cardiac Risk Factors Related to Rheumatoid Arthritis

Background and Objectives: The most frequent cause of mortality in rheumatoid arthritis (RA) patients is cardiovascular disease (CVD). Inflammation, dyslipidemia, and decreased physical activity are some of the main risk factors for CVD. Siwan sand therapy is a type of traditional therapy used in Egypt to treat RA. The approach of this therapy depends on the experience of the healers. The aim of the current study was to compare the effects of three sessions of Siwan traditional therapy to five sessions on common CVD risk factors and physical function in rheumatoid arthritis patients. Materials and Methods: Thirty patients (9 male and 21 female) were assigned into two groups of equal size: group (A) received three sessions of Siwan traditional therapy in the form of a sand bath. Group (B) received the same form of therapy for five days. Erythrocyte sedimentation rate (ESR), lipid profile, atherogenic index of plasma (AIP), and a health assessment questionnaire (HAQ) were measured before and after treatment. Results: There was a significant increase above normal within group (A) for ESR (p = 0.001), triglycerides (TG; p = 0.015), total cholesterol (Tot-Chol; p = 0.0001), and low-density lipoprotein (LDL; p = 0.0001). However, there were no considerable differences in high-density lipoprotein (HDL; p = 0.106), very low-density lipoprotein (VLDL; p = 0.213), AIP (p = 0.648), and HAQ (p = 0.875). For the second group, there were significant changes within group B only in Tot-Chol (p = 0.0001), HDL (p = 0.0001), VLDL (p = 0.0001), AIP (p = 0.008), and HAQ (p = 0.014). There was a significant difference between both groups regarding HDL (p = 0.027), LDL (p = 0.005), AIP (p = 0.029), ESR (p = 0.016), and HAQ (p = 0.036). Conclusions: For RA patients, five days of Siwan traditional therapy caused significant changes regarding inflammation, Tot-Chol, LDL, HDL, AIP, and functional activity when compared to three days of Siwan hot sand therapy.

Comparative safety of Janus kinase inhibitors and tumor necrosis factor inhibitors in patients undergoing treatment for rheumatoid arthritis

OBJECTIVES

Since 2010, biological disease-modifying antirheumatic drugs (bDMARDs) have been the dominant mode of treatment for rheumatoid arthritis (RA). However, the safety of DMARDs, such as tumor necrosis factor inhibitors (TNFis) and Janus kinase inhibitors (JAKis), in treating patients with RA is a concern. We compared the safety outcomes of JAKis and TNFis in RA patients in clinical settings.

METHODS

Patients diagnosed with RA between 2015 and 2017 were identified from the Taiwan National Health Insurance Research Database and followed till 2018. Propensity score stabilized weighting was used to balance the baseline characteristics of the JAKis and TNFis groups. The incidences of safety outcomes, namely cardiovascular (CV) events, tuberculosis (TB), total hip replacement (THR), total knee replacement (TKR), and all-cause mortality, were compared between the 2 study groups.

RESULTS

A total of 3179 patients with RA who were administered JAKis (n = 822) and TNFis (n = 2357) were included in this study. The mean follow-up duration was 2.02 years in the JAKis group and 2.10 in the TNFis group. All-cause mortality had the highest incidence rate, followed by TKR, THR, CV events, and TB. A lower incidence rate of the study outcomes was observed in the JAKis group than in the TNFis group but without statistical significance.

CONCLUSION

Comparable safety issues and mortality rates were observed for JAKis and TNFis in RA patients treated in real-world settings.

The effects of biologic agents on cardiovascular risk factors and atherosclerosis in rheumatoid arthritis patients: a prospective observational study

We aimed to evaluate the impact of biologic treatment on subclinical atherosclerosis and risk factors for cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA). Forty-nine biologic naïve RA patients, treated with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), who were eligible for treatment with a biologic agent, were included in the study. The serum levels of lipid parameters, as well as disease activity parameters were determined in RA patients before and after 3 and 6 months of therapy. Carotid artery intima-media thickness (cIMT) was measured before and after treatment. A comparison analysis of change of these parameters was also performed between anti-tumor necrosis factor (anti-TNF) and non-anti-TNF users. Furthermore, 31 non-smoking healthy volunteers, matched for age and gender, were used as a control group. At baseline, RA patients had a decrease in serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) levels compared with controls (209 ± 63 vs 233 ± 44 and 58 ± 15 vs 61 ± 14, p < 0.004), while cIMT was higher versus controls [0.9 (0.8-1) vs 0.6 (0.5-0.7), p < 0.001]. TC, HDL-C and apolipoprotein A1 levels were significantly increased 3 months after treatment (209 ± 63, 58 ± 15, 162 ± 32, vs 227 ± 45, 60 ± 15, 169 ± 29, respectively, p < 0.03) and this observation remained stable at a 6-month follow-up. After 6 months, there was also a statistically significant decrease in the cIMT [0.9 (0.8-1) vs 0.7 (0.6-0.8), p < 0.001]. Anti-TNF and non-anti-TNF users had comparable changes in cardiovascular risk parameters. The atherogenic lipid profile and subclinical atherosclerosis are features of RA, which appeared improved after biologic therapy initiation.

Prevalence of Common Comorbidities in Rheumatoid Arthritis in Rural New York Compared With National Data

Background Rheumatoid arthritis (RA) is a systemic autoimmune disease with multiple known comorbidities and risk factors. The rate and severity of different comorbidities among RA patients are influenced by various demographic, behavioral, and socioeconomic factors, which can vary widely between urban and rural areas. However, limited information is currently available regarding the association of comorbidities with RA in rural settings. In this study, we investigated the prevalence of common comorbidities and risk factors of RA among RA patients from a rural hospital located in rural northern New York and compared them against national patient records obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Methodology We compared de-identified patient records of 153 RA patients obtained from St. Lawrence Health (SLH) to 198 RA patients from the NHAMCS. After performing the descriptive analyses and removing outliers, two-sample tests of proportions were used for comparing the binary categories of sex, age, obesity, hypertension, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) between the two datasets. These analyses were applied to both weighted and unweighted sets of national data, and a p-value of <0.05 was considered statistically significant. The differences were then explored at a greater resolution by binning body mass index, blood pressure (BP), COPD prevalence, and tobacco usage data across different age groups. Results A significantly higher rate of diastolic hypertension (χ2 = 17.942, w = 0.232, p < 0.001) and over two times higher prevalence of COPD (χ2 = 7.635, w = 0.147, p = 0.006) were observed among RA patients in the rural group. The rates of CHF were significantly different only when sample weighting was applied. When categorized by age groups, diastolic BP showed a peak at 40-49 years, coinciding with the age group for high tobacco smoking and peak disease activity in rural RA patients. Conclusions A higher prevalence of comorbidities of RA such as hypertension (diastolic) and COPD are observed in patients from northern rural New York compared to the national average. Our findings indicate that rural RA patients might have a distinct comorbidity burden, suggesting the need for larger-scale studies.

