Risk factors for cardiovascular disease and endothelin-1 levels in Takayasu arteritis patients

Hyperhomocysteinemia in Takayasu arteritis-genetically defined or burden of the proinflammatory state?

Takayasu arteritis (TAK) is associated with high plasma homocysteine (Hcy) and elevated Hcy predicts ischemic events. Thus, this study aims to compare the frequency of single-nucleotide polymorphisms (SNPs) of genes involved in Hcy metabolism between TAK and controls and analyze associations with Hcy levels, TAK features, and acute ischemic arterial events (AIAEs). A cross-sectional study was performed with 73 TAK patients and 71 controls. SNPs of genes involved in the Hcy metabolism, plasma Hcy, and risk factors were analyzed for hyperhomocysteinemia (HHcy), cardiovascular disease (CVD), and AIAEs. Patients presented a higher frequency of risk factors for CVD and HHcy. At least one AIAE was observed in 27 (37.0%) patients and one control. The frequency of the SNPs was similar between both groups, and there was no association between SNP carriage and AIAEs. TAK patients presented higher Hcy levels than controls (13.9 ± 5.6 µmol/L vs. 8.6 ± 4.0 µmol/L; p < 0.001), and patients carrying MTHFR677TT presented higher Hcy levels than those carrying MTHFR677CT (20.4 ± 7.8 µmol/L vs. 13.7 ± 5.2 µmol/L; p = 0.02) or MTHFR677CC (20.4 ± 7.8 µmol/L vs. 13.1 ± 4.7 µmol/L; p = 0.009). TAK was an independent risk factor for HHcy [odds ratio (OR) = 10.20; 95% confidence interval (95% CI): 4.16-25.00; p < 0.001], and in TAK, thiazide diuretic use was a risk factor for HHcy (OR = 11.61; 95% CI: 1.63-82.63; p < 0.01). In conclusion, TAK was a risk factor for HHcy but not related to SNPs in genes encoding Hcy metabolism enzymes. The burden of chronic inflammation and thiazide diuretics contribute to HHcy in TAK.

Physical Exercise in Managing Takayasu Arteritis Patients Complicated With Cardiovascular Diseases

Takayasu arteritis (TA) is a kind of large-vessel vasculitis that mainly affects the aorta and its branches, and the patients are usually women at a relatively young age. The chronic inflammation of arteries in TA patients leads to stenosis, occlusion, dilatation, or aneurysm formation. Patients with TA thereby have a high risk of cardiovascular disease (CVD) complications, which are the most common cause of mortality. This review summarizes the main cardiovascular complications and the risk factors of cardiovascular complications in patients with TA. Here, we discuss the benefits and potential risks of physical exercise in patients with TA and give recommendations about exercise prescription for TA patients to decrease the risks of CVD and facilitate rehabilitation of cardiovascular complications, which might maximally improve the outcomes.

Disease-specific factors associated with cardiovascular events in patients with Takayasu arteritis

Background

To identify disease-specific factors associated with cardiovascular events in patients with Takayasu arteritis (TAK).

Methods

Patients with TAK who fulfilled the American College of Rheumatology 1990 criteria for the classification of TAK and were followed up between 2006 and 2019 were included. Traditional cardiovascular risk factors and TAK disease-specific factors at the index date and incident cardiovascular events during the follow-up were retrospectively assessed. To estimate the risk of cardiovascular events according to TAK disease-specific factors, Cox regression analysis with adjustment for traditional cardiovascular risk factors was performed.

Results

Of the total 207 patients with TAK, cardiovascular events occurred in 41 (19.8%) patients. Compared with patients who did not develop cardiovascular events, patients who developed cardiovascular events were older (38.5 ± 13.4 years vs. 43.6 ± 11.8 years, p = 0.028), more commonly had diabetes mellitus (6.6% vs. 19.5%, p = 0.029), had lower high-density lipoprotein cholesterol (57.3 ± 17.1 mg/dl vs. 51.2 ± 15.7 mg/dl, p = 0.040), more commonly had type V vascular involvement (33.1% vs. 63.4%, p 0.001), and less commonly received methotrexate (65.1% vs. 43.9%, p = 0.013). In Cox regression analysis, type V vascular involvement was significantly associated with increased risk of cardiovascular events (adjusted HR 2.852, 95% CI 1.474–5.518, p = 0.002), whereas the use of methotrexate was associated with reduced risk of cardiovascular events (adjusted HR 0.515, 95% CI 0.268–0.993, p = 0.047).

