Heart Involvement in Inflammatory Rheumatic Diseases: A Systematic Literature Review

Correlation between myocardial work and disease activity in rheumatoid arthritis patients with preserved left ventricular ejection fraction: a retrospective study based on non-invasive pressure-strain loop：

BACKGROUND

Early cardiac damage is very common in RA patients, but it is usually subclinical. Therefore, finding a non-invasive method for the early detection and treatment of cardiac damage in autoimmune diseases is particularly important.diac dam RA ，。，。 OBJECTIVE: To evaluate left ventricular function changes in rheumatoid arthritis (RA) patients with preserved left ventricular ejection fraction (LVEF) using left ventricular pressure-strain loop (LV-PSL) technology and to explore the correlation between myocardial work (MW) and disease activity.- （LV-PSL） （LVEF） （RA） ， （MW） 。 METHODS: A total of 62 RA patients with preserved LVEF, treated at Wujin Hospital Affiliated with Jiangsu University from January 2021 to September 2023, were included. Patients were categorized into low (25), medium (18), and high (19) disease activity groups based on the 28 joint disease activity score (DAS28). A control group of 29 healthy individuals was also established. LV-PSL technology assessed left ventricular global longitudinal strain (GLS) and MW parameters: global constructive work (GCW), global wasted work (GWW), global work index (GWI), and global work efficiency (GWE). Correlations between MW parameters, GLS, LVEF, and DAS28 scores were analyzed. 2021 1 20239 62 LVEF RA 。 28 （DAS28） （25） 、 （18） （19） 。 29 。LV-PSL （GLS） MW ： （GCW）、 （GWW）、 （GWI） （GWE）。 MW 、 GLS 、 LVEF DAS28 。 RESULTS: There were no significant differences in general data between study and control groups (p > 0.05). However, laboratory indicators (RF, CRP, ESR) showed significant differences (p < 0.05). GWI, GCW, GWE, and GLS were significantly lower in the high disease activity group compared to controls (p < 0.05). GWI, GCW, and GWE were positively correlated with LVEF and absolute GLS, while GWW correlated negatively with LVEF (p < 0.05). （p > 0.05）。， （RF、CRP、ESR） （p < 0.05）。， GWI、GCW、GWE GLS （p < 0.05）。GWI、GCW GWE LVEF GLS ， GWW LVEF （p < 0.05）。 （p > 0.05）。， （RF、CRP、ESR） （p < 0.05）。， GWI、GCW、GWE GLS （p < 0.05）。GWI、GCW GWE LVEF GLS ， GWW LVEF （p < 0.05）。 CONCLUSION: RA disease activity is closely associated with impaired myocardial work. LV-PSL technology effectively monitors myocardial function abnormalities in RA patients, providing valuable insights for clinical management. Key Points • Myocardial work is significantly impaired in RA patients with high disease activity. • Left ventricular pressure-strain loop (LV-PSL) technology effectively assesses cardiac function in this patient population. • Increased disease activity correlates with reduced myocardial work parameters.

The impact of biologic agents on cardiovascular risk factors in patients with rheumatoid arthritis: A meta analysis

OBJECTIVE

The purpose of the study is to evaluate the effects of biologic therapy on cardiovascular risk factors in rheumatoid arthritis patients to determine its clinical efficacy.

METHODS

Relevant literature was systematically searched in PubMed, Embase, and Cochrane Library databases. Meta-analysis was conducted using standardized mean differences (SMDs) and 95% confidence intervals (CIs) to evaluate cardiovascular risk factors and atherosclerosis. Heterogeneity, sensitivity analysis, and publication bias were assessed. Statistical significance was set at P<0.05.

RESULTS

The meta-analysis revealed that biologic treatment in RA patients was associated with decreased high-density lipoprotein cholesterol (HDL-C) levels compared to controls (MD: -0.10, 95% CI: [-0.14, -0.05], P<0.0001). Subgroup analysis based on treatment duration showed heterogeneity and a potential decrease in total cholesterol levels after 12 months of treatment (MD = -0.03, 95% CI [-0.21, -0.15], P = 0.76). Biologic therapy significantly reduced triglyceride levels compared to controls (MD = -0.23, 95% CI [-0.37, -0.09], P = 0.001), as observed in subgroup analysis. Moreover, biologics effectively decreased low-density lipoprotein cholesterol (LDL-C) levels (MD: -0.10, 95% CI: [-0.14, -0.05], P<0.0001). However, biologic treatment was associated with increased inner carotid artery thickness (MD: 0.05, 95% CI: [0.03, 0.07], P<0.0001), indicating potential adverse effects on cardiovascular health. No significant effect on pulse wave velocity (PWV) was observed (MD: -0.23, 95% CI: [-0.80, 0.34], P = 0.43, I2 = 0%, P = 0.55).

CONCLUSION

Biologic agents may improve lipid profiles in RA patients but could also have adverse effects on cardiovascular health. Further research is needed to comprehensively understand the impact of biologic therapy on lipid metabolism and cardiovascular outcomes in RA patients.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, CRD42024504911.

Inflammatory Response Genes' Polymorphism Associated with Risk of Rheumatic Heart Disease

Rheumatic heart disease (RHD) caused by group A streptococcus infection is one of the most important reasons of cardiovascular morbidity and mortality in low- and middle-income countries. Aberrant host immune response modulated by polymorphisms in inflammatory response genes plays an important role in RHD pathogenesis. This study aimed to determine risk-associated polymorphic variants in inflammatory response genes in Caucasian RHD patients. A total of 251 Caucasian RHD patients and 300 healthy donors were recruited for this study, and 27 polymorphic sites in 12 genes (TLR1, TLR2, TLR4, TLR6, IL1B, IL6R, IL6, IL10, IL12RB1, IL12B, TNF and CRP) were analyzed using allele-specific PCR. It was demonstrated that the polymorphic variants rs1800871 and rs1800872 in the IL10 gene, rs 1130864, rs3093077 and rs1205 in the CRP gene, rs375947 in the IL12RB1 gene, rs 5743551 and rs5743611 in the TLR1 gene, and rs3775073 in the TLR6 gene can modify RHD risk in a gender- and age-dependent manner. The obtained results can be used to determine the personalized risk of RHD in healthy donors during medical examination or screening, as well as to develop appropriate early prevention strategies targeting RHD in the risk groups.