Assessment of the relationship between estimated cardiovascular risk and structural damage in patients with axial spondyloarthritis

Aims

To evaluate the association of estimated cardiovascular (CV) risk and subclinical atherosclerosis with radiographic structural damage in patients with axial spondyloarthritis (axSpA).

Methods

Cross-sectional study including 114 patients axSpA from the SpA registry of Córdoba (CASTRO) and 132 age- and sex-matched healthy controls (HCs). Disease activity and the presence of traditional CV risk factors were recorded. The presence of atherosclerotic plaques and carotid intima media thickness (cIMT) were evaluated through carotid ultrasound and the SCORE index was calculated. Radiographic damage was measured though modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). The association between mSASSS and SCORE was tested using generalized linear models (GLM), and an age-adjusted cluster analysis was performed to identify different phenotypes dependent on the subclinical CV risk.

Results

Increased traditional CV risk factors, SCORE, and the presence of carotid plaques were found in axSpA patients compared with HCs. The presence of atherosclerotic plaques and SCORE were associated with radiographic structural damage. The GLM showed that the total mSASSS was associated independently with the SCORE [β coefficient 0.24; 95% confidence interval (CI) 0.10-0.38] adjusted for disease duration, age, tobacco, C-reactive protein, and non-steroidal anti-inflammatory drugs (NSAID) intake. Hard cluster analysis identified two phenotypes of patients. Patients from cluster 1, characterized by the presence of plaques and increased cIMT, had a higher prevalence of CV risk factors and SCORE, and more structural damage than cluster two patients.

Conclusion

Radiographic structural damage is associated closely with increased estimated CV risk: higher SCORE levels in axSpA patients were found to be associated independently with mSASSS after adjusting for age, disease duration, CRP, tobacco and NSAID intake.

Cardiovascular outcomes in patients with co-existing coronary artery disease and rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Through this analysis, we aimed to systematically compare the cardiovascular outcomes observed in patients with co-existing coronary artery disease (CAD) and rheumatoid arthritis (RA).

METHODS

Mendeley, Web of Science (WOS), MEDLINE, Cochrane central, EMBASE, Google scholar, and http://www.ClinicalTrials.gov were searched for English-based publications on CAD and RA. Selective cardiovascular outcomes were the endpoints in this analysis. The statistical software RevMan 5.3 was used for data assessment. Risk ratios (RR) with 95% confidence intervals (CI) were used to represent each subgroup analysis.

RESULTS

One thousand four hundred forty six (1446) participants had co-existing CAD and RA whereas 205,575 participants were in the control group (only CAD without RA). This current analysis showed that the risk of asymptomatic or stable angina was similar in CAD patients with versus without RA (RR: 0.98, 95% CI: 0.84 - 1.14; P = .78). However, all-cause mortality (RR: 1.47, 95% CI: 1.34 - 1.61; P = 0.00001), cardiac death (RR: 1.51, 95% CI: 1.05 - 2.17; P = .03) and congestive heart failure (RR: 1.41, 95% CI: 1.27 - 1.56; P = .00001) were significantly higher in CAD patients with RA. However, multi-vessel disease (RR: 2.03, 95% CI: 0.57 - 7.26; P = .28), positive stress test (RR: 1.69, 95% CI: 0.70 - 4.08; P = .24), and ischemic events (RR: 1.18, 95% CI: 0.81 - 1.71; P = .40) were similar in both groups. The risk for myocardial infarction, repeated revascularization, and the probability of patients undergoing percutaneous coronary intervention (PCI) (RR: 1.20, 95% CI: 0.75 - 1.93; P = .45) were also similar in CAD patients with versus without RA. When we considered outcomes only in those patients who underwent revascularization by PCI, all-cause mortality (RR: 1.43, 95% CI: 1.29 - 1.60; P = .00001) was still significantly higher in CAD patients with RA.

CONCLUSIONS

This analysis showed a significantly higher mortality risk in CAD patients with RA when compared to the control group. Congestive heart failure also significantly manifested more in CAD patients with co-existing RA. However, the risks all the other cardiovascular outcomes were similar in both groups. Nevertheless, due to the several limitations of this analysis, this hypothesis should be confirmed in forthcoming trials based on larger numbers of CAD patients with co-existing RA.

Incidence and Risk of Glucocorticoid-Associated Adverse Effects in Patients With Rheumatoid Arthritis

OBJECTIVE

Using the UK Clinical Practice Research Datalink, we examined the incidence of glucocorticoid (GC)-related serious adverse events (SAEs) in rheumatoid arthritis (RA) and non-RA patients and quantified the risk of SAEs in patients with RA.

METHODS

We matched incident patients with RA to an age- and sex-matched, non-RA comparison group of equal size. In a cohort analysis, we estimated incidence rates (IRs) and IR ratios (IRRs) for GC-related AEs (i.e., diabetes mellitus [DM], osteoporosis, fractures, glaucoma, hypertension, gastrointestinal [GI] perforation or bleeding, thrombotic stroke or myocardial infarction [MI], or death), stratified by GC use. We conducted a series of nested case-control analyses among patients with RA, evaluating the effects of increasing cumulative and average daily GC dose. Cases of each outcome were matched to controls for age, sex, and general practice. We calculated adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) for each outcome.

RESULTS

Patients with RA had a higher incidence for all investigated SAEs except glaucoma, compared to non-RA patients. IRRs were greater in those patients prescribed a GC than in those without. In patients with RA, GCs were associated with an elevated risk of DM (adjusted OR 1.33 [95% CI 1.14-1.56]), osteoporosis (adjusted OR 1.41 [95% CI 1.25-1.59]), thrombotic stroke or MI (adjusted OR 1.28 [95% CI 1.07-1.52]), serious infection (adjusted OR 1.28 [95% CI 1.11-1.48]), and death (adjusted OR 1.33 [95% CI 1.19-1.48]). There was a trend of increasing risk with increasing cumulative and average daily GC dose for all outcomes other than glaucoma, hypertension, and GI perforations or bleeding (P < 0.05).

CONCLUSION

Patients with RA had an increased incidence of GC-related AEs. Increasing cumulative and average daily GC doses were found to be associated with an increasing risk of developing an AE.