Conclusion

Type V vascular involvement was associated with increased risk of cardiovascular events, while the use of methotrexate was associated with reduced risk of cardiovascular events, in patients with TAK.

Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis

Objective

To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.

Methods

Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).

Results

A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.

Conclusions

Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.

Takayasu arteritis - epidemiology, pathogenesis, diagnosis and treatment

Takayasu disease belongs to the group of autoimmune vasculitis which most often affects the aorta and its branches. It is rare, and it mainly affects young women. Recent epidemiologic studies suggest that Takayasu arteritis is being increasingly recognized in Europe. The first symptoms are non-specific and an early diagnosis is difficult and requires clinical awareness and suspicion. Patients with Takayasu arteritis often present increased inflammatory markers, including C-reactive protein and erythrocyte sedimentation rate, but systemic inflammatory response does not always show a positive correlation with inflammatory activity in the vessel wall. Therefore, imaging studies play a principal role in diagnosis and control of the disease. Glucocorticoids remain the most effective and serve as a cornerstone first line treatment. Immunosuppressive drugs play an important role as well, and biological therapy is increasingly being included in the treatment. This article describes the epidemiology, pathophysiology, diagnostics and treatment of this rare disease, so as to alert clinicians because disease left untreated can lead to narrowing and even closure of vital blood vessels. The most common Takayasu arteritis complications include pulmonary thrombosis, aortic regurgitation, congestive heart failure, cerebrovascular events, vision degeneration or blindness, and hearing problems.

Endothelial progenitor cells and vascular endothelial growth factor in patients with Takayasu's arteritis

BACKGROUND

Endothelial progenitor cells (EPCs) are responsible for endothelial damage repair. Takayasu's arteritis (TA) is a chronic inflammatory disease that affects large vessels. The aim of the study was to evaluate the number of EPCs and the levels of vascular endothelial growth factor (VEGF) and the relationship of these variables in patients with TA.

METHODS

Thirty women with TA and 30 healthy controls were included. EPCs were assessed by flow cytometry and cell culture and VEGF quantification was performed by commercial ELISA kits.

RESULTS

Ages of patients and controls were similar. The number of EPCs in patients and controls (median (interquartile range) were 0.0073% (0.0081%) vs. 0.0062% (0.0089%), p = 0.779 by flow cytometry and 27.0 (42.3) colony forming units (CFUs) vs. 27.0 (20.5) CFUs, p = 0.473 by cells culture, respectively. VEGF levels in patients and controls was 274.5 (395.5) pg/ml vs. 243.5 (255.3) pg/ml, p = 0.460. There was no difference in the number of EPCs and VEGF level between patients with active and inactive disease. There was a tendency of the number of angioblast-like EPCs in patients taking anti-TNFs to be higher; and in patients using methotrexate to be lower.

CONCLUSION

No significant difference was found in the quantification of EPCs and VEGF levels in TA patients compared to controls, and no difference was observed between patients with active and inactive disease.

Assessment of the frequency of cardiovascular risk factors in patients with Takayasu's arteritis

Objectives

The prevalence of atherosclerotic risk factors and disease in Takayasu's arteritis (TAK) has not been well defined. We aimed to assess the frequency of cardiovascular (CV) risk factors and the incidence of CV events (CVEs) in patients with TAK from two ethnically different populations.

Methods

Patients with TAK followed at Mayo Clinic, Rochester, MN, USA and Marmara University, Istanbul, Turkey were included in this retrospective study. Patients with TAK were compared with age-, sex- and calendar year-matched controls from the same geographical region without TAK. The 2008 Framingham 10-year general CV risk score (FRS) was used for the evaluation of CV risk at the time of TAK incidence/index date.

Results

In total, 191 patients with TAK and 191 non-TAK controls were included. Hypertension and the prevalence of lipid-lowering treatments were significantly more frequent in TAK. Prior to the incidence/index date, occurrence of CVE was significantly higher in TAK. The FRS was significantly higher in TAK compared with non-TAK at incidence/index date. The cumulative incidence of CVE was 15.4% at 10 years in TAK vs 5.8% in non-TAK; the risk of CVE was increased among patients with TAK (hazard ratio = 4.36; 95% CI: 1.25, 15.13).

Conclusion

CV risk factors are more common in patients with TAK, particularly hypertension. The FRS is higher in patients with TAK at the time of diagnosis. The cumulative incidence of CVE was also significantly higher during follow-up in TAK. Our results suggest that patients with TAK should undergo careful assessment of CV risk factors, and an aggressive risk modification approach is warranted.