Relationship Between Ankylosing Spondylitis and Cerebrovascular Disorders: A Systematic Review

Cerebrovascular events are linked to ankylosing spondylitis. Accelerated atherosclerosis and endothelial dysfunction against a backdrop of inflammation have been widely blamed for the increased cerebrovascular risk in ankylosing spondylitis. The absence of a comprehensive review encouraged us to consider the link between ankylosing spondylitis and cerebrovascular diseases. Web of Science, PubMed, Medline, Scopus, and EMBASE were searched to identify studies published from 2000 to June 10, 2023. All observational and cohort studies reporting myocardial infarction or stroke and considering classic cerebrovascular risk in ankylosing spondylitis patients and healthy controls were included. Most of the included studies reported that the risk of cerebrovascular disorders was greater in ankylosing spondylitis than in the general population. Also, most studies showed that for both sexes, the prevalence of cardiovascular illnesses rose with age, and this trend was consistent across all subgroups of cardiovascular disorders. Also, most studies reported that the rate of cerebrovascular accidents in ankylosing spondylitis patients was higher than in control groups. Some studies reported that the risk of developing an ischemic stroke was higher in young patients with ankylosing spondylitis, while others did not. Our systematic analysis found that most studies agreed that ankylosing spondylitis patients had a higher risk of cerebrovascular diseases than the general population. Still, this increased risk was influenced by several factors that need further research exploration.

Variability of Multiple Sclerosis Walking Scale and Multiple Sclerosis Impact Scale Scores in People Without Multiple Sclerosis

Introduction  Many people with multiple sclerosis (pwMS) experience problems with mobility at some point in their disease course. The Multiple Sclerosis Impact Scale (MSIS) and Multiple Sclerosis Walking Scale (MSWS) are validated patient-reported outcome measures of physical impairment in pwMS. The range of scores on MSIS and MSWS in people without MS (pwoMS) are not well understood. Methods People over the age of 16 who did not have a diagnosis of multiple sclerosis (MS) were invited to complete an online survey consisting of a general health questionnaire, MSIS and the MSWS. Scores for MSIS and MSWS from pwoMS were compared to those from a cohort of 35 pwMS from a previous study. Scores for MSIS and MSWS were correlated with age, sex and comorbidities in pwoMS. Results One hundred eighty-nine ambulant pwoMS were recruited (52.5% female), aged over 16 years of age. Ninety-nine percent reported no difficulty with walking, 89.4% were non-smokers, and 14% had a physical co-morbidity. None used a walking aid. For pwoMS, the MSIS score was a mean of 39.14±13.75 (range 29-127), compared to a mean of 77.2±24.94 (range 40-126) for pwMS. For pwoMS, the mean MSWS score was 8.46±16.2 (0-87) compared to a mean of 56.9±28.9 (4-100) for pwMS. There was no significant effect of sex or smoking on MSIS or MSWS scores in pwoMS. Presence of a physical co-morbidity was associated with significantly higher MSIS and MSWS scores in pwoMS. There was a significant correlation of increasing age with increasing MSWS score in pwoMS but no correlation of age with MSIS score. Conclusion There is a wide range of MSWS and MSIS scores in pwoMS. The age and presence of comorbidities influence both MSWS and MSIS scores. Our findings have implications for the selection of control groups for clinical studies in pwMS.

Echocardiography Coupled with Strain Method in the Screening for Cardiac Involvement in Rheumatoid Arthritis

OBJECTIVE

In this study, the usefulness of transthoracic echocardiography (TTE) in systematic screening was assessed for various cardiac abnormalities in patients with rheumatoid arthritis (RA).

METHODS

We performed a comparative cross-sectional study from July 2020 to February 2021. Each patient underwent a TTE coupled with the strain technique.

RESULTS

Seventy-two RA patients and 72 controls were included. Abnormalities detected by TTE were more frequent in RA patients (80.6% vs. 36.1%; p < 0.01), and they were asymptomatic in 65.5% of cases. Valvular involvement was found in 45.8% of RA patients, with a significant difference (p < 0.01). Left ventricular diastolic dysfunction was also more frequent in the RA group (36.1% vs. 13.9%; p < 0.01). Left ventricular systolic dysfunction was absent in our study, but subclinical left ventricular myocardial damage assessed by Global Longitudinal Strain (GLS) method was found in 37.5% of RA patients and 16.6% of controls (p < 0.01). The mean GLS in RA patients was -17.8 ± 2.9 (-22 to -10.7) vs. -19.4 ± 1.9 (-24.7 to -15.7) in controls. Left ventricular hypertrophy was detected in 22.2% of RA patients and in 6.9% of controls (p < 0.01). Pericardial effusion and pulmonary arterial hypertension were present only in the RA group (2.8% of cases). We found a significant relationship between echocardiographic damage and disease activity (p < 0.01), number of painful joints (p < 0.01), functional impact (HAQ) (p = 0.01), CRP level (p < 0.01) and the use and dose of Corticosteroids (p = 0.02; p = 0.01).

CONCLUSION

Echocardiographic damage in RA is frequent and often asymptomatic, hence there has been an increased interest in systematic screening in order to improve the quality of life and vital prognosis of patients. Early management of RA can reduce the risk of occurrence of cardiac involvement.

A synthesis of pathways linking diet, metabolic risk and cardiovascular disease: a framework to guide further research and approaches to evidence-based practice

Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature has provided useful insights into the important role that diet plays in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g. not properly addressing confounders and mediators) and experimental research designs (e.g. not appropriate or well designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors, with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course into the spotlight.

High blood pressure prevalence, awareness, treatment, and blood pressure control among Ugandans with rheumatic and musculoskeletal disorders

BACKGROUND

Rheumatic and musculoskeletal disorders (RMDs) are associated with cardiovascular diseases (CVDs), with hypertension being the most common. We aimed to determine the prevalence of high blood pressure (HBP), awareness, treatment, and blood pressure control among patients with RMDs seen in a Rheumatology clinic in Uganda.

METHODS

We conducted a cross-sectional study at the Rheumatology Clinic of Mulago National Referral Hospital (MNRH), Kampala, Uganda. Socio-demographic, clinical characteristics and anthropometric data were collected. Multivariable logistic regression was performed using STATA 16 to determine factors associated with HBP in patients with RMDs.

RESULTS

A total of 100 participants were enrolled. Of these, majority were female (84%, n = 84) with mean age of 52.1 (standard deviation: 13.8) years and median body mass index of 28 kg/m2 (interquartile range (IQR): 24.8 kg/m2-32.9 kg/m2). The prevalence of HBP was 61% (n = 61, 95% CI: 51.5-70.5), with the majority (77%, n = 47, 95% CI: 66.5-87.6) being aware they had HTN. The prevalence of HTN was 47% (n = 47, 37.2-56.8), and none had it under control. Factors independently associated with HBP were age 46-55years (adjusted prevalence ratio (aPR): 2.5, 95% confidence interval (CI): 1.06-5.95), 56-65 years (aPR: 2.6, 95% CI: 1.09-6.15), >65 years (aPR: 2.5, 95% CI: 1.02-6.00), obesity (aPR: 3.7, 95% CI: 1.79-7.52), overweight (aPR: 2.7, 95% CI: 1.29-5.77).

CONCLUSION

There was a high burden of HBP among people with RMDs in Uganda with poor blood pressure control, associated with high BMI and increasing age. There is a need for further assessment of the RMD specific drivers of HBP and meticulous follow up of patients with RMDs.