Management and Comorbidities in Middle-European Patients with Rheumatoid Arthritis: A Retrospective, Cross-sectional Comparison with COMORA Data

Objective:

To assess disease-specific characteristics and comorbidities in consecutive Middle-European Rheumatoid Arthritis (RA) patients, and to compare results with international data.

Methods:

Cross-sectional retrospective analysis of consecutive RA patients from a Middle-European outpatient service. Data are compared to those of the international “Co-morbidity in Rheumatoid Arthritis” (COMORA) cohort.

Results:

80 RA patients with mean disease duration of 10.6 ± 8.3 years were enrolled within 5 months. Age was 62 ± 13 years and 75% were female. The Middle-European cohort showed slightly lower disease activity than the Austrian COMORA subcohort. 88.8% of all Middle-European RA patients were in remission or had low disease activity. Despite comparable disease characteristics, the percentage of patients ever treated with biological disease-modifying antirheumatic drugs (bDMARDs) was lower in the middle-European cohort (36.3%) than in the Austrian subcohort of COMORA (59%), but similar to the international COMORA cohort (39%). More smokers were in the Austrian COMORA subcohort (48.0) than in the Middle-European (22.5%) and the COMORA cohort (13%). Hypertension (38.8%) and osteoporosis (30.0%) were the most frequent comorbidities.

Conclusion:

Comparison of RA patients from this Middle-European cohort with the Austrian COMORA subcohort showed less frequent use of bDMARDs during disease course – probably according to the local referral structure. 88.8% of the Middle-European RA-patients achieved the treat-to target-aim of remission or low disease activity.

Is Rheumatoid Arthritis a Cardiovascular Risk-Equivalent to Diabetes Mellitus?

OBJECTIVE

The 2013 American College of Cardiology/American Heart Association cholesterol treatment guidelines recommend statins for patients with diabetes mellitus ages 40-75 years due to their elevated cardiovascular disease (CVD) risk. We compared the incidence of hospitalized acute myocardial infarction (MI), stroke, and coronary revascularization according to whether patients had diabetes mellitus, rheumatoid arthritis (RA), both, or neither.

METHODS

Using 2006-2010 private and public health plan claims, we identified 4 mutually exclusive retrospective cohorts ages >40 years: patients with RA and diabetes mellitus, RA only, diabetes mellitus only, or neither condition. Patients with prevalent CVD were excluded. Outcomes included acute MI and stroke, identified from inpatient discharge diagnosis codes, and coronary revascularization from procedure codes. Across the 4 cohorts, we calculated incidence rates (IRs) of the outcomes, standardized to the 2010 US census age and sex distribution.

RESULTS

We identified 920,772 eligible participants. The age- and sex-standardized IRs (per 1,000 person-years) for MI were highest among patients with RA and diabetes mellitus (IR 12.6 [95% confidence interval (95% CI) 10.7-14.7]), followed by patients with diabetes mellitus only (IR 10.7 [95% CI 10.3-11.0]), RA only (IR 5.7 [95% CI 5.2-6.3]), and with neither condition (IR 4.2 [95% CI 4.1-4.3]).

CONCLUSION

Findings from the present study suggest that while CVD risk in RA is elevated, it is lower in magnitude compared to the CVD risk associated with diabetes mellitus. Therefore, considering RA a diabetes mellitus risk-equivalent with respect to hyperlipidemia management may not be appropriate.

Prescribing Trend of Antirheumatic Drugs in Taiwan and Risk of Cardiovascular Disease in Patients with Rheumatoid Arthritis: A Nationwide Cohort Study

We aimed to investigate the prescribing trend of antirheumatic drugs and assess the risk of cardiovascular disease in patients with rheumatoid arthritis in Taiwan. This study was a retrospective cohort study, conducted based on the Taiwan National Health Insurance Research Database. The study subjects were 15,366 new rheumatoid arthritis patients from 2003 to 2010. To avoid selection bias, we applied propensity score matching to obtain general patients, as the control group. Cox proportional hazard model was used to evaluate the risk of cardiovascular disease in rheumatoid arthritis patients. The most common prescriptions of rheumatoid arthritis were nonsteroidal anti-inflammatory drugs. After controlling for related variables, rheumatoid arthritis patients had a higher risk of cardiovascular disease than general patients (adjusted hazard ratio [aHR] = 1.31; 95% confidence interval [CI]: 1.23-1.39). Age was the most significantly associated risk factor with the cardiovascular disease. Other observed risk factors for cardiovascular disease included hypertension (aHR = 1.57, 95% CI: 1.48-1.65), diabetes mellitus (aHR = 1.47, 95% CI: 1.38-1.57), and chronic kidney disease (aHR = 1.48, 95% CI: 1.31-1.66). Patients with rheumatoid arthritis indeed had a higher risk of incident cardiovascular diseases. Besides, age, hypertension, diabetes mellitus, and chronic kidney disease were also associated with a higher risk of cardiovascular disease.

Recent-onset of rheumatoid arthritis leads to increase in wall thickness of left anterior descending coronary artery. An evidence of subclinical coronary artery disease

OBJECTIVES

To explore the atherosclerotic changes of the left anterior descending coronary artery (LADCA) in patients with early onset of rheumatoid arthritis (RA).

METHODS

Transthoracic echocardiographic scans were performed on 15 early RA patients and 20 control subjects, free of rheumatological diseases, diabetes mellitus (DM), and cardiovascular disease (CVD). Out of 15 RA patients, 10 were matched for age and gender with control. Left anterior descending coronary artery wall thickness was compared between RA subjects and their matched control. Among early RA patients, correlation was assessed between LADCA wall thickness and the demographic features, RA activity features, and cardiovascular risk factors.  Results: Left anterior descending coronary artery wall thickness was significantly increased (p=0.001) in early RA compared to controls, as it was reported to be 0.61±0.04 mm (CI: 0.52-0.7); and 0.48±0.08 mm (CI: 0.44-0.51) respectively. Within early RA, LADCA wall thickness was related to the disease activity score (p=0.025, ß-coefficient 0.066, CI: 0.01-0.122) as well as to the patient global assessment of disease activity (PGADA) at RA onset (p=0.006, ß-coefficient 0.003, CI: 0.001-0.005), in a positive linear relationship. Left anterior descending coronary artery  wall thickness was found to be thicker among RA patients with rheumatoid factor (RF) positive (p=0.015, CI: 0.53-0.66). Conclusion: Early RA patients have increased coronary arteries atherosclerotic burden compared to healthy subjects matched for age, and gender. Rheumatoid factor positivity, high disease activity score and PGADA were found to be associated with coronary artery wall thickness.