Inflammatory response and endothelial dysfunction in the hearts of mice co-exposed to SO2 , NO2 , and PM2.5

SO2 , NO2 , and PM2.5 are typical air pollutants produced during the combustion of coal. Increasing evidence indicates that air pollution has contributed to the development and progression of heart-related diseases over the past decades. However, little experimental data and few studies of SO2 , NO2 , and PM2.5 co-exposure in animals exist; therefore, the relevant mechanisms underlying this phenomenon are unclear. An important characteristic of air pollution is that co-exposure persists at a low concentration throughout a lifetime. In the present study, we treated adult mice with SO2 , NO2 , and PM2.5 at various concentrations (0.5 mg/m3 SO2 , 0.2 mg/m3 NO2 6 h/d, with intranasal instillation of 1 mg/kg PM2.5 every other day during these exposures; or 3.5 mg/m3 SO2 , 2 mg/m3 NO2 6 h/d, and 10 mg/kg PM2.5 for 28 d). Blood pressure (BP), heart rate (HR), histopathological damage, and inflammatory and endothelial cytokines in the heart were assessed. The results indicate that co-exposure caused endothelial dysfunction by elevating endothelin-1 (ET-1) expression and repressing the endothelial nitric oxide synthase (eNOS) level as well as stimulating the inflammatory response by increasing the levels of cyclooxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). Additionally, these alterations were confirmed by histological staining. Furthermore, we observed decreased BP and increased HR after co-exposure. Our results indicate that co-exposure to SO2 , NO2 , and PM2.5 may be a major risk factor for cardiac disease and may induce injury to the hearts of mammals and contribute to heart disease. © 2015 Wiley Periodicals, Inc. Environ Toxicol 31: 1996-2005, 2016.

Outcome assessment in Takayasu arteritis

Takayasu arteritis (TAK) is a systemic granulomatous large-vessel vasculitis with a phenotype that overlaps with GCA and defined by the 1993 and 2012 Chapel Hill Consensus Conference statements. However, the diagnosis of TAK is often delayed since TAK patients may be asymptomatic or have non-specific symptoms. Once a diagnosis is made, it is difficult to judge remission or recurrence since there are no reliable assessment tools. With the availability of newer agents, such as cytokine blockade, which are being evaluated in GCA, there is the potential for real advances in TAK patient management. Without reliable assessment tools it will be difficult to introduce newer agents in an organized way or to optimally benefit patients in the future. In this article we review the use and performance of disease indicators in TAK clinical trials as a basis for the further development of assessment tools for this disease.

Takayasu Arteritis-associated Pulmonary Hypertension

Objective.

To investigate the probable pathogenesis, clinical features, diagnosis, and therapy of patients with pulmonary hypertension (PH) in Takayasu arteritis (TA).

Methods.

A total of 48 patients with TA who had PH, 20 patients with TA who had pulmonary arterial involvement (PA) without PH, and 30 patients with idiopathic pulmonary arterial hypertension (IPAH) were enrolled in the study from 2009 to 2013.

Results.

Among the 48 patients with TA who had PH, 36 (75.0%) had PA, and left heart disease (LHD) was present in 12 (25.0%). Serum levels of big endothelin 1 (ET-1) were independently correlated with pulmonary arterial systolic pressure (r = 0.33, p = 0.04). Compared to patients with IPAH, patients with PH because of PA who underwent right heart catheterization had lower average cardiac indexes (2.0 ± 0.5 vs 3.0 ± 1.2 l/min/m2, p = 0.05), and they all developed favorable responses to acute vasodilator testing (100%) in comparison to 10 of the patients with IPAH (33.3%). During a mean followup of 36.0 ± 13.2 months (12.0–65.0 mos), of the patients with PH associated with PA, 3 died of heart failure. Six patients who underwent pulmonary artery revascularization were found to have good prognoses after followup for a mean duration of 6.2 ± 1.9 months. Additionally, 12 patients with PH with LHD were followed for 38.4 ± 15.6 months (12.0–60.0 mos), and 1 patient died of heart failure during the followup period.

Conclusion.

Patients with TA are at increased risk for PH. Early screening of patients with TA with unexplained symptoms related to PH should be applied. PH-specific therapies or revascularization may be effective treatments in the early stages of patients with PA, PH, and severe pulmonary artery stenosis.

