Cause of death in rheumatoid arthritis

Vascular health in subjects with rheumatoid arthritis: assessment of endothelial function indices and serum biomarkers of vascular damage

BACKGROUND

The cardiovascular risk (CVD) in patients with rheumatoid arthritis (RA) is 1.5-2 times higher than that in individuals of the same age and sex.

AIMS

To analyse the degree of endothelial dysfunction, the atherogenic immunoinflammatory serum background and the relationships among some vascular indices, cardiovascular comorbidities, and cognitive performance in subjects with RA.

PATIENTS AND METHODS

All consecutive patients with a rheumatoid arthritis diagnosis admitted to the Rheumatology Ward of "Policlinico Paolo Giaccone" Hospital of Palermo were enrolled from July 2019 to September 2020. We evaluated our patients' cognitive functions by administering the Mini-Mental State Examination (MMSE). Reactive Hyperaemia Index (RHI) was evaluated for assessment of endothelial function. Serum levels of angiopoietin 2, osteopontin and pentraxin 3 were assessed by blood collection.

RESULTS

Fifty-eight consecutive patients with RA and 40 control subjects were analysed. RA patients showed significantly lower mean RHI values, significantly higher mean Augmentation Index (AIX) values and significantly lower mean Mini-Mental State Examination (MMSE) score values than the control group. Patients with rheumatoid arthritis also showed higher mean serum values of pentraxin 3 and angiopoietin 2 than healthy controls. Multivariate logistic regression analysis showed a significant association between pentraxin 3 and angiopoietin 2 and the presence of RA.

DISCUSSION

Angiopoietin 2 and pentraxin 3 could be considered surrogate biomarkers of endothelial activation and vascular disease, as they could play an essential role in the regulation of endothelial integrity and inflammation.

Rheumatoid Arthritis-Linked Artificial Joint Infections Leading to Amputations

Rheumatoid arthritis (RA) is a common autoimmune condition that can rarely cause more serious complications, such as permanent joint damage or infection, and may pose a significant additional risk during certain routine procedures. One major consequence of RA is that it can lead to serious and permanent joint damage requiring arthroplasty. Additionally, RA is a known cause of infection, with orthopedic prosthetic joint infections (PJIs) being documented. We explore one such serious case of a patient with long-term RA and a left knee joint replacement who presented to the emergency room with a serious PJI. History revealed that he repeatedly was affected by infections and had an extensive and severe clinical course, including nine revision surgeries. After a physical examination, imaging was performed, which further supported the diagnosis of joint infection. Considering the extensive number of attempts to salvage the joint, clinicians decided an above-knee amputation was necessary. This case highlights the fact that RA both increases the need for orthopedic arthroplasties and the risk of complications from these procedures, complicating clinical decision-making for physicians. Additionally, this patient had other underlying medical conditions and social habits that may have contributed to his severe clinical course, and we hope to explore these, discuss possible methods of modifying them, and assist clinicians in not only better treating similar patients but also emphasizing the importance of further developing standardized predictive algorithms and scoring tools.

Poor glycemic control enhances the disease activity in the RA patients with undiagnosed diabetes—a cross-sectional clinical study

Background

Rheumatoid arthritis (RA), an autoimmune disorder, characterized by systemic inflammation and swollen joints, establishes itself as a critical threat. A pro-inflammatory cytokine TNF-α is a well-known driver of RA pathogenesis and at the same time predisposes to insulin resistance through signal impediment which ultimately paves the way for type 2 diabetes (T2DM). However, in patients with RA, T2DM remains significantly undiagnosed or undertreated, apparently which increases the risk of developing cardio-metabolic comorbidities. This study aimed to evaluate the glycemic status among RA patients and its association with disease activity.

Result

One hundred fifty inpatients RA cases according to ACR/EULAR standards were included in the cross-sectional study who have an average age of 45.4±12.15 years and a median and interquartile period of RA of 2.25 years and 0.48–6 years, respectively. We discovered that 36% of people had T2DM, 26% were prediabetic, and 38% were non-diabetic. Age was shown to be significantly correlated with DM frequency in RA patients (p=0.007). There were 28 patients with elevated disease activity (19%) and 60 patients with low disease activity (40%) in this study. No substantial associations were found in the presence of DM with gender, anti-CCP, RF, disease duration, or DAS28.