Risk of Arrhythmia Among New Users of Hydroxychloroquine in Rheumatoid Arthritis and Systemic Lupus Erythematosus: A Population-Based Study

OBJECTIVES

We assessed the association between hydroxychloroquine (HCQ) initiation and risk of arrhythmia among patients with incident rheumatoid arthritis (RA) or with incident systemic lupus erythematosus (SLE).

METHODS

All patients with incident RA or SLE and no arrhythmic events, not receiving antiarrhythmic medications, and not receiving HCQ prior to the index date of disease in British Columbia, Canada, between January 1996 and December 2014 were identified from administrative databases. We identified patients who were dispensed HCQ prescriptions (HCQ initiators) or were not dispensed HCQ prescriptions (HCQ noninitiators) during each study year; groups were matched 1:1 by propensity scores using baseline confounders on demographics, comorbidities, medications, and health care utilization. Outcomes were any new arrhythmias, atrial fibrillation, abnormal electrocardiograms, including long QT syndrome and conduction disorder, and other unspecified arrhythmias during follow-up. We used cause-specific Cox proportional hazards models with death as a competing event to assess the association between HCQ initiation and the outcomes.

RESULTS

We identified 11,518 propensity score-matched patients with RA or SLE in each group. Over the mean follow-up of 8 years, there were 1,610 and 1,646 incident arrhythmias in the HCQ initiator group and the noninitiator group, respectively, with crude incidence rates of arrhythmia of 17.5 and 18.1 in 1,000 persons per year, respectively. The adjusted cause-specific hazard ratio (cHR) for patients who received HCQ was 0.96 (95% confidence interval [95% CI] 0.89-1.03) compared with HCQ noninitiators, and the cHRs for patients who took HCQ and had arrhythmia subtypes of atrial fibrillation, abnormal electrocardiograms, and other unspecified arrhythmias were 0.93 (95% CI 0.83-1.04), 0.98 (95% CI 0.87-1.11), and 0.95 (95% CI 0.84-1.07), respectively.

CONCLUSION

Risk of any type of arrhythmia was not increased among new users of HCQ.

Assessment of the incidence of fragmented QRS in electrocardiography in patients with systemic sclerosis and systemic lupus erythematosus

OBJECTIVE

In systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) cardiac involvement is very common, and it might be asymptomatic. We aimed to assess the presence of fragmented QRS (fQRS) - possible indicator of a scar, diffuse damage or conduction system disturbances in those patients.

METHODS

We examined 74 patients with SSc, 77 with SLE and 40 healthy controls. The incidence of fQRS in ECG was examined according to criteria by Das et al. Disease severity was estimated by Rodnan and SLICCC/ACRDI scores in SSc and SLE respectively.

RESULTS

Patients with SSc were slightly older than those with SLE (53 ± 14 vs 46 ± 14 yrs), women constituted 91% and 88% of studied groups (p = 0.80). The duration of disease in both groups was similar (p = 0.59). Median of Rodnan and SLICCC/ACR-DI scores were 5 and 4 points, respectively. Left ventricle ejection fraction in both groups was similar (65.5 vs 65.1%, p = 0.51), hypertension incidence was lower in SSc (24 vs 48%, p = 0.004), patients with SLE presented prolonged corrected QT interval (432 vs 424 ms, p = 0.03). Of note, fQRS were observed in 34 (46%) SSc and 29 (38%) SLE patients, p = 0.33. Notched S waves were significantly more frequent in SSc (in 26% vs 10%, p = 0.02). fQRS occurred in 3 (7.5%) of healthy subjects only.

CONCLUSION

The incidence of fQRS is similar in SSc and SLE, but is much more common than in healthy subjects. It is possible that fQRS may be considered an additional marker of heart involvement in these rare diseases.

Recent insights into comorbidities in atopic dermatitis

INTRODUCTION

The relationship between atopic dermatitis and atopic diseases such as food allergies, asthma, and allergic rhinitis in terms of co-occurrence, underlying mechanisms, and therapy is well documented. There is increasing evidence that atopic dermatitis is associated with non-atopic comorbidities such as cardiac, autoimmune, and neuropsychological comorbidities, as well as cutaneous and extracutaneous infections, establishing atopic dermatitis as a systemic disease.

AREAS COVERED

The authors reviewed evidence on atopic and non-atopic comorbidities of atopic dermatitis. A literature search was conducted in PubMed for peer-reviewed articles published until October 2022.

EXPERT OPINION

Atopic and non-atopic diseases coexist with atopic dermatitis more often than would be expected by chance. The effect of biologics and small molecules on atopic and non-atopic comorbidities may contribute to a better understanding of the relationship between atopic dermatitis and its comorbidities. Their relationship needs to be explored further to dismantle the underlying mechanism and move toward an atopic dermatitis endotype-based therapeutic approach.

Fructose-Induced Alteration of the Heart and Vessels Homeostasis

To date, the role of uncontrolled sugar consumption in the triggering and progression of cardiovascular events is undeniable. Modern concepts offer a new hypothesis regarding the direct myocardiotoxic effects of fructose. Experimental studies have demonstrated that cardiomyocytes have a unique ability to transport and use fructose along with the expression of all components involved in fructose metabolism. The purpose of this review article is to assess and analyze the available knowledge on fructose-induced cardiotoxicity detection since understanding the pathophysiological mechanisms and pathobiochemical aspects will become the basis for the determination of a rational myocardioprotection regimen.

Serum Vitamin D Levels, Disease Activity Score-28 for Rheumatoid Arthritis with C-Reactive Protein (DAS28-CRP), and Cardiac Remodeling Determined by Ventricular Dimensions and Left Atrium Diameter in Patients with Rheumatoid Arthritis: A Prospective Observational Study

BACKGROUND Rheumatoid arthritis (RA) can cause extra-articular manifestations, and the myocardium can be a target. This study aimed to describe structural and functional cardiac echocardiographic variables in RA patients and to evaluate whether vitamin D (VD) levels and inflammation markers, evaluated by Disease Activity Score-28 for Rheumatoid Arthritis with C-reactive protein (DAS28-CRP), are associated with cardiac remodeling (CR) in this population. MATERIAL AND METHODS This prospective observational study evaluated 90 patients with RA in Botucatu University Hospital wards from 2014 to 2017. Clinical data were recorded, including demographic information, comorbidities, length of disease, and treatment type. Serum VD and C-reactive protein levels were measured, and the DAS28-CRP was calculated. A transthoracic echocardiography study was performed. The outcome evaluated was CR. This parameter was assessed by left ventricular geometric patterns and left atrium diameter. RESULTS We evaluated 90 RA patients. The mean age was 52.9±10.8 years, and 17.8% were male. The length of the disease was 96 (60-180) months. Serum VD levels were 30.7±10.4 ng/mL and the DAS28 was 2.7±0.9. Regarding the CR parameters, 56.7% had altered left ventricular geometric patterns and 25.8% had enlargement of left atrium diameter. Even in multivariate analysis, the left ventricular geometric patterns were not associated with the VD levels and the inflammation marker used. However, sufficient VD levels protect from left atrium enlargement (OR: 0.905; IC 95%: 0.843-0.973; P=0.007). CONCLUSIONS Low serum vitamin D values, but not inflammation, are associated with CR in patients with RA.