Takayasu arteritis: diagnosis, treatment and prognosis

Takayasu arteritis (TA) is a chronic nonspecific granulomatous vasculitis affecting aorta and its main branches, coronary and pulmonary arteries. TA often occurs in young women and has a characteristic heterogeneity depending on ethnicity and geographical location. Although the pathogenesis of TA remains unclear, the interaction of many factors, such as autoimmunity, inflammation, genetic and environmental factors and so on, is involved in the occurrence and development of TA. Angiography, which is recognized as the gold standard in evaluating vascular lesions in TA, combined with computer tomography angiography (CTA), magnetic resonance angiography (MRA), ultrasonography, (18)Fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) could not only provide important information for early diagnosis but also detect disease activity, and thus further guide the treatment in TA. In addition, beside the commonly used corticosteroids, immunosuppressive agents, percutaneous transluminal angioplasty (PTA) and surgical revascularization, anti-tumor necrosis factor (TNF) agent has been more widely used in refractory cases of TA. The objective of this review is to systemically describe the pathogenesis, clinical characteristics, diagnosis, treatment and prognosis of TA.

Particulate matter (PM10) exposure induces endothelial dysfunction and inflammation in rat brain

Epidemiological studies suggest that particulate matter (PM(10)) inhalation was associated with adverse effects on brain-related health, however, existing experimental data lacked relevant evidences. In this study, we treated Wistar rats with PM(10) at different concentrations (0.3, 1, 3 and 10 mg/kg body weight (bw)), and investigated endothelial dysfunction and inflammatory responses in the brain. The results indicate that mild pathological abnormal occurred after 15-day exposure (five times with 3 days each), followed by the changes of endothelial mediators (ET-1 and eNOS) and inflammatory markers (IL-1β, TNF-α, COX-2, iNOS and ICAM-1). Also, the sample up-regulated bax/bcl-2 ratio and p53 expression, and induced neuronal apoptosis. It implicates that PM(10) exerted injuries to mammals' brain, and the mechanisms might be involved in endothelial dysfunction and inflammatory responses.

Pathogenesis of Takayasu's arteritis: a 2011 update

While our knowledge of the pathogenesis of Takayasu's arteritis (TA) has considerably improved during the last decade, the exact pathogenic sequence remains to be elucidated. It is now hypothesised that an unknown stimulus triggers the expression of the 65kDa Heat-shock protein in the aortic tissue which, in turn, induces the Major Histocompatibility Class I Chain-Related A (MICA) on vascular cells. The γδ T cells and NK cells expressing NKG2D receptors recognize MICA on vascular smooth muscle cells and release perforin, resulting in acute vascular inflammation. Pro-inflammatory cytokines are released and increase the recruitment of mononuclear cells within the vascular wall. T cells infiltrate and recognize one or a few antigens presented by a shared epitope, which is associated with specific major Histocompatibility Complex alleles on the dendritic cells, these latter being activated through Toll-like receptors. Th1 lymphocytes drive the formation of giant cells through the production of interferon-γ, and activate macrophages with release of VEGF resulting in increased neovascularisation and PDGF, resulting in smooth muscle migration and intimal proliferation. Th17 cells induced by the IL-23 microenvironnement also contribute to vascular lesions through activation of infiltrating neutrophils. Although still controversial, dendritic cells may cooperate with B lymphocytes and trigger the production of anti-endothelial cell auto-antibodies resulting in complement-dependent cytotoxicity against endothelial cells. In a near future, novel drugs specifically designed to target some of the pathogenic mechanisms described above could be expanding the physician's therapeutic arsenal in Takayasu's arteritis.

Development of outcome measures for large-vessel vasculitis for use in clinical trials: opportunities, challenges, and research agenda

Giant cell (GCA) and Takayasu's arteritis (TAK) are 2 forms of large-vessel vasculitis (LVV) that involve the aorta and its major branches. GCA has a predilection for the cranial branches, while TAK tends to affect the extracranial branches. Both disorders may also cause nonspecific constitutional symptoms. Although some clinical features are more common in one or the other disorder and the ages of initial presentation differ substantially, there is enough clinical and histopathologic overlap between these disorders that some investigators suggest GCA and TAK may be 2 processes within the spectrum of a single disease. There have been few randomized therapeutic trials completed in GCA, and none in TAK. The lack of therapeutic trials in LVV is only partially explained by the rarity of these diseases. It is likely that the lack of well validated outcome measures for LVV and uncertainties regarding trial design contribute to the paucity of trials for these diseases. An initiative to develop a core set of outcome measures for use in clinical trials of LVV was launched by the international OMERACT Vasculitis Working Group in 2009 and subsequently endorsed by the OMERACT community at the OMERACT 10 meeting. Aims of this initiative include: (1) to review the literature and existing data related to outcome assessments in LVV; (2) to obtain the opinion of experts and patients on disease content; and (3) to formulate a research agenda to facilitate a more data-based approach to outcomes development.