Conclusion

RA patients are more likely to experience diabetes, and resultantly a high index of notion must be kept. Clinician should be aware about the affliction of undiagnosed diabetes and prediabetes in RA patients. Furthermore, keeping an eye on glycemic control in RA patients could prevent metabolic and cardiovascular comorbidities in those susceptible patients.

The versatile role of the contact system in cardiovascular disease, inflammation, sepsis and cancer

The human contact system consists of plasma proteins, which - after contact to foreign surfaces - are bound to them, thereby activating the zymogens of the system into enzymes. This activation mechanism gave the system its name - contact system. It is considered as a procoagulant and proinflammatory response mechanism, as activation finally leads to the generation of fibrin and bradykinin. To date, no physiological processes have been described that are mediated by contact activation. However, contact system factors play a pathophysiological role in numerous diseases, such as cardiovascular diseases, arthritis, colitis, sepsis, and cancer. Contact system factors are therefore an interesting target for new therapeutic options in different clinical conditions.

Evaluating the Use of Hydroxychloroquine in Treating Patients With Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases present today. Although treatment options may differ among clinicians, a commonly prescribed treatment is hydroxychloroquine (HCQ), alone or in combination with other medications. HCQ has been studied for its immunomodulatory effects as well as its role in treating adverse conditions associated with RA. This systematic review examined the use of HCQ therapy in RA patients. A systematic search for relevant literature through PubMed, National Institute of Informatics, Japan (CiNii), and Science Direct databases were carried out in August 2021. Literature directly related to HCQ therapy for RA patients, RA-associated chronic kidney disease, and cardiovascular disease (including lipid profile) was considered relevant. HCQ associated retinopathic adverse effects were also selected for this review. Thirty-eight articles were found to be relevant, passed quality assessment, and were included in this review. Nine articles discussed HCQ therapy in comparison with other therapies (mainly methotrexate and sulfasalazine), but were contradictory in their outcomes, as were the seven papers that reviewed kidney function in RA patients with and without HCQ. Five articles credited better cardiovascular outcomes to RA patients taking HCQ. Sixteen articles studied the relationship between HCQ and retinal toxicity, providing insights into the risks associated with HCQ therapy. HCQ therapy was found not only to be beneficial in slowing the disease progression in RA patients but enhanced the effects of methotrexate in treating RA as well. Data strongly associates HCQ therapy with the mitigation of RA-related cardiovascular and kidney conditions. However, if HCQ is prescribed, it is imperative to be aware of the possible (although rare) retinopathic adverse effects associated with this therapy.

Relevance of the antioxidant properties of methotrexate and doxycycline to their treatment of cardiovascular disease

Many medications exhibit clinical benefits that are unrelated to their primary therapeutic uses. In many cases, the mechanisms underpinning these pleotropic effects are unknown. Two commonly prescribed medications that exhibit pleotropic benefits in cardiovascular disease and other diseases associated with chronic inflammation are methotrexate (MTX) and doxycycline (DOX). The vast majority of cardiovascular disease is associated with atherosclerosis. Because atherosclerosis is a chronic inflammatory disease, possible mechanisms by which MTX and DOX reduce inflammation have been investigated. Interestingly, the primary structure of both of these medications contain aromatic phenolic rings, which resemble polyphenols that are known to possess antioxidant activity. Inflammation and oxidative stress are intimately related. Inflammation promotes oxidative stress, which in turn leads to further inflammation; in this way, oxidative stress and inflammation can establish a self-perpetuating cycle. It has been shown that MTX and DOX act as antioxidants and are capable of scavenging free radicals and the reactive oxygen species (ROS) superoxide (O₂^-). Furthermore, both MTX and DOX inhibit the formation of malondialdehyde acetaldehyde (MAA) adducts, products of oxidative stress and lipid peroxidation. Importantly, MAA-adducts are highly immunogenic and initiate inflammatory responses; thereby, fueling the cycle of inflammation and oxidative stress that results in chronic inflammation. Thus, reducing the formation of MAA-adducts may ameliorate inflammation that leads to ROS production and in this way, break the self-sustaining cycle of oxidative stress and inflammation. It is possible that the under-recognized antioxidant properties of these medications may be a mechanism by which they and other medications provide pleotropic benefit in the treatment of chronic inflammatory disease.

Combination effect of anti-rheumatic medications for coronary artery diseases risk in rheumatoid arthritis: a nationwide population-based cohort study

OBJECTIVES

To determine whether a combination of anti-rheumatic drugs is associated with the risk of coronary artery diseases (CAD) in incident rheumatoid arthritis (RA) patients.