The Role of Inflammation and Oxidative Stress in Rheumatic Heart Disease

Rheumatic heart disease (RHD), an acquired valvular disease, remains an important cause of morbidity and mortality in developing countries. This chronic illness starts from untreated streptococcal throat infection, resulting in acute rheumatic fever (ARF) in susceptible individuals. Repeated infections lead to a chronic phase characterized by the damage of heart valves. Inflammation has been found to play important role in the development of this disease. All the studies presented in this review clearly show the involvement of the inflammatory state in the progression of this disease. However, the exact role of cytokines in inflammation sites remains to be examined, since most studies have so far focused on peripheral blood. Such analysis would provide information on inflammatory mechanisms in situ.

Macrophage Dysfunction in Autoimmune Rheumatic Diseases and Atherosclerosis

One of the problems of modern medical science is cardiovascular pathology caused by atherosclerotic vascular lesions in patients with autoimmune rheumatic diseases (ARDs). The similarity between the mechanisms of the immunopathogenesis of ARD and chronic low-grade inflammation in atherosclerosis draws attention. According to modern concepts, chronic inflammation associated with uncontrolled activation of both innate and acquired immunity plays a fundamental role in all stages of ARDs and atherosclerotic processes. Macrophage monocytes play an important role among the numerous immune cells and mediators involved in the immunopathogenesis of both ARDs and atherosclerosis. An imbalance between M1-like and M2-like macrophages is considered one of the causes of ARDs. The study of a key pathogenetic factor in the development of autoimmune and atherosclerotic inflammation-activated monocyte/macrophages will deepen the knowledge of chronic inflammation pathogenesis.

A Useful Blood Flow Restriction Training Risk Stratification for Exercise and Rehabilitation

Blood flow restriction training (BFRT) is a modality with growing interest in the last decade and has been recognized as a critical tool in rehabilitation medicine, athletic and clinical populations. Besides its potential for positive benefits, BFRT has the capability to induce adverse responses. BFRT may evoke increased blood pressure, abnormal cardiovascular responses and impact vascular health. Furthermore, some important concerns with the use of BFRT exists for individuals with established cardiovascular disease (e.g., hypertension, diabetes mellitus, and chronic kidney disease patients). In addition, considering the potential risks of thrombosis promoted by BFRT in medically compromised populations, BFRT use warrants caution for patients that already display impaired blood coagulability, loss of antithrombotic mechanisms in the vessel wall, and stasis caused by immobility (e.g., COVID-19 patients, diabetes mellitus, hypertension, chronic kidney disease, cardiovascular disease, orthopedic post-surgery, anabolic steroid and ergogenic substance users, rheumatoid arthritis, and pregnant/postpartum women). To avoid untoward outcomes and ensure that BFRT is properly used, efficacy endpoints such as a questionnaire for risk stratification involving a review of the patient's medical history, signs, and symptoms indicative of underlying pathology is strongly advised. Here we present a model for BFRT pre-participation screening to theoretically reduce risk by excluding people with comorbidities or medically complex histories that could unnecessarily heighten intra- and/or post-exercise occurrence of adverse events. We propose this risk stratification tool as a framework to allow clinicians to use their knowledge, skills and expertise to assess and manage any risks related to the delivery of an appropriate BFRT exercise program. The questionnaires for risk stratification are adapted to guide clinicians for the referral, assessment, and suggestion of other modalities/approaches if/when necessary. Finally, the risk stratification might serve as a guideline for clinical protocols and future randomized controlled trial studies.

Cardiovascular Risk Prediction Parameters for Better Management in Rheumatic Diseases

The early detection of cardiovascular disease (CVD) serves as a key element in preventive cardiology. The risk of developing CVD in patients with rheumatic disease is higher than that of the general population. Thus, the objective of this narrative review was to assess and describe updated risk-prediction parameters for CVD in patients suffering from rheumatic diseases, and, additionally, to evaluate therapeutic and risk management possibilities. The processes of recognizing CVD risk factors in rheumatic diseases, establishing diagnoses, and discovering CV risk assessments are currently displeasing in clinical practice; they have a limited clinical impact. A large number of references were found while screening PUBMED, Scopus, and Google scholar databases; the 47 most relevant references were utilized to build up this study. The selection was limited to English language full text articles, RCTs, and reviews published between 2011 and 2021. Multiple imaging techniques, such as ECG, ultrasound, and cIMT, as well as biomarkers like osteoprotegerin cytokine receptor and angiopoietin-2, can be beneficial in both CV risk prediction and in early subclinical diagnosis. Physical exercise is an essential non-pharmacological intervention that can maintain the health of the cardiovascular system and, additionally, influence the underlying disease. Lipid-lowering drugs (methotrexate from the non-biologic DMARDs family as well as biologic DMARDs such as anti-TNF) were all associated with a lower CV risk; however, anti-TNF medication can decrease cardiac compliance and promote heart failure in patients with previously diagnosed chronic HF. Although they achieved success rates in reducing inflammation, glucocorticoids, NSAIDs, and COX-2 inhibitors were correlated with an increased risk of CVD. When taking all of the aforementioned points into consideration, there appears to be a dire need to establish and implement CVD risk stratification models in rheumatic patients.

Pericarditis With Cardiac Tamponade Mimicking Yellow Nail Syndrome in a Patient With Rheumatoid Arthritis and a Paucity of Joint Symptoms

Pericarditis is a cardiac disease that commonly manifests with rheumatoid arthritis, and its complications are related to rheumatoid arthritis disease activity. The diagnosis can be complicated in patients with multiple extra-joint complications of rheumatoid arthritis. We report a case of pericarditis in an 82-year-old woman with few joint symptoms who was admitted to the hospital due to worsening edema of the lower legs and dyspnea, which progressed to cardiac tamponade. The patient presented with gradual onset of edema of both lower limbs and bilateral pleural effusion and was initially diagnosed with yellow nail syndrome. Ultimately, the patient was diagnosed with rheumatoid pericarditis due to a rapid increase in pericardial effusion. She was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine; however, the symptoms were progressive and required pericardiocentesis. After pericardiocentesis, the patient responded well to NSAIDs and colchicine, and systemic edema was relieved. This case highlights the fact that pericarditis associated with rheumatoid arthritis is not necessarily related to the severity of joint symptoms. Moreover, it can be difficult to differentiate pericarditis from multiple other diseases, such as yellow nail syndrome, in patients with rheumatoid arthritis who mainly have extra-articular symptoms.

Organ Manifestation and Systematic Organ Screening at the Onset of Inflammatory Rheumatic Diseases

BACKGROUND

Inflammatory rheumatic diseases (IRD) are often associated with the involvement of various organs. However, data regarding organ manifestation and organ spread are rare. To close this knowledge gap, this cross-sectional study was initiated to evaluate the extent of solid organ manifestations in newly diagnosed IRD patients, and to present a structured systematic organ screening algorithm.