What role does rheumatoid arthritis disease activity have in cardiovascular risk?

Rheumatoid arthritis (RA) is associated with a 1.3 to 3-fold increase in mortality, being the major cause of death from cardiovascular complications (40%-50%). Therefore, the initial approach should include cardiovascular risk (CVR) assessment using algorithms adapted for this population. Although, SCOREM is an important advance, there are data indicating that subclinical atherosclerosis may be underdiagnosed.

OBJECTIVE

To estimate the strength of association between carotid ultrasound and SCOREM in this population, as well as the implication of disease activity.

METHODOLOGY

Cross-sectional, observational, analytical study performed at the General Hospital of Ciudad Real, Spain, between June 2013 and May 2014. The evaluation of CVR was performed and, according to SCOREM, the population was divided into low and high (medium, high and very high) risk. We studied the presence of subclinical atherosclerosis in low-risk patients.

RESULTS

Of the total of 119 RA patients, 73.1% had traditional risk factors. Thirty-eight patients were excluded because of a previous cardiovascular event, diabetes mellitus and/or nephropathy. Atheromatous plaque was observed in 14.63% of the low-risk population. The factor with the strongest association to the presence of subclinical atherosclerosis was a moderate or high activity of RA measured by the simplified disease activity index with an odds ratio of 4.95 (95% CI: 1.53-16.01).

CONCLUSIONS

Although there was an acceptable correlation between the presence of subclinical atherosclerosis and SCOREM, there was a considerable proportion of atheromatous plaques in low-risk patients. Disease activity was the risk factor most closely associated with increased CVR.

Body Mass Index, Weight Loss, and Cause-Specific Mortality in Rheumatoid Arthritis

OBJECTIVE

To examine associations of body mass index (BMI) and weight loss with cause-specific mortality in rheumatoid arthritis (RA).

METHODS

A cohort of US veterans with RA was followed until death or through 2013. BMI was categorized as underweight, normal, overweight, and obese. Weight loss was calculated as the 1) annualized rate of change over the preceding 13 months, and 2) cumulative percent. Vital status and cause of death were obtained from the National Death Index. Multivariable competing-risks regression models were utilized to assess the time-varying associations of BMI and weight loss with cause-specific mortality.

RESULTS

Among 1,600 participants and 5,789 patient-years of followup, 303 deaths occurred (95 cardiovascular, 74 cancer, and 46 respiratory). The highest weight-loss rate and weight-loss percent were associated with a higher risk of cardiovascular mortality (rate: subdistribution hazard ratio [sHR] 2.27 [95% confidence interval (95% CI) 1.61-3.19]; percent: sHR 2.31 [95% CI 1.06-5.01]) and cancer mortality (rate: sHR 2.36 [95% CI 1.11-5.01]; percent: sHR 1.90 [95% CI 1.00-3.62]). Overweight BMI was protective of cardiovascular mortality (sHR 0.59 [95% CI 0.38-0.91]), while underweight BMI was associated with a near 3-fold increased risk of respiratory mortality (sHR 2.93 [95% CI 1.28-6.67]). Incorporation of time-varying BMI and weight loss in the same models did not substantially alter individual associations for cardiovascular and cancer mortality, but an association between weight-loss percentage and respiratory mortality was attenuated after BMI adjustment.

CONCLUSION

Both BMI and weight loss are predictors of cause-specific mortality in RA. Weight loss is a strong predictor of cardiovascular and cancer mortality, while underweight BMI is a stronger predictor of respiratory mortality.

Metabolic abnormalities in rheumatoid arthritis patients with comorbid diabetes mellitus

The metabolic characteristics of rheumatoid arthritis (RA) or diabetes mellitus (DM) have been studied, but the metabolic abnormalities of RA patients complicated with DM are not completely understood. Therefore, we recruited RA patients with DM to investigate the metabolic abnormalities in these patients. We collected data of RA patients with DM and age- and sex-matched RA and DM patients from Changhai Hospital's electronic medical record system. Data of demographically matched healthy controls were also collected from the health management system of the Hangzhou Sanatorium of People's Liberation Army. Blood pressure, uric acid, glucose, and lipid levels were compared. The clinical data of RA with DM (n = 104), DM (n = 100), and RA (n = 100) patients and healthy controls (n = 100) were collected and compared. RA patients with DM had higher blood pressure and lower high-density lipoprotein cholesterol levels than the other three groups, a higher triglycerides (TG) level than healthy controls and RA patients, and a lower TG level than DM patients. RA patients with DM exhibited a relatively high proportion of metabolic abnormalities based on existing standards. Our study examined metabolic abnormalities in RA patients with DM for the first time, and our results suggest that clinicians should pay more attention to the metabolic abnormalities of RA patients with DM.

Comparison of cardiovascular risk algorithms in patients with vs without rheumatoid arthritis and the role of C-reactive protein in predicting cardiovascular outcomes in rheumatoid arthritis

Objectives

The aims were to compare the performance of cardiovascular risk calculators, Framingham Risk Score (FRS) and QRISK2, in RA and matched non-RA patients and to evaluate whether their performance could be enhanced by the addition of CRP.

Methods

We conducted a retrospective analysis, using a clinical practice data set linked to Hospital Episode Statistics (HES) data from the UK. Patients presenting with at least one RA diagnosis code and no prior cardiovascular events were matched to non-RA patients using disease risk scores. The overall performance of the FRS and QRISK2 was compared between cohorts, and assessed with and without CRP in the RA cohort using C-Index, Akaike Information Criterion (AIC) and the net reclassification index (NRI).

Results

Four thousand seven hundred and eighty RA patients met the inclusion criteria and were followed for a mean of 3.8 years. The C-Index for the FRS in the non-RA and RA cohort was 0.783 and 0.754 (P < 0.001) and that of the QRISK2 was 0.770 and 0.744 (P < 0.001), respectively. Log[CRP] was positively associated with cardiovascular events, but improvements in the FRS and QRISK2 C-Indices as a result of inclusion of CRP were small, from 0.764 to 0.767 (P = 0.026) for FRS and from 0.764 to 0.765 (P = 0.250) for QRISK2. The NRI was 3.2% (95% CI: -2.8, 5.7%) for FRS and -2.0% (95% CI: -5.8, 4.5%) for QRISK2.

Conclusion

The C-Index for the FRS and QRISK2 was significantly better in the non-RA compared with RA patients. The addition of CRP in both equations was not associated with a significant improvement in reclassification based on NRI.