METHODS

This population-based cohort study used administrative data to identify 6260 newly-diagnosed patients with RA (age ≥20 years) as the study group. The study end-point was occurrence of CAD according to the ICD-9-CM codes. Exposure to different combinations of drugs and the risk of CAD was assessed. These included different combinatiosn of celecoxib (Cx), hydroxychloroquine (HCQ), methotrexate (MTX), and sulfasalazine (SSZ). Patients who never used Cx, HCQ, MTX, or SSZ were used as a reference group. A Cox proportional hazards model was used to estimate the hazard ratio (HR) of disease after controlling for demographic and other co-morbidities. When the proportionality assumption was violated, the spline curve of the Scaled Schoenfeld residuals was fitted to demonstrate the estimated effect on CAD over time for drug usage.

RESULTS

Among RA patients, the adjusted HR (95% confidence interval) of CAD for "Cx only", "Cx and HCQ ever", and "Cx, HCQ, MTX, and SSZ ever", were 0.29 (0.19-0.44), 0.46 (0.24-0.88), and 0.42 (0.24- 0.75), respectively, during the first period of 0-3, 4, or 7 years. However, they became 1.04 (0.78-1.38), 1.16 (0.62-2.19), and 0.59 (0.32-1.08), respectively, during the second time period of 3, 4, or 7-10 years. The adjusted HR (95% CI) of CAD for "Cx, MTX, and SSZ ever" remains constant at 0.12 (0.02-0.89).

CONCLUSIONS

Celecoxib-DMARDs drug combinations were associated with reduced CAD risk on incident RA patients, and some of them exhibited the time-varying drug effect.

Assessment of left atrial function using speckle tracking echocardiography in ankylosing spondylitis: a case-control study

The aim of this study is to assess the left atrium (LA) deformation parameters by using 2D speckle tracking echocardiography (2D-STE) in ankylosing spondylitis (AS) patients and to evaluate the relationship between these parameters and AS clinical indexes. 30 patients with AS (22 males, 8 females) and 30 healthy individuals (19 males, 11 females) were enrolled in this study. Transthoracic echocardiography was performed to both groups. Besides the conventional echocardiographic parameters, the LA strain parameters; including systolic-reservoir (LA S-S), early diastolic-conduit (LA S-E), late diastolic-contraction (LA S-A) were measured. No significant difference was found between two groups in terms of conventional echocardiographic parameters except mean deceleration time (DT). Mean DT was prolonged in the AS patients compare with the control group (173.5 ± 22.5 vs. 155.3 ± 36.7, p = 0.025). In the AS patients, LA S-S (48.3 ± 9.4 vs. 56.9 ± 10.1, p = 0.001), LA S-E (26.4 ± 6.4 vs. 31.6 ± 7.3, p = 0.005) and LA S-A (21.9 ± 4.7 vs. 25.4 ± 5.7, p = 0.013) values were statistically lower than the control group. Also a negative correlation was observed between the Bath Ankylosing Spondylitis Metrology Index (BASMI) and LA S-S (r = - 0.509, p = 0.004), LA S-E (r = - 0.501, p = 0.005). Our study demonstrated that 2D-STE is a useful method to determine the left atrial involvement in AS patients without the clinical evident of cardiovascular disease.

Etanercept for the treatment of rheumatoid arthritis

Etanercept was the first specific anticytokine therapy approved for the treatment of rheumatoid arthritis (RA). Its clinical efficacy and safety has been demonstrated by several clinical trials in early as well as established disease. Etanercept, along with other TNF inhibitors, have revolutionized management of RA and dramatically improved disease activity, function, quality of life and mortality for these patients. It is structurally distinct from other TNF inhibitors and thus has desirable profiles for immunogenicity, drug survival and infection rate. With the increasing number of etanercept biosimilars, there will likely be a resurgence of their prescription. This article reviews the pharmacology, efficacy and safety of the etanercept reference product, and its biosimilars, in the context of RA treatment.