MATERIALS AND METHODS

The study included 84 patients (63 women, 21 men) with newly diagnosed IRD. None of the patients received any rheumatic therapy. All patients underwent a standardised organ screening programme encompassing a basic screening (including lungs, heart, kidneys, and gastrointestinal tract) and an additional systematic screening (nose and throat, central and peripheral nervous system) on the basis of clinical, laboratory, and immunological findings.

RESULTS

Represented were patients with connective tissue diseases (CTD) (72.6%), small-vessel vasculitis (16.7%), and myositis (10.7%). In total, 39 participants (46.5%) had one or more organ manifestation(s) (one organ, 29.7%; two organs, 10.7%; ≥three organs, 6.0%). The most frequently involved organs were the lungs (34.5%), heart (11.9%), and kidneys (8.3%). Lastly, a diagnostic algorithm for organ manifestation was applied.

CONCLUSION

One-half of the patients presented with a solid organ involvement at initial diagnosis of IRD. Thus, in contrast to what has been described in the literature, organ manifestations were already present in a high proportion of patients at the time of diagnosis of IRD rather than after several years of disease. Therefore, in IRD patients, systematic organ screening is essential for treatment decisions.

A preliminary study on the evaluation of left atrial function of rheumatoid arthritis by two dimensional speckle tracking imaging

To evaluate the changes of left atrial (LA) geometry and function in patients with rheumatoid arthritis (RA) by conventional echocardiography and two-dimensional speckle tracking imaging (2D-STI). We enrolled 46 RA patients with a duration of < 5 years as Group I, 40 RA patients with a duration of ≥ 5 years as Group II, and 40 normal subjects as the control group. Conventional echocardiography was conducted to measure traditional parameters. The LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd), LA strain during contraction phase (LASct), and LA global longitudinal strain (LAGLS) were obtained from 2D-STI. Related ultrasound results were compared. The LASct was significantly higher in Group I than in control group (P < 0.05). The LASr, LAScd, and LAGLS were significantly lower in Group I than in control group (all P < 0.05). The LASr, LAScd, LASct, and LAGLS were significantly lower in Group II than in control group and Group I (all P < 0.05). The function of LA impaired in RA patients, and the impairment aggravated with the clinical course of RA patients. 2D-STI technology can early and accurately evaluate the LA function of RA patients by evaluating LASr, LAScd, LASct, and LAGLS.

Autoimmune Rheumatic Diseases and Vascular Function: The Concept of Autoimmune Atherosclerosis

Autoimmune rheumatic diseases (AIRDs) with unknown etiology are increasing in incidence and prevalence. Up to 5% of the population is affected. AIRDs include rheumatoid arthritis, system lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. In patients with autoimmune diseases, the immune system attacks structures of its own body, leading to widespread tissue and organ damage, which, in turn, is associated with increased morbidity and mortality. One third of the mortality associated with autoimmune diseases is due to cardiovascular diseases. Atherosclerosis is considered the main underlying cause of cardiovascular diseases. Currently, because of finding macrophages and lymphocytes at the atheroma, atherosclerosis is considered a chronic immune-inflammatory disease. In active inflammation, the liberation of inflammatory mediators such as tumor necrotic factor alpha (TNFa), interleukine-6 (IL-6), IL-1 and other factors like T and B cells, play a major role in the atheroma formation. In addition, antioxidized, low-density lipoprotein (LDL) antibodies, antinuclear antibodies (ANA), and rheumatoid factor (RF) are higher in the atherosclerotic patients. Traditional risk factors like gender, age, hypercholesterolemia, smoking, diabetes mellitus, and hypertension, however, do not alone explain the risk of atherosclerosis present in autoimmune diseases. This review examines the role of chronic inflammation in the etiology-and progression-of atherosclerosis in autoimmune rheumatic diseases. In addition, discussed here in detail are the possible effects of autoimmune rheumatic diseases that can affect vascular function. We present here the current findings from studies that assessed vascular function changes using state-of-the-art techniques and innovative endothelial function biomarkers.

Comorbidity burden in the first three years after diagnosis in patients with rheumatoid arthritis, psoriatic arthritis or spondyloarthritis: a general practice registry-based study

OBJECTIVES

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA) are chronic inflammatory rheumatic conditions with high levels of comorbidity requiring additional therapeutic attention. We aimed to compare the 3-year comorbidity incidence and pain medication prescription in patients diagnosed with RA, PsA or SpA versus controls.

METHODS

Data between 1999 and 2012 were obtained from Intego, a general practitioner (GP) morbidity registry in Flanders, Belgium. Cases were identified by International Classification of Primary Care (ICPC-2) codes representing 'rheumatoid/seropositive arthritis (L88)' or 'musculoskeletal disease other (L99)'. The registered keywords mapped to these ICPC-2 codes were further verified and mapped to a RA/SpA/PsA diagnosis. Controls were matched on age, gender, GP practice and diagnosis date. We analysed the 3-year comorbidity burden in cases and controls, measured by the Rheumatic Diseases Comorbidity Index (RDCI). All electronically GP-prescribed drugs were registered.

RESULTS

In total, 738, 229 and 167 patients were included with a diagnosis of RA, SpA or PsA, respectively. Patients with RA or PsA had comparable median RDCI scores at baseline, but higher scores at year 3 compared with controls (RA: p=0.010; PsA: p=0.008). At baseline, depression was more prevalent in PsA patients vs controls (p<0.003). RA patients had a higher 3-year incidence of cardiovascular disease including myocardial infarction than controls (p<0.035). All disease population were given more prescriptions than controls for any pain medication type, even opioids excluding tramadol.

CONCLUSIONS

This study highlights the increasing comorbidity burden of patients with chronic inflammatory rheumatic conditions, especially for individuals with RA or PsA. The high opioid use in all populations was remarkable.

Heart Involvement in a Moroccan Population with Spondyloarthritis: A Cross-sectional Study

OBJECTIVES

The aim of this study was to investigate the prevalence of cardiac manifestations and their predictive factors in Moroccan patients with spondyloarthritis (SpA).

METHODS

We have conducted a cross-sectional study over four months at the Department of Rheumatology in Mohammed VI University Hospital of Oujda, Morocco. All SpA patients fulfilled the 2009 Assessment SpondyloArthritis international Society (ASAS) criteria. Every patient had a cardiac check up including clinical examination, 12-lead electrocardiogram (ECG) and transthoracic echocardiography (TTE). Multiple logistic regression was used to analyze the associated factors with cardiac manifestations.