Association between antibodies to carbamylated proteins and subclinical atherosclerosis in rheumatoid arthritis patients

BACKGROUND

Rheumatoid arthritis (RA) patients carry a high risk of cardiovascular morbidity and mortality. The excess of cardiovascular disease cannot be entirely explained by traditional risk factors and the immune system contributes to the development of atherosclerosis. Moreover, post-translational modifications such as citrullination and carbamylation have been linked to inflammation and atherosclerosis. Anti-carbamylated proteins antibodies (anti-CarP) are a new subset of autoantibodies identified in RA patients. This study aimed to investigate a possible association between anti-CarP and subclinical atherosclerosis in RA patients.

METHODS

We enrolled RA patients and normal healthy controls (NHS) without known cardiovascular risk factors or heart disease. Cardiovascular risk was assessed using the Modified Systemic Coronary Risk Evaluation (mSCORE). Anti-CarP were investigated by a solid phase "home-made" ELISA. Anti-citrullinated protein antibodies (ACPA) and Rheumatoid Factor (RF) were investigated by ELISA assays. Subclinical atherosclerosis was evaluated by brachial artery Flow-Mediated Dilatation (FMD) and Carotid Intima-Media Thickness (c-IMT) while arterial stiffness by Ankle-Brachial Index (ABI) and Cardio-Ankle Vascular Index (CAVI).

RESULTS

We enrolled 50 RA patients (34 F and 16 M, mean age 58.4 ± 13.1 years, mean disease duration 127 ± 96.7 months) and 30 age and sex matched NHS. According to the mSCORE, 58% of patients had a low risk, 32% a moderate and 8% a high risk for cardiovascular disease. FMD was significantly lower in RA patients than in NHS (5.6 ± 3.2 vs 10.7 ± 8.1%; p < 0.004) and CAVIs significantly higher in a RA patients compared to NHS (left CAVI 8.9 ± 1.7 vs 8.1 ± 1.5; p < 0.04 for and right CAVI 8.8 ± 1.6 vs 8.0 ± 1.4; p < 0.04 for the). ABI and c-IMT did not differ between the two populations. The multivariate regression analysis showed a significant association of anti-CarP antibodies with FMD, left and right CAVI and both c-IMT (r = 1.6 and p = 0.05; r = 1.7 and p = 0.04; r = 2.9 and p = 0.05; r = 1.5 and p = 0.03; r = 1.1 and p = 0.03 respectively).

CONCLUSIONS

This study confirms that RA patients, without evidence of cardiovascular disease or traditional risk factors, have an impaired endothelial function. Moreover, we found an association with anti-CarP antibodies suggesting a possible contribution of these autoantibodies to endothelial dysfunction, the earliest stage of atherosclerosis. Besides ultrasound assessment, anti-CarP should be assessed in RA patients and considered an additional cardiovascular risk factor.

Lipid abnormalities in patients with Rheumatoid Arthritis

Objective:

To determine the frequency of dyslipidemia in patients with Rheumatoid Arthritis.

Methods:

This is a prospective, cross-sectional, observational study, conducted at the ‘Rheumatology Clinic’ of Jinnah Postgraduate Medical Center (JPMC), Karachi, from November 2013 to May 2014. A total of 200 patients of Rheumatoid Arthritis (RA), diagnosed according to the ACR/EULAR criteria 2010, were included in the study. Laboratory investigations including creatinine, ALT, CBC, TSH and fasting lipid profile (LDL, HDL, and Total cholesterol) were done for all patients.

Results:

Out of 200 patients, 23 (11.5%) were male and 177 (88.5%) were female. The mean age was 36.31±10.46 years and the mean duration of disease was 3.82±3.03 years. A total of 107 (53.5%) patients had dyslipidemia, and the commonest abnormality was a low HDL, seen in 83 (41.5 %) patients.

Conclusion:

Dyslipidemia was frequently observed in Rheumatoid Arthritis. This may be considered as a secondary impact of chronic inflammatory state, seen in RA. Lipid abnormalities should be sought at regular intervals, and corrective actions taken to mitigate increased cardiovascular disease risk.

Cardiovascular risk assessment in patients with rheumatoid arthritis: a correlative study of noninvasive arterial health testing

This study aimed to determine the relationship between noninvasive measures of arterial health and both estimated 10-year cardiovascular risk and measures of disease activity over time in established rheumatoid arthritis. Fifty rheumatoid arthritis patients underwent noninvasive arterial health testing (brachial artery reactivity, aortic augmentation index [AIx], pulse wave velocity, carotid artery intima-media thickness, and carotid artery plaque presence) and assessment of clinical disease activity (tender or swollen joint counts, Clinical Disease Activity Index [CDAI], and Health Assessment Questionnaire II [HAQ-II]). Clinical measures during 3 years before the study visit were averaged. Arterial health testing was compared with the American Heart Association/American College of Cardiology (AHA/ACC) Pooled Cohort Equation. Spearman methods identified correlations between disease activity measures, cardiac biomarkers, and arterial health parameters. Among the patients (mean age, 57.5 years), disease activity was moderate (mean [SD] CDAI, 16.9 [15.3]). At the study visit, corrected aortic augmentation index correlated with CDAI (r = 0.37, P = .009) and HAQ-II (r = 0.33, P = .02). AIx correlated with time-averaged tender joint count (r = 0.37, P = .008), CDAI (r = 0.36, P = .01), HAQ-II (r = 0.36, P = .01), swollen joint count (r = 0.36, P = .10), patient global assessment (r = 0.33, P = .02), physician global assessment (r = 0.35, P = .01), and pain score (r = 0.38, P = .007). The AHA/ACC low-risk group (<5% 10-year risk) had highest prevalence of carotid plaques. Arterial health testing may identify increased risk of cardiovascular disease compared with risk obtained through AHA/ACC Pooled Cohort Equation. Measures of arterial stiffness correlate with the burden of disease activity over time.

Efficacy of a Rheumatoid Arthritis-Specific Smoking Cessation Program: A Randomized Controlled Pilot Trial

OBJECTIVE

Smoking adversely influences comorbidities in rheumatoid arthritis (RA). The aim of this pilot study was to investigate whether smoking cessation is increased following a 3-month smoking cessation intervention tailored for people with RA.

METHODS

Thirty-nine current smokers with RA were recruited. Participants were randomized into the control group to receive the current local standard of care for smoking cessation (i.e., ABC = brief advice and subsidized nicotine replacement therapy [NRT], or into the intervention group to receive ABC plus additional smoking cessation advice for 3 months (ABC+), including face-to-face, telephone, and e-mail contact. Advice was tailored to the participants' specific needs from a range of intervention tools focused on education about smoking and RA, pain control, exercise, coping, and support. The primary outcome was smoking cessation at 6 months. The secondary outcome was sustained reduction in smoking at 6 months. Disease and psychosocial characteristics of quitters and nonquitters were examined.