Subclinical atherosclerosis in patients with rheumatoid arthritis

We performed a systematic review with meta-analysis and meta-regression of literature studies evaluating the impact of rheumatoid arthritis (RA) on common carotid artery intima-media thickness (CCAIMT) and on the prevalence of carotid plaques. Studies evaluating the relationship between RA and markers of cardiovascular (CV) risk (CCA-IMT and prevalence of carotid plaques) were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. A total of 59 studies (4,317 RA patients and 3,606 controls) were included in the final analysis, 51 studies with data on CCA-IMT (52 data-sets on 3,600 RA patients and 3,020 controls) and 35 studies reporting on the prevalence of carotid plaques (2,859 RA patients and 2,303 controls). As compared to controls, RA patients showed a higher CCA-IMT (mean difference [MD]: 0.10 mm; 95 % confidence interval [CI]: 0.07, 0.12; p < 0.00001), and an increased prevalence of carotid plaques (odds ratio [OR]: 3.61; 95 %CI: 2.65, 4.93; p< 0.00001). Interestingly, when analysing studies on early RA, the difference in CCAIMT among RA patients and controls was even higher (MD: 0.21 mm; 95 %CI: 0.06, 0.35; p=0.006), and difference in the prevalence of carotid plaques was entirely confirmed (OR: 3.57; 95 %CI: 1.69, 7.51; p=0.0008). Meta-regression models showed that male gender and a more severe inflammatory status [as expressed by disease activity score in 28 joints (DAS28), C-reactive protein (CRP) levels, and erythrocyte sedimentation rate (ESR)] significantly impacted on CCA-IMT. In conclusion, RA appears significantly associated with subclinical atherosclerosis and CV risk. These findings can be useful to plan adequate prevention strategies and therapeutic approaches.

Interleukin 6 Inhibition and Coronary Artery Disease in a High-Risk Population: A Prospective Community-Based Clinical Study

Background

Atherosclerosis is a chronic inflammatory disease, with interleukin 6 (IL‐6) as a major player in inflammation cascade. IL‐6 blockade may reduce cardiovascular risk, but current treatments to block IL‐6 also induce dyslipidemia, a finding with an uncertain prognosis.

Methods and Results

We aimed to determine the endothelial function responses to the IL‐6–blocking agent tocilizumab, anti–tumor necrosis factor α, and synthetic disease‐modifying antirheumatic drug therapies in patients with rheumatoid arthritis in a 16‐week prospective study. Sixty consecutive patients with rheumatoid arthritis were enrolled. Tocilizumab and anti–tumor necrosis factor α therapy were started in 18 patients each while 24 patients were treated with synthetic disease‐modifying antirheumatic drugs. Forty patients completed the 16‐week follow‐up period. The main outcome was flow‐mediated dilation percentage variation before and after therapy. In the tocilizumab group, flow‐mediated dilation percentage variation increased statistically significantly from a pre‐treatment mean of (3.43% [95% CI, 1.28–5.58] to 5.96% [95% CI, 3.95–7.97]; P=0.03). Corresponding changes were 4.78% (95% CI, 2.13–7.42) to 6.75% (95% CI, 4.10–9.39) (P=0.09) and 2.87% (95% CI, −2.17 to 7.91) to 4.84% (95% CI, 2.61–7.07) (P=0.21) in the anti–tumor necrosis factor α and the synthetic disease‐modifying antirheumatic drug groups, respectively (both not statistically significant). Total cholesterol increased significantly in the tocilizumab group from 197.5 (95% CI, 177.59–217.36) to 232.3 (201.62–263.09) (P=0.003) and in the synthetic disease‐modifying antirheumatic drug group from 185.8 (95% CI, 169.76–201.81) to 202.8 (95% CI, 176.81–228.76) (P=0.04), but not in the anti–tumor necrosis factor α group. High‐density lipoprotein did not change significantly in any group.

Conclusions

Endothelial function is improved by tocilizumab in a high‐risk population, even as it increases total cholesterol and low‐density lipoprotein levels.

Improvement in 5-year mortality in incident rheumatoid arthritis compared with the general population-closing the mortality gap

OBJECTIVE

Excess mortality in rheumatoid arthritis (RA) is expected to have improved over time, due to improved treatment. Our objective was to evaluate secular 5-year mortality trends in RA relative to general population controls in incident RA cohorts diagnosed in 1996-2000 vs 2001-2006.

METHODS

We conducted a population-based cohort study, using administrative health data, of all incident RA cases in British Columbia who first met RA criteria between January 1996 and December 2006, with general population controls matched 1:1 on gender, birth and index years. Cohorts were divided into earlier (RA onset 1996-2000) and later (2001-2006) cohorts. Physician visits and vital statistics data were obtained until December 2010. Follow-up was censored at 5 years to ensure equal follow-up in both cohorts. Mortality rates, mortality rate ratios and HRs for mortality (RA vs controls) using proportional hazard models adjusting for age, were calculated. Differences in mortality in RA versus controls between earlier and later incident cohorts were tested via interaction between RA status (case/control) and cohort (earlier/later).