RESULTS

We included 64 men and 30 women with a mean age of 37.32 ± 12.65 years old. The mean disease duration was 10.60 ± 7.61 years. Patients had a mean Ankylosing Spondylitis Disease Activity Score (ASDAS) CRP of 2.25 ± 1.38, a mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 2.88 ± 2.26 and a mean Bath Ankylosing Spondylitis Functional Index (BASFI) of 33.52 ± 30.49. Traditional cardiovascular risk factors (CVRF) included dyslipidemia in 14.9%, hypertension in 9.6% and type 2 diabetes in 7.4% of the cases. Eight patients (8.5%) smoked and 3 patients (3.2%) used alcohol whereas 20 patients (21.3%) had a history of smoking and 5 patients (6.3%) a history of alcohol. Cardiac manifestations were found in 12 patients (13.3%): 3.3% had aortic regurgitation (AR), 1.1% had aortic dilatation, 1.1% had aortic valve thickening (AVT), 2.2% had mitral thickening, 1.1% had mitral regurgitation (MR), 1.1% had mitral stenosis (MS), 3.3 had pericarditis and 2.2% had complete right bundle branch block (RBBB). In multivariate analysis, cardiac involvement was significantly associated with extra-articular manifestations (OR = 6.05; 95% CI: 1.197-30.607, p = 0.029).

CONCLUSION

Based on these results, cardiac involvement was common and associated with the severity of the disease; hence, early detection of cardiac abnormalities and targeted treatment strategies of SpA and comorbidities are necessary to control the systemic inflammation and improve the excess of cardiovascular mortality in this group of patients.

Increased risk of valvular heart disease in patients with ankylosing spondylitis: a nationwide population-based longitudinal cohort study

AIMS

We aimed to evaluate the risk of valvular heart disease (VHD) among patients with ankylosing spondylitis (AS).

METHODS

This was a population-based cohort study utilizing the Longitudinal Health Insurance Research Database of the National Health Insurance in Taiwan. Patients with and without coding of newly diagnosed AS from 1999 to 2013 were assigned to the AS and non-AS groups, respectively. Primary outcome was the incidental risk of VHD. Multiple Cox regression was used to estimate the adjusted hazard ratio of VHD. Subgroup analysis and sensitivity tests were also conducted.

RESULTS

The AS group included 3780 patients, and 22,680 matched subjects without an AS diagnosis were identified as controls. The AS group had an increased risk of VHD compared with non-AS controls (adjusted hazard ratio: 1.63; 95% confidence interval: 1.43-1.86; p < 0.001). Subgroup analysis also revealed an increased risk of individual types of VHD, including aortic, mitral, and tricuspid valve disease. Patients in the AS group had a higher incidence of valve replacement surgery after the onset of VHD.

CONCLUSION

Patients with AS had a significant risk of VHD compared to non-AS controls in this population-based cohort study. Screening for VHD may be needed in caring patients with AS. We suggest that echocardiography may be performed when patients are diagnosed with AS.

Cardiac manifestations of rheumatic diseases

Autoimmune rheumatic diseases are inflammatory disorders that can involve multiple organs, including the heart. The high risk of cardiovascular pathology in these patients is not only due to traditional cardiovascular risk factors, but also to chronic inflammation and autoimmunity. All cardiac structures may be affected during the course of systemic autoimmune diseases (valves, the conduction system, the myocardium, endocardium and pericardium, and coronary arteries), and the cardiac complications have a variety of clinical manifestations. As these are all associated with an unfavourable prognosis, it is essential to detect subclinical cardiac involvement in asymptomatic systemic autoimmune disease patients and begin adequate management and treatment early. In this review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders and available management strategies.

Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures

Background: we aimed to analyze the influence of antithrombotic medication in delaying surgery for fragility hip fractures; Method: a total of 312 consecutive hip fracture cases over 55 years who underwent surgery in our Orthopedic Clinic; Results: of these, 90 patients received chronic antithrombotic medication. There were no differences between the medicated group and controls (n = 222) regarding age, gender, type of fracture and haemoglobin at admittance. However, median time to surgery was significantly longer in the medicated group: 4(3–6) days compared to 2(1–4) (p < 0.0001). By type of medication, time to surgery was: 3(1–4) days for acetylsalicylic acid (n = 44), 6(5.25–7.75) days for clopidogrel (n = 15), 4.5(4–7) days for acenocoumarin (n = 18) and 5(4–7.25) days for novel direct oral anticoagulants (n = 13). The Charlson comorbidity index was significantly higher in the medicated group: 5 [4–5] versus 4 [3–5]. There were no differences in transfusions except for fresh frozen plasma, which was administered more in the medicated patients; Conclusions: the prevalence of platelet aggregation inhibitors and anticoagulant use among fragility hip fracture patients is high, with almost a third using some form of antithrombotic medication. This may significantly lengthen time to surgery.

Myocardial ischaemia reperfusion injury and cardioprotection in the presence of sensory neuropathy: Therapeutic options

During the last decades, mortality from acute myocardial infarction has been dramatically reduced. However, the incidence of post-infarction heart failure is still increasing. Cardioprotection by ischaemic conditioning had been discovered more than three decades ago. Its clinical translation, however, is still an unmet need. This is mainly due to the disrupted cardioprotective signalling pathways in the presence of different cardiovascular risk factors, co-morbidities and the medication being taken. Sensory neuropathy is one of the co-morbidities that has been shown to interfere with cardioprotection. In the present review, we summarize the diverse aetiology of sensory neuropathies and the mechanisms by which these neuropathies may interfere with ischaemic heart disease and cardioprotective signalling. Finally, we suggest future therapeutic options targeting both ischaemic heart and sensory neuropathy simultaneously. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc.

Sinus node disfunction in an adolescent with systemic lupus erythematosus

Cardiac involvement in systemic lupus erythematosus (SLE) is well documented. The pericardium, myocardium and endocardium, as well as the coronary arteries, the valves and the conduction system can all be affected. While pericarditis is common, arrythmias are less frequently described.We present a 13-year-old male, who had fatigue, anorexia, weight loss, myalgias and arthralgias for four months. On physical examination, we identified bradycardia (heart rate 31-50 bpm), oral and nasal ulcers and polyarthritis. The laboratory results showed hemolytic anemia, hypocomplementemia, antinuclear and anti-dsDNA antibodies, hematuria and non-nephrotic proteinuria. Renal function was normal. Lupus nephritis class II was diagnosed by kidney biopsy. On the transthoracic echocardiogram we identified a minimal pericardial effusion, suggesting pericarditis, and, on the electrocardiogram, we detected sinus arrest with junctional rhythm, denoting sinus node dysfunction. The patient was diagnosed with juvenile SLE with cardiac, renal, musculoskeletal and hematologic involvement. Disease remission and cardiac rhythm control were obtained with steroids and mycophenolate mofetil. Currently, the patient is asymptomatic, with normal sinus rhythm.We described an adolescent with SLE who had sinus node dysfunction upon diagnosis. Other cases have been reported in adults but none in juvenile SLE. All SLE patients should have a thorough cardiac examination to promptly diagnose and treat the innumerous cardiac manifestations of this disease.