RESULTS

The overall smoking cessation rate was 24%. There was no significant difference in smoking cessation rates between the ABC and ABC+ groups (21% versus 26%; P = 0.70). The mean number of cigarettes smoked daily was reduced by 44% (P < 0.001) but did not differ between ABC and ABC+ groups (mean reduction 47% versus 41%; P = 0.72). Successful quitters had more years in education and had smoked less across their lifetime, but these differences were not statistically significant.

CONCLUSION

Smoking cessation in RA may lead to a reduced comorbid burden. The lack of added benefit of the tailored intervention suggests that brief advice and NRT are currently the best practice for supporting people with RA who wish to quit smoking.

Gaps in Addressing Cardiovascular Risk in Rheumatoid Arthritis: Assessing Performance Using Cardiovascular Quality Indicators

OBJECTIVE

Cardiovascular disease (CVD) is a major comorbidity for patients with rheumatoid arthritis (RA). This study sought to determine the performance of 11 recently developed CVD quality indicators (QI) for RA in clinical practice.

METHODS

Medical charts for patients with RA (early disease or biologic-treated) followed at 1 center were retrospectively reviewed. A systematic assessment of adherence to 11 QI over a 2-year period was completed. Performance on the QI was reported as a percentage pass rate.

RESULTS

There were 170 charts reviewed (107 early disease and 63 biologic-treated). The most frequent CVD risk factors present at diagnosis (early disease) and biologic start (biologic-treated) included hypertension (26%), obesity (25%), smoking (21%), and dyslipidemia (15%). Performance on the CVD QI was highly variable. Areas of low performance (< 10% pass rates) included documentation of a formal CVD risk assessment, communication to the primary care physician (PCP) that patients with RA were at increased risk of CVD, body mass index documentation and counseling if overweight, communication to a PCP about an elevated blood pressure, and discussion of risks and benefits of antiinflammatories in patients at CVD risk. Rates of diabetes screening and lipid screening were 67% and 69%, respectively. The area of highest performance was observed for documentation of intent to taper corticosteroids (98%-100% for yrs 1 and 2, respectively).

CONCLUSION

Gaps in CVD risk management were found and highlight the need for quality improvements. Key targets for improvement include coordination of CVD care between rheumatology and primary care, and communication of increased CVD risk in RA.

Effects of tofacitinib and other DMARDs on lipid profiles in rheumatoid arthritis: implications for the rheumatologist

Cardiovascular (CV) morbidity and mortality are increased in patients with active, untreated rheumatoid arthritis (RA), despite lower levels of total and low-density lipoprotein cholesterol reported in individuals with active RA compared with those without RA. Alterations in non-traditional lipid assessments, such as high-density lipoprotein (HDL) function and HDL-associated proteins, have been described in patients with active RA, including elevated HDL-associated serum amyloid A and decreased paraoxonase-1 activity. We review changes in both traditional lipoprotein concentrations and non-traditional lipoprotein assessments in multiple studies of treatment with disease-modifying antirheumatic drugs (DMARDs), including non-biologic and biologic DMARDs and tofacitinib. In addition, data from a recently published clinical trial with tofacitinib that describe a potential mechanism for suppression of cholesterol levels in active RA patients are reviewed. Finally, CV event data from various studies of DMARDs are presented, and the current management of RA patients with regard to the CV risk is reviewed.

The specialist physician's approach to rheumatoid arthritis in South Africa

Rheumatoid arthritis (RA) is expected to increase in Africa and South Africa. Due to the low numbers of rheumatologists in South Africa, specialist physicians also have to care for patients with RA. Furthermore several new developments have taken place in recent years which improved the management and outcome of RA. Classification criteria were updated, assessment follow-up tools were refined and above all, several new biological disease-modifying anti-rheumatic drugs were developed. Therefore it is imperative for specialist physicians to update themselves with the newest developments in the management of RA. This article provides an overview of the newest developments in the management of RA in the South African context. This approach may well apply to countries with similar specialist to patient ratios and disease profiles.

Cardiovascular risk factor management in patients with RA compared to matched non-RA patients

Objective. RA is associated with a 50–60% increase in risk of cardiovascular (CV) death. This study aimed to compare management of CV risk factors in RA and matched non-RA patients.

Methods. A retrospective cohort study was conducted using UK clinical practice data. Patients presenting with an incident RA diagnosis were matched 1:4 to non-RA patients based on a propensity score for RA, entry year, CV risk category and treatment received at index date (date of RA diagnosis). Patients tested and treated for CV risk factors as well as those attaining CV risk factor management goals were evaluated in both groups.

Results. Between 1987 and 2010, 24 859 RA patients were identified and matched to 87 304 non-RA patients. At index date, groups had similar baseline characteristics. Annual blood pressure, lipids and diabetes-related testing were similar in both groups, although CRP and ESR were higher in RA patients at diagnosis and decreased over time. RA patients prescribed antihypertensives increased from 38.2% at diagnosis to 45.7% at 5 years, from 14.0 to 20.6% for lipid-lowering treatments and from 5.1 to 6.4% for antidiabetics. Similar treatment percentages were observed in non-RA patients, although slightly lower for antihypertensives. Modest (2%) but significantly lower attainment of lipid and diabetes goals at 1 year was observed in RA patients.

Conclusion. There were no differences between groups in the frequency of testing and treatment of CV risk factors. Higher CV risk in RA patients seems unlikely to be driven by differences in traditional CV risk factor management.

The interplay between inflammation and metabolism in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by extensive synovitis resulting in erosions of articular cartilage and marginal bone that lead to joint destruction. The autoimmune process in RA depends on the activation of immune cells, which use intracellular kinases to respond to external stimuli such as cytokines, immune complexes, and antigens. An intricate cytokine network participates in inflammation and in perpetuation of disease by positive feedback loops promoting systemic disorder. The widespread systemic effects mediated by pro-inflammatory cytokines in RA impact on metabolism and in particular in lymphocyte metabolism. Moreover, RA pathobiology seems to share some common pathways with atherosclerosis, including endothelial dysfunction that is related to underlying chronic inflammation. The extent of the metabolic changes and the types of metabolites seen may be good markers of cytokine-mediated inflammatory processes in RA. Altered metabolic fingerprints may be useful in predicting the development of RA in patients with early arthritis as well as in the evaluation of the treatment response. Evidence supports the role of metabolomic analysis as a novel and nontargeted approach for identifying potential biomarkers and for improving the clinical and therapeutical management of patients with chronic inflammatory diseases. Here, we review the metabolic changes occurring in the pathogenesis of RA as well as the implication of the metabolic features in the treatment response.

Cardiovascular risk profile at the onset of psoriatic arthritis: a population-based cohort study

OBJECTIVE

The role of cardiovascular disease (CVD) risk factors in psoriatic arthritis (PsA) is poorly understood. We examined the prevalence of CVD risk factors at initial onset of PsA and compared the observed incidence of CVD events with that predicted by the Framingham Risk Score (FRS) to determine its applicability in this patient population.

METHODS

A population-based incidence cohort of 158 patients with PsA who fulfilled Classification of Psoriatic Arthritis criteria for PsA in 1989-2008 was assembled. Medical records were reviewed to ascertain CVD risk factors and CVD events. Future risk of CVD was estimated using the FRS algorithm.

RESULTS

Mean age was 43.4 years (range 19-74 years), 61% were men, and 44% were obese (body mass index ≥30 kg/m(2) ). Fifty-four patients (34%) presented with ≥2 CVD risk factors at PsA incidence. Among 126 patients ages ≥30 years at PsA incidence with no prior history of CVD, 33% had an FRS ≥10%, with 11% having an FRS ≥20%, and 18 experienced a CVD event in the first 10 years of disease duration. The 10-year cumulative incidence of CVD events was 17% (95% confidence interval [95% CI] 10%-24%), almost twice as high as the predicted incidence based on the FRS (standardized incidence ratio 1.80, 95% CI 1.14-2.86; P = 0.012).

CONCLUSION

The majority of newly diagnosed PsA patients have a >10% risk of CVD within 10 years of PsA incidence. The CVD risk in these patients is higher than expected and underestimated by the FRS.

Republished: The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis

OBJECTIVE

To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients.

METHODS

We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes.

RESULTS

We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS.

CONCLUSIONS

This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.

Identifying barriers to smoking cessation in rheumatoid arthritis

OBJECTIVE

The aim of this study was to investigate disease-related issues that make smoking cessation challenging for patients with rheumatoid arthritis (RA). There is currently a lack of research on tailoring smoking cessation interventions for RA patients. Qualitative exploration is a necessary first step in planning targeted interventions.

METHODS

A qualitative mixed-methods study was undertaken. Participants attended either a focus group or an individual interview and completed a set of standardized questionnaires. The sample consisted of 36 RA patients: 24 current smokers and 12 ex-smokers. The transcripts were analyzed thematically using a critical realist approach to inductively identify themes.

RESULTS

Five key barriers to smoking cessation that are faced by RA patients were identified. First, participants were unaware of the relationship between smoking and RA and therefore did not perceive this as a reason to quit. Second, smoking was used as a distraction from pain. Third, participants found it difficult to exercise and therefore were unable to use exercise as an alternative distraction. Fourth, smoking was used as a coping mechanism for the frustrations of living with RA. Fifth, participants felt unsupported and isolated from other RA patients.

CONCLUSION

Disease-related issues may hinder smoking cessation for RA patients. Through an understanding of patients' perspectives there is an opportunity to plan an effective targeted intervention that may increase the chance of smoking cessation in RA patients where smoking may adversely influence disease progression and comorbidities.

The impact of traditional cardiovascular risk factors on cardiovascular outcomes in patients with rheumatoid arthritis: a systematic review and meta-analysis

Background

Rheumatoid arthritis (RA) is known to increase the risk of cardiovascular (CV) disease. However, the individual impact of traditional CV risk factors in RA is unknown.

Objective

To assess the strength of the association between individual CV risk factors and rate of either myocardial infarction (MI), combined CV morbidity (MI, angina pectoris, heart failure, stroke, and peripheral arterial disease (PAD)) or CV mortality in RA patients.

Methods

RA studies reporting traditional CV risk factors [hypertension, type 2 diabetes (T2D), smoking, hypercholesterolaemia, obesity, and physical inactivity] as exposures and MI, CV morbidity (MI, angina, heart failure, stroke, and PAD combined) or CV mortality alone as outcomes were searched until March 2013 using MEDLINE, Scopus and Cochrane. Meta-analyses combined relative risk (RR) estimates from each study where either the RR and 95% confidence intervals or where raw counts were available.

Results

Ten studies reporting sufficient data for inclusion into meta-analyses were identified. Relevant data was available for each risk factor and MI and CV morbidity but no studies reported on CV mortality. Risk of MI increased in RA patients with hypertension (RR 1.84, 95% CI 1.38, 2.46) and T2D (RR 1.89, 95% CI 1.36, 2.63). CV morbidity increased with hypertension (RR 2.24, 95% CI 1.42, 3.06), T2D (RR 1.94, 95% CI 1.58, 2.30), smoking (RR 1.50, 95% CI 1.15, 1.84), hypercholesterolaemia (RR 1.73, 95% CI 1.03, 2.44) and obesity (RR 1.16, 95% CI 1.03, 1.29) but not with physical inactivity (RR 1.00, 95% CI 0.71, 1.29).

Conclusion

Hypertension, T2D, smoking, hypercholesterolaemia and obesity increased CV risk in patients with RA. These results highlight the importance of managing CV risk factors in RA, similarly to non-RA patients.

Epicardial fat thickness as cardiovascular risk factor and therapeutic target in patients with rheumatoid arthritis treated with biological and nonbiological therapies

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with high cardiovascular morbidity and mortality. Epicardial adipose tissue (EAT) thickness may act as a therapeutic target during treatments with drugs modulating the adipose tissue. We evaluate EAT thickness in RA patients treated with biological and nonbiological disease-modifying antirheumatic drugs (DMARDs). A cross-sectional study was conducted with a cohort of 34 female RA patients and 16 controls matched for age and body mass index (BMI). Plasma glucose, basal insulin, plasma lipids, and high-sensitivity C-reactive protein (hs-CRP) were assessed. EAT thickness and left ventricular mass (LVM) were measured by echocardiography. No significant differences in waist circumference (WC), blood pressure, fasting blood glucose, basal insulin, and lipid parameters were found between the groups. The control group showed lower concentrations (P = 0.033) of hs-CRP and LVM (P = 0.0001) than those of the two RA groups. Patients treated with TNF-α inhibitors showed significantly lower EAT thickness than those treated with nonbiological DMARDs (8.56 ± 1.90 mm versus 9.71 ± 1.45 mm; P = 0.04). Women with no RA revealed reduced EAT thickness (5.39 ± 1.52 mm) as compared to all RA patients (P = 0.001). Results suggest that RA patients have greater EAT thickness than controls regardless of BMI and WC.