RESULTS

24 914 RA cases and controls experienced 2747 and 2332 deaths, respectively. Mortality risk in RA versus controls differed across incident cohorts for all-cause, cardiovascular diseases (CVD) and cancer mortality (interactions p<0.01). A significant increase in mortality in RA versus controls was observed in earlier, but not later, cohorts (all-cause mortality adjusted HR (95% CI): 1.40 (1.30 to 1.51) and 0.97 (0.89 to 1.05), respectively).

CONCLUSIONS

In our population-based incident RA cohort, mortality compared with the general population improved over time. Increased mortality in the first 5 years was observed in people with RA onset before, but not after, 2000.

Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs

Objective

To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ).

Methods

In 13 310 patients with RA observed in the German biologics register Rheumatoid Arthritis: Observation of Biologic Therapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure.

Results

37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2−0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment.

Conclusions

The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation.

Clinical assessment of endothelial function in patients with rheumatoid arthritis: A meta-analysis of literature studies

BACKGROUND

Several studies reported an increased cardiovascular (CV) morbidity and mortality in patients with rheumatoid arthritis (RA). Flow-mediated (FMD) and nitrate-mediated dilation (NMD) are considered non-invasive methods to assess endothelial function and surrogate markers of subclinical atherosclerosis.

METHODS

We performed a systematic review with meta-analysis and meta-regression of literature studies evaluating the impact of RA on FMD and NMD. Studies evaluating the relationship between RA and markers of CV risk (FMD and NMD) were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. The random-effect method was used for analyses and results were expressed as mean difference (MD).

RESULTS

A total of 20 studies (852 RA patients, 836 controls) were included in the final analysis. In detail, 20 studies with data on FMD (852 cases, 836 controls) and 5 studies with data on NMD (207 cases, 147 controls) were analyzed. Compared to controls, RA patients showed a significantly lower FMD (MD: -2.16%; 95% CI: -3.33, -0.98; P=0.0003), with no differences in NMD (MD: -0.41%; 95% CI: -2.89, 2.06; P=0.74). Interestingly, a lower FMD (MD: -2.00%; 95% CI: -3.20, -0.80; P=0.001) and no differences in NMD (P=0.49) were confirmed when excluding data on patients with early-RA. Meta-regression models showed that a more severe inflammatory status was associated with a more significant impairment in FMD.

CONCLUSIONS

RA patients show impaired FMD, which is currently considered an independent predictor of CV events. The presence of endothelial dysfunction in RA should be taken into account to plan adequate prevention strategies and therapeutic approaches.

Association of Cardiovascular Risk Factors with Carotid Intima Media Thickness in Patients with Rheumatoid Arthritis with Low Disease Activity Compared to Controls: A Cross-Sectional Study

Objectives

Rheumatoid arthritis (RA) has been identified as an independent cardiovascular risk factor. The importance of risk factors such as hypertension and hyperlipidemia in the generation of atherosclerosis in RA patients is unclear. This study analyzed clinical parameters associated with carotid intima media thickness (cIMT) in patients with RA.

Methods

Subjects with RA and healthy controls without RA, both without known cardiovascular disease, were included. Participants underwent a standard physical examination and laboratory measurements including a lipid profile. cIMT was measured semi-automatically by ultrasound.

Results

In total 243 RA patients and 117 controls were included. The median RA disease duration was 7 years (IQR 2–14 years). The median DAS28 was 2.4 (IQR 1.6–3.2) and 114 (50.4%) of the RA patients were in remission. The presence of RA and cIMT were not associated (univariate analysis). Multivariable regression analysis showed that cIMT in RA patients was associated with age (B = 0.006, P<0.001) and systolic blood pressure (B = 0.003, P = 0.003). In controls, cIMT was associated with age (B = 0.006, P<0.001) and smoking (B = 0.097, P = 0.001).

Conclusion

cIMT values were similar between RA patients and controls. Hypertension was strongly associated with cIMT in RA patients. After adjustment, no association between cIMT and specific RA disease characteristics was found in this well treated RA cohort.

Biological agents and respiratory infections: Causative mechanisms and practice management

Biological agents are increasingly being used to treat patients with immune-mediated inflammatory disease. In Japan, currently approved biological agents for patients with rheumatoid arthritis (RA) include tumor necrosis factor inhibitors, interleukin-6 receptor-blocking monoclonal antibody, and T-cell costimulation inhibitor. Rheumatologists have recognized that safety issues are critical aspects of treatment decisions in RA. Therefore, a wealth of safety data has been gathered from a number of sources, including randomized clinical trials and postmarketing data from large national registries. These data revealed that the most serious adverse events from these drugs are respiratory infections, especially pneumonia, tuberculosis, nontuberculous mycobacteriosis, and Pneumocystis jirovecii pneumonia, and that the most common risk factors associated with these respiratory infections are older age, concomitant corticosteroid use, and underlying respiratory comorbidities. Because of this background, in 2014, the Japanese Respiratory Society published their consensus statement of biological agents and respiratory disorders. This review summarizes this statement and adds recent evidence, especially concerning respiratory infections in RA patients, biological agents and respiratory infections, and practice management of respiratory infections in patients treated with biological agents. To decrease the incidence of infections and reduce mortality, we should know the epidemiology, risk factors, management, and methods of prevention of respiratory infections in patients receiving biological agents.

Non-invasive assessment of arterial stiffness in patients with rheumatoid arthritis: a systematic review and meta-analysis of literature studies

INTRODUCTION

Patients with rheumatoid arthritis (RA) have an increased cardiovascular (CV) morbidity and mortality. Pulse-wave velocity (PWV) and augmentation index (AIx) are non-invasive methods to assess arterial stiffness, a marker of CV risk. We performed a meta-analysis evaluating the impact of RA on aortic-PWV, brachial-PWV, brachial-ankle (ba-) PWV, AIx, and AIx normalized to a 75 beats/minute heart rate (AIx@75).

MATERIALS AND METHODS

Studies evaluating the relationship between RA and aortic-PWV, brachial-PWV, ba-PWV, AIx, and AIx@75 were systematically searched. A total of 25 studies (1,472 RA patients, 1,583 controls) were included.

RESULTS

Compared to controls, RA patients showed a significantly higher aortic-PWV (mean difference 1.32 m/s; 95% CI 0.77, 1.88; P < 0.00001), ba-PWV (MD 198.42 cm/s; 95% CI 45.79, 342.76; P = 0.01), AIx (MD 11.50%; 95% CI 5.15, 17.86; P = 0.0004), and AIx@75 (MD 6.99%; 95% CI 4.92, 9.06; P < 0.00001), with a trend toward a higher brachial-PWV (MD 0.34 m/s; 95% CI -0.03, 0.70; P = 0.07). When analyzing studies on early RA, the difference in aortic-PWV among RA patients and controls was even higher (MD 2.30 m/s; 95% CI 1.15, 3.45; P < 0.0001).

CONCLUSION

Meta-regression showed that a more severe inflammatory status impacted on aortic-PWV, AIx, and AIx@75. Arterial stiffness, a recognized marker of CV risk, is increased in RA patients. This alteration is associated with the severity of the inflammatory status and is present even in early-stage disease.

[Vaccination in patients from Brasília cohort with early rheumatoid arthritis]

INTRODUCTION

Patients with a diagnosis of rheumatoid arthritis (RA) are at increased risk of infections. Vaccination is a recommended preventive measure. There are no studies evaluating the practice of vaccination in patients with early RA.

OBJECTIVES

To evaluate the frequency of vaccination and the orientation (by the doctor) about vaccines among patients with early RA diagnosis.

METHODS

Cross-sectional study including patients from the early RA Brasilia cohort. Demographic data, disease activity index (Disease Activity Score 28 - DAS28), functional disability (Health Assessment Questionnaire - HAQ), and data on treatment and vaccination after diagnosis of RA were analyzed.

RESULTS

68 patients were evaluated, 94.1% women, mean age 50.7±13.2 years. DAS28 was 3.65±1.64, and HAQ was 0.70. Most patients (63%) had vaccination card. Only five patients (7.3%) were briefed by the doctor about the use of vaccines. Patients were vaccinated for MMR (8.8%), tetanus (44%), yellow fever (44%), hepatitis B (22%), influenza (42%), H1N1 (61.76%), pneumonia (1.4%), meningitis (1.4%), and chickenpox (1.4%). All patients vaccinated with live attenuated virus were undergoing immunosuppressive therapy, and were vaccinated inadvertently, without medical supervision. There was no association between the use of any vaccine and disease activity, functional disability, years of education, lifestyle, and comorbidities.

CONCLUSION

Patients were infrequently briefed by the physician regarding use of vaccines, with high frequency of inadvertent vaccination with live attenuated component, