Mechanisms of atherosclerosis and cardiovascular disease in antiphospholipid syndrome and systemic lupus erythematosus. New therapeutic approaches

Metabolic syndrome in antiphospholipid syndrome versus rheumatoid arthritis and diabetes mellitus: Association with arterial thrombosis, cardiovascular risk biomarkers, physical activity, and coronary atherosclerotic plaques

Background

Cardiovascular disease (CVD) is the foremost cause of morbidity and deaths in antiphospholipid syndrome (APS), driven by thrombo-inflammation and atherothrombosis mechanisms. Metabolic syndrome (MetS) is a proinflammatory and prothrombotic state characterized by increased CVD risk. We aimed to evaluate the prevalence of MetS in APS patients compared to rheumatoid arthritis (RA) and diabetes mellitus (DM) and its associations with clinical and laboratory patient characteristics and vascular ultrasound (US) markers of subclinical atherosclerosis.

Methods

We included 414 patients in our study: 138 patients with APS (median age: 44.9 years, females 70%) and matched 1:1 for age and sex RA and DM subjects. Three sets of criteria were used for MetS diagnosis: Joint Interim Statement (JIS), International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII). The demographic, clinical and laboratory characteristics of all participants were recorded and carotid and femoral US was performed in patients with APS. Multivariate regression models were applied.

Results

Prevalence of MetS was 23.9%, 23.2%, 20.3% (based on JIS, IDF, modified NCEP-ATPIII criteria, respectively) in APS versus 17.4%, 17.4%, 13% in RA (p=0.181, p=0.231, p=0.106, respectively), and 44.2%, 44.2%, 40.6% in DM patients. In multivariate analysis, patients with systemic lupus erythematosus- related APS had an approximately 2.5-fold higher risk of MetS versus RA patients. MetS in APS was independently associated with arterial thrombosis (Odds ratio 3.5, p=0.030). Odds ratio for MetS was 1.16 for each one unit increase in C-reactive protein levels according to JIS and IDF criteria, and 1.49 and 1.47 for each one unit increase in uric acid levels using the IDF and modified NCEP-ATPIII models, respectively. APS patients with atherosclerotic carotid plaques had 4 to 6.5-fold increased risk of MetS. Odds for MetS were decreased by 26% with an increase in physical activity by one hour per week.

Conclusions

MetS is present in approximately one-fourth of APS patients at a comparable prevalence to that observed in patients with RA. MetS in APS is associated with arterial thrombosis, cardiovascular risk biomarkers, physical activity, and subclinical atherosclerosis, supporting its role in cardiovascular risk stratification and management in APS.

Cardiovascular risk management in antiphospholipid syndrome: trends over time and comparison with rheumatoid arthritis and diabetes mellitus

OBJECTIVE

Antiphospholipid syndrome (APS) is characterised by increased cardiovascular morbidity and mortality, related to thrombo-inflammatory and atherogenic mechanisms. We examined the achievement of traditional cardiovascular risk factor (CVRF) therapeutic goals in APS versus other high cardiovascular risk disorders such as rheumatoid arthritis (RA) and diabetes mellitus (DM), and trends over time.

METHODS

122 patients with APS (74 primary APS, female 68%, mean age 44.5±11.3) were classified according to their first visit (2011-2015 and 2016-2020 APS subgroups, 61 patients in each subgroup) and matched 1:1 for age/sex with patients with RA and DM. Cardiovascular risk was estimated by the Systemic Coronary Risk Evaluation, and the CVRF therapeutic targets were defined according to the European Society of Cardiology (ESC) guidelines. Individual and multiple CVRF control was compared between APS subgroups, and in APS versus RA and DM.

RESULTS

We found a comparable or higher prevalence of CVRFs between APS and age-matched/sex-matched patients with RA and DM but low CVRF target attainment in APS according to the ESC guidelines. Despite improving trends between 2011-2015 and 2016-2020, CVRF control in high/very high-risk patients with APS was 12%, 18%, 24% and 35% for low-density lipoprotein, waist circumference, exercise and body mass index, respectively, and 59%-65% for triglycerides, high-density lipoprotein (HDL) and blood pressure, in 2016-2020 subgroup. CVRF control was worse in APS versus RA for smoking (p=0.014), HDL (p<0.001), waist circumference (p=0.042) and five CVRFs (p=0.030), and versus DM for exercise (p=0.077). Similar results were found in the sensitivity analysis.

CONCLUSIONS

Comparable prevalence of modifiable CVRFs to RA and DM but suboptimal CVRF target achievement was observed in APS, especially in high/very high-risk patients, highlighting the need for CVRF management strategies.

Hyperoside Protects Human Umbilical Vein Endothelial Cells Against Anticardiolipin Antibody-Induced Injury by Activating Autophagy

Anticardiolipin antibody (aCL), an important characterization of antiphospholipid syndrome, shows an intense association with vascular endothelial injury. Hyperoside is a flavonoid extracted from medicinal plants traditionally used in Chinese medicines, displaying anti-inflammatory, anti-cancer, and anti-oxidative properties in various diseases. Recent studies have shifted the focus on the protective effects of hyperoside on vascular endothelial injury. However, little is known about the mechanisms involved. In the present study, we investigated the effect of hyperoside on aCL-induced injury of human umbilical vein endothelial cells (HUVECs) in vitro. Our data illustrated that aCL induced HUVEC injury via inhibiting autophagy. Hyperoside reduced aCL-induced secretion of proinflammatory cytokines IL-1β and IL-8 and endothelial adhesion cytokines TF, ICAM1, and VCAM1 in HUVECs. Additionally, hyperoside activated autophagy and suppressed the mTOR/S6K and TLR4/Myd88/NF-κB signaling transduction pathways in aCL-induced HUVECs. To the best of our knowledge, this is the first study to investigate the effect of hyperoside on aCL-induced injury, as well as offer insights into the involved mechanisms, which is of great significance for the treatment of antiphospholipid syndrome.