Total calcium-sensing receptor expression in circulating monocytes is increased in rheumatoid arthritis patients with severe coronary artery calcification

Introduction

Human circulating monocytes express the calcium-sensing receptor (CaSR) and are involved in atherosclerosis. This study investigated the potential association between vascular calcification in rheumatoid arthritis (RA) and CaSR expression in circulating monocytes.

Methods

In this cross-sectional study, 50 RA patients were compared to 25 control subjects matched for age and gender. Isolation of peripheral blood mononuclear cells and flow cytometry analysis were performed to study the surface and total CaSR expression in circulating monocytes. Coronary artery calcium (CAC) and abdominal aortic calcification (AAC) scores were evaluated by computed tomography and an association between these scores and the surface and/or total CaSR expression in circulating monocytes in RA patients was investigated.

Results

The two groups were similar in terms of age (RA: 60.9 ± 8.3 years, versus controls: 59.6 ± 5.3 years) and gender (RA: 74.0% females versus 72.0% females). We did not find a higher prevalence and greater burden of CAC or AAC in RA patients versus age- and gender-matched controls. When compared with control subjects, RA patients did not exhibit greater total CaSR (101.6% ± 28.8 vs. 99.9% ± 22.0) or surface CaSR (104.6% ± 20.4 vs. 99.9% ± 13.7) expression, but total CaSR expression in circulating monocytes was significantly higher in RA patients with severe CAC (Agatston score ≥200, n = 11) than in patients with mild-to-moderate CAC (1 to 199, n = 21) (P = 0.01).

Conclusions

This study demonstrates for the first time that total CaSR expression in human circulating monocytes is increased in RA patients with severe coronary artery calcification.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis

OBJECTIVE

To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients.

METHODS

We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes.

RESULTS

We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS.

CONCLUSIONS

This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.

The -308 G/A polymorphism in the tumor necrosis factor-α gene is not associated with development and progression of rheumatoid arthritis in Argentinean patients

AIM

A polymorphism in the tumor necrosis factor-alpha (TNF-α) promoter region has been associated with disease susceptibility and progression in rheumatoid arthritis (RA). The presence of an adenosine (TNF2 allele) instead of a guanine (TNF1 allele) at position -308 may be responsible for a general increase in the transcriptional activity of the TNF-α gene. Our aim was to evaluate the association of the TNF2 allele with the risk of disease development and/or progression of RA in an Argentine population cohort.

METHODS

Two hundred and twenty-three consecutive patients with RA according to the 1987 criteria of the American College of Rheumatology were included in the study. Clinical variables, Disease Activity Score 28, Health Assessment Questionnaire and Rheumatoid Arthritis Quality of Life were recorded. The radiographic erosions were determined by the method of Sharp/van der Heijde. A group of 111 healthy subjects matched by sex and age was used as a control. All samples were genotyped for the -308 G/A TNF-α polymorphism.

RESULTS

No significant differences were observed either in the frequency of the TNF2 allele or in the genotypic distributions of the -308 G/A TNF-α polymorphism (P > 0.05) between the control group and the RA patients. No association was found between the TNF2 allele and the variables related to the course and outcome of the disease (P > 0.05).

CONCLUSION

In this cohort of Argentinean patients with RA, the TNF2 allele was neither associated with susceptibility to the disease nor was it associated with the variables related to the course and outcome of the disease.

Retinol binding protein 4 concentrations relate to enhanced atherosclerosis in obese patients with rheumatoid arthritis

Background

Retinol binding protein 4 (RBP) enhances metabolic risk and atherogenesis. Whether RBP4 contributes to cardiovascular risk in rheumatoid arthritis (RA) is unknown.

Methods

We assessed RBP4 concentrations and those of endothelial activation molecules including E-selectin, vascular cell adhesion molecule-1, intercellular adhesion molecule-1 and monocyte chemoattractant protein-1 by ELISA, and the common carotid artery intima-media thickness (cIMT) and carotid artery plaque by ultrasound in 217 (112 black and 105 white) patients with RA. Relationships were identified in potential confounder and mediator adjusted mixed regression models.

Results

RBP4 concentrations were associated with systolic and mean blood pressure, and those of glucose and E-selectin (partial R = −0.207 (p = 0.003), −0.195 (p = 0.006), −0.155 (p = 0.03) and −0.191 (p = 0.007), respectively in all patients); these RBP4-cardiovascular risk relations were mostly reproduced in patients with but not without adverse traditional or non-traditional cardiovascular risk profiles. RBP4 concentrations were not associated with atherosclerosis in all patients, but related independently to cIMT (partial R = 0.297, p = 0.03) and plaque (OR (95%CI) = 2.95 (1.31–6.68), p = 0.008) in those with generalized obesity, as well as with plaque in those with abdominal obesity (OR (95%CI) = 1.95 (1.12–3.42), p = 0.01).

Conclusion

In the present study, RBP4 concentrations were inversely associated with metabolic risk and endothelial activation in RA. This requires further investigation. RBP4 concentrations were related to enhanced atherosclerosis in patients with generalized or/and abdominal obesity.

The role of rheumatologists vis-à-vis assessment of traditional cardiovascular risk factors in rheumatoid arthritis

This study was designed to estimate the burden of care that would be placed on rheumatologists to undertake cardiovascular (CV) risk assessment of traditional CV risk factors in their patients. This cross-sectional study was set in a rheumatology ambulatory clinic of a tertiary care, university hospital. Consecutive rheumatoid arthritis (RA) patients were recruited over 6 weeks and matched 1:1 on age and sex to patients with non-inflammatory problems who presented to the same clinic. CV risk was calculated using the Framingham Risk Score. We recruited 68 RA patients and 64 controls. The distribution of CV risk factors in RA patients and controls was similar. Ten-year Framingham CV risk scores based on traditional risk factors were moderate and similar in RA patients and controls (13.7 and 14.3%, respectively). Nevertheless, the proportion of RA patients with a history of coronary artery disease was more than twice that of controls (13 versus 5%, respectively). Approximately 20% of RA patients and controls did not have a primary care physician. In rheumatology practice, the problem of elevated CV risk due to traditional risk factors is not unique to RA patients. The burden for rheumatologists of undertaking CV risk assessment in their clinic could be considerable. Rheumatologists should manage inflammatory disease and health services should be improved to ensure the optimal management of traditional CV risk factors for all rheumatology patients.