Oxidative stress, endothelial dysfunction and inflammatory response in rat heart to NO₂ inhalation exposure

Epidemiological studies suggest that NO₂ inhalation is associated with adverse effects on heart-related health, however, existing experimental data lack relevant evidences. In this study, a role for oxidative stress, endothelial dysfunction and inflammatory responses in the heart of rats treated with different concentrations of NO₂ (0, 5, 10 and 20 mg m⁻³) was investigated. Mild heart pathology occurred after 7-d exposure (6 h d⁻¹). Marked oxidative stress were induced as evaluated by reduction/induction of antioxidants (Cu/Zn-SOD, Mn-SOD and GPx) activity and increasing formation of MDA and PCO. Also, mRNA and protein biomarkers of vasoconstriction (ET-1, eNOS) and inflammation (TNF-α, IL-1β and ICAM-1) were up-regulated, and p53 mRNA expression, bax/bcl-2 ratio and the mean number of TUNEL-positive myocytes were increased as well. All the results implicate that NO₂ exerted injuries to mammals' heart, and the damage mechanisms were possibly associated with oxidative stress, endothelial dysfunction and inflammation.

Antiplatelet therapy for the prevention of arterial ischemic events in takayasu arteritis

BACKGROUND

Vessel wall inflammation, atherosclerosis and hypercoagulability may be responsible for ischemic events in Takayasu arteritis (TA). No study has evaluated the effect of antiplatelet therapy for the prevention of ischemic events in TA.

METHODS AND RESULTS

Forty-eight patients who met the ACR Classification Criteria for TA under follow-up at the Vasculitis Unit of Universidade Federal de São Paulo were evaluated retrospectively for clinical manifestations, therapy and arterial ischemic events. The mean age at study was 38.0 years and the mean age at TA diagnosis was 29.1 years. Women comprised for 89.6% of patients and 60.4% were Caucasian. Risk factors for cardiovascular disease were found in 44 patients (91.7%) The most common comorbidities for TA patients were hypertension (77.1%), high low-density lipoprotein (45.8%) and obesity (16.7%). Antiplatelet therapy was used by 62.5% of patients whereas anticoagulants were used by 12.5%. Acute ischemic events occurred in 29.2% of patients. TA patients with ischemic events used significantly less antiplatelet agents (14.3%) than those without ischemic events (82.4%), P<0.0001. No difference concerning ischemic events was observed in patients on anticoagulant therapy (P=0.339). The 3 deaths of TA patients were observed only in those who had presented ischemic events (P=0.021). Antiplatelet agents had a protective effect against ischemic events (hazard ratio =0.055, 95% confidence interval: 0.06-0.514; P=0.011).

CONCLUSIONS

Antiplatelet therapy is associated with a lower frequency of ischemic events in patients with TA.

Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients

We conducted a single-center retrospective study to compare the characteristics of Takayasu arteritis (TA) among white, North African, and black patients in a French tertiary care center (Hospital Pitié-Salpêtrière, Paris). Eighty-two patients were studied (82.9% female) during a median follow-up of 5.1 years (range, 1 mo to 30 yr). Among these 82 patients, 39 (47.6%) were white, 20 (24.4%) were North African, and 20 (24.4%) were black patients. Median age at diagnosis was 39.3 years (range, 14-70 yr) in white patients vs. 28.4 years (range, 12-54 yr) in North African (p = 0.02), and 28.0 years (range, 13-60 yr) in black patients (p = 0.08). Patients aged >40 years at TA onset were more frequently white than non-white (40.0% vs. 18.6%, p = 0.03). North African patients had more frequent occurrence of ischemic stroke (p = 0.03) and poorer survival (p = 0.01) than white patients. Type V of the Hata classification was the most frequent type among white (38.5%), North African (65.0%), and black patients (40.0%). Corticosteroids were used in 96.1% of patients. Fifty-three percent of white and North African patients, and 44% of black patients required a second line of immunosuppressive treatment (p = 0.60). Vascular surgical procedures were respectively performed in 46.1%, 50.0%, and 55.0% of white, North African, and black patients, p = 0.81. The 5-year and 10-year survival rates were 100% and 95.0%, respectively, in white patients; 67.4% at both 5 years and 10 years in North African patients; and 100% at both 5 years and 10 years in black patients. This study is one of the first direct comparisons of TA profiles among patients of distinct ethnic backgrounds. Our data support the idea that late-onset TA or an overlap between TA and large-vessel giant cell arteritis may be observed in white patients. North African patients have a higher occurrence of ischemic stroke and poorer survival than white patients.