Pro-Atherogenic Inflammatory Mediators in Inflammatory Bowel Disease Patients Increase the Risk of Thrombosis, Coronary Artery Disease, and Myocardial Infarction: A Scientific Dilemma

Inflammatory bowel disease (IBD), comprising ulcerative colitis and Crohn’s disease, is characterized by widespread inflammation of the gastrointestinal tract with systemic manifestations. Inflammation is one of the driving forces for the pathogenesis of atherosclerosis and its dreaded complications like myocardial infarction (MI). Yet, the association between IBD and myocardial infarction has not been thoroughly established.

Myocardial infarction in IBD patients was predominantly seen in young women during the active disease process. At the same time, elevated levels of C-reactive protein and other pro-inflammatory markers were observed in both IBD and atherosclerosis. Increasing evidence suggests inflammation inhibits fibrinolysis, expresses procoagulants, and suppresses anticoagulants promoting thrombosis formation. Moreover, the alteration of gut microbiota impacts the pathogenesis of inflammation and predisposes one to ischemic heart disease.

Accordingly, all IBD patients should be screened and counseled on lifestyle modifications for the traditional risk factors of atherosclerosis. Future researchers should consider conducting more clinical trials on anti-inflammatory medication targeting atherosclerosis and therapeutics, while targeting the gut microbiota to reverse the inflammatory atherosclerotic process.

The effect of a group exercise program on functional performance of patients with moderate knee osteoarthritis

Introduction. The aim of this study was to evaluate the effects of a weekly group exercise program on the functional performance of patients with knee osteoarthritis. Material and methods. Patients (aged 51-78 years) with knee osteoarthritis Kellgren-Lawrence grade II-III were included in an exercise program. The exercise sessions were held once-a week, for six months, being supervised by a physical therapist. The scope of the program was to increase the mobility, muscular strength and balance. The physical function outcome was assessed using the Short Physical Performance Battery (SPPB) in two moments – before and after participating in the exercise program. Results. All patients completed the group exercise program. The SPPB score at the time of inclusion in the study was 8.33 ± 1.9. After six months of exercising in the weekly group exercise program, the score increased significantly at 9.07 ± 1.73 (p<0.0001). Conclusions. In conclusion, participating in a group-based exercise program for six months have been proved to have beneficial outcomes in physical performance in patients with knee osteoarthritis.

Capacitive micromachined ultrasound transducers for intravascular ultrasound imaging

Intravascular ultrasound (IVUS) is a burgeoning imaging technology that provides vital information for the diagnosis of coronary arterial diseases. A significant constituent that enables the IVUS system to attain high-resolution images is the ultrasound transducer, which acts as both a transmitter that sends acoustic waves and a detector that receives the returning signals. Being the most mature form of ultrasound transducer available in the market, piezoelectric transducers have dominated the field of biomedical imaging. However, there are some drawbacks associated with using the traditional piezoelectric ultrasound transducers such as difficulties in the fabrication of high-density arrays, which would aid in the acceleration of the imaging speed and alleviate motion artifact. The advent of microelectromechanical system (MEMS) technology has brought about the development of micromachined ultrasound transducers that would help to address this issue. Apart from the advantage of being able to be fabricated into arrays with lesser complications, the image quality of IVUS can be further enhanced with the easy integration of micromachined ultrasound transducers with complementary metal-oxide-semiconductor (CMOS). This would aid in the mitigation of parasitic capacitance, thereby improving the signal-to-noise. Currently, there are two commonly investigated micromachined ultrasound transducers, piezoelectric micromachined ultrasound transducers (PMUTs) and capacitive micromachined ultrasound transducers (CMUTs). Currently, PMUTs face a significant challenge where the fabricated PMUTs do not function as per their design. Thus, CMUTs with different array configurations have been developed for IVUS. In this paper, the different ultrasound transducers, including conventional-piezoelectric transducers, PMUTs and CMUTs, are reviewed, and a summary of the recent progress of CMUTs for IVUS is presented.

Subclinical atherosclerosis in systemic sclerosis and rheumatoid arthritis: a comparative matched-cohort study

Systemic autoimmune inflammatory disorders confer a higher risk of cardiovascular (CV) disease leading to increased morbidity and mortality and reduced life expectancy compared to the general population. CV risk in systemic sclerosis (SSc) has not been studied extensively but surrogate markers of atherosclerosis namely carotid intima media thickness (cIMT) and pulse wave velocity (PWV) are impaired in some but not all studies in SSc patients. The aim of this study was to investigate the prevalence of subclinical atherosclerosis assessed by cIMT and PWV between two well-characterized SSc and Rheumatoid Arthritis (RA) cohorts. Consecutive SSc patients attending the Scleroderma Clinic were compared with RA patients recruited in the Dudley Rheumatoid Arthritis Co-morbidity Cohort (DRACCO), a prospective study examining CV burden in RA. Augmentation Index (Aix75) and cIMT were measured in all participants. Propensity score matching was utilised to select patients from the two cohorts with similar demographic characteristics, CV risk factors and inflammatory load. Unpaired analysis was performed using unpaired t test for continuous variables and χ² test for dichotomous variables. Statistical analysis was repeated using paired t test for continuous normal variables and McNemar's test for dichotomous variables. Fifty five age- and sex-matched SSc and RA patients were included in the analysis. No difference was demonstrated between SSc and RA subjects regarding cIMT (0.66 mm vs 0.63 mm, respectively) and Aix75% measurements (33.4 vs 31.7, respectively) neither in paired (p = 0.623 for cIMT and p = 0.204 for Aix%) nor in unpaired t test analysis (p = 0.137 for cIMT and p = 0.397 for AIx%). The results of this comparative study show that subclinical atherosclerosis is comparable between SSc and RA, a systemic disease with well-defined high atherosclerotic burden. Such findings underscore the importance of CV risk management in SSc in parallel with other disease-related manifestations.

Influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in electrocardiographic assessment of patients with systemic lupus erythematosus

Background

There are no data on the influence of disease severity and cardiac autonomic tone on ventricular repolarization and dispersion in 24-hour Holter monitoring in systemic lupus erythematosus (SLE).

Methods

Consecutive 92 SLE and 51 healthy subjects were studied. The standard 12-lead electrocardiography (ECG), Holter monitoring with heart rate turbulence (HRT) and QT, Tp-e and Tp-e/QT ratio assessment (including corrected values) were performed. Subjects with conditions causing repolarization abnormalities or insufficient number of beats suitable for QT evaluation were excluded (17 SLE and 8 controls).

Results

Finally, 75 SLE and 43 sex- and age-matched controls were included to the study. In SLE patients, the median disease severity score (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI)) was 3.0. The mean values of QTc, cTp-e and cTp-e/QTc were significantly higher in SLE patients than in controls. QTc ≥ 460 ms was observed in 18.7% of patients using standard ECG and in 58.7% using Holter monitoring. With Holter monitoring, patients with SLICC/ACR-DI >3.0 presented longer QTc than those with SLICC/ACR-DI ≤3.0 (418±15 vs. 409 ± 16, p = 0.04), while cTp-e and cTp-e/QTc values were similar. Patients with abnormal HRT presented longer cTp-e and higher cTp-e/QTc than those with normal HRT (92 ± 52 vs. 71 ± 16 ms, p = 0.04; 0.244 ± 0.126 vs. 0.187 ± 0.035, p = 0.03), while QTc values were similar. No differences in QT and Tp-e parameters were observed according to disease duration.

Conclusion

In SLE patients, Holter monitoring revealed QTc prolongation more frequently than standard ECG. Longer QTc values were observed in patients with more advanced disease, while increased cTp-e and cTp-e/QTc were related to cardiac autonomic dysfunction expressed by abnormal HRT.

A case of complete atrioventricular block in secondary hemophagocytic syndrome/hemophagocytic lymphohistiocytosis recovered by plasma exchange and cytokine absorbing therapy with AN69ST continuous hemodiafiltration

We report a case of incipient systemic lupus erythematosus (SLE) that rapidly progressed to complete atrioventricular block (cAVB). A 20-year-old man was admitted with facial erythema, painless oral aphtha, polyarthritis, and myalgia of each extremity. On admission, he developed first-degree atrioventricular block, pericarditis, pleuritis, renal failure, hemophagocytic lymphohistiocytosis, neurophychiatric SLE (left cerebellar infarction), and Staphylococcus aureus bacteremia. He was subsequently diagnosed with SLE based on several positive findings on immunological tests (including positive for antinuclear antibody). Despite immediate glucocorticoid pulse therapy and plasma exchange (PE) along with antibiotic, he developed cAVB that required temporary pacing on day 2. Because it was thought that hypercytokinemia exacerbated pericarditis, which progressed to myocarditis and cAVB, we decided to PE and cytokine-adsorbing therapy with AN69ST-continuous hemodiafiltration (CHDF). Other than renal failure, his organ dysfunctions improved with the multidisciplinary therapy. CAVB improved and temporary pacing was no longer required on day 11. Even a first-degree atrioventricular block can rapidly progress to cAVB; therefore, strict attention to electrocardiogram is necessary in severe SLE cases. When presenting with organ dysfunctions caused by hypercytokinemia such as severe SLE cases or SLE with severe infection cases, use of the combination of PE and AN69ST-CHDF might be beneficial.

Cardiac Autonomic Control in Women with Rheumatoid Arthritis During the Glittre Activities of Daily Living Test

Background: Cardiovascular autonomic dysfunction is one of the most common complications in rheumatoid arthritis (RA), which can be assessed by heart rate variability (HRV) analysis. Because the autonomic nervous system plays an important role in orchestrating the cardiovascular response to stressors, assessing HRV during exercise is critical. The Glittre Activities of Daily Living test (GA-T) was recently proposed as a multitask field test that requires the performance of the upper and lower limbs, both of which are affected in individuals with RA. Objectives: This study was conducted to evaluate autonomic impairment by HRV in women with RA using the GA-T and to correlate these changes with physical functioning and muscle strength. Methods: This cross-sectional study enrolled 20 women (median [interquartile range]: age 55 [47.5 - 68.8] years) with RA (time since diagnosis: 15 [6.50 - 23.5] years) who underwent HRV assessment during GA-T. They also underwent physical functioning assessment through the Health Assessment Questionnaire Disability Index (HAQ-DI) and handgrip strength (HGS) and quadriceps strength (QS) measures. Results: The GA-T time exhibited significant correlations with the following HRV indices: root mean square of successive differences (RMSSD, rs = -0.451, P = 0.041), proportion of iRR differing by > 50 ms from previous intervals (pNN50, rs = -0.697, P = 0.0006), high frequency (HF, rs = -0.693, P = 0.0007), standard deviation of the points perpendicular to the line-of-identity (SD1, rs = -0.476, P = 0.034), and approximate entropy (ApEn, rs = 0.545, P = 0.013). In addition, the HAQ-DI exhibited significant correlations with the following HRV indices: pNN50 (rs = -0.467, P = 0.038) and HF (rs = -0.444, P = 0.049). We did not observe significant correlation between the HRV indices during the GA-T and the muscle strength measures (HGS and QS). Conclusions: In women with RA, the longer the required to perform the GA-T the worse their parasympathetic modulation, sympathetic-vagal imbalance, and complexity of the autonomic nervous system (i.e., increased index of ApEn) were. Physical functioning level was also related to vagal modulation.

Correlations between Vascular Stiffness Indicators, OPG, and 25-OH Vitamin D3 Status in Heart Failure Patients

Background and objectives: The purpose of the study is to correlate vascular calcification biomarkers osteoprotegerin (OPG) and 25-hydroxyvitamin D₃ (25-OH-D₃), indicators of arterial stiffness carotid-femoral pulse wave velocity (c-f PWV) and renal resistive index (RRI), with parameters of left ventricular function in heart failure patients versus control. Materials and methods: Our case-control study compared 60 patients with ischemic heart failure and reduced left ventricular ejection fraction (LVEF) (<40%) with a control group of 60 healthy age-matched subjects (CON). Serum levels of OPG and 25-OH-D₃ were determined by ELISA. Left ventricular volumes (LVESV, LVEDV) and LVEF were measured by echocardiography. C-f PWV was determined using the arteriograph device. RRI was measured by duplex Doppler. Peak systolic velocity (PSV) and minimum end-diastolic velocity (EDV) were determined using angle correction. The estimated glomerular filtration rate (eGFR) was calculated using the MDRD equation. The Pearson’s correlation coefficient was used for interpretation of results. Results: OPG values were significantly higher in heart failure (HF) patients vs. CON (4.7 ± 0.25 vs. 1.3 ± 0.67 ng/mL, p < 0.001). 25-OH vitamin D₃ levels were significantly lower in HF patients vs. CON (20.49 ± 7.31 vs. 37.09 ± 4.59 ng/mL, p < 0.001). Multiple regression analysis considering 25-OH D3 as a dependent variable demonstrated indicators of vascular stiffness RRI, c-f PWV and vascular calcification biomarker OPG as predictors. OPG values were significantly correlated with cardiac parameters LVEDV (r = 0.862, p < 0.001), LVEF (r = −0.832, p < 0.001), and c-f PWV(r = 0.833, p < 0.001), and also with 25-OH-D₃ (r = −0.636, p < 0.001). RRI values were significantly correlated with cardiac parameters LVEDV (r = 0.586, p < 0.001) and LVEF (r = −0.587, p < 0.001), and with eGFR (r = −0.488, p < 0.001), c-f PWV(r = 0.640, p < 0.001), and 25-OH-D₃ (r = −0.732, p < 0.001). Conclusions: This study showed significant correlations between vitamin D deficit and vascular stiffness indicators in heart failure patients with reduced ejection fraction, demonstrating the importance of these examinations for a better evaluation of these patients. Together with the evaluation of renal function, the measurement of vascular stiffness indicators and biomarkers might play a key role in identifying patients at greater risk for worsening disease prognosis and for shorter life expectancy, who could benefit from vitamin D supplementation. The abstract was accepted for presentation at the Congress of the European Society of Cardiology, Munich, 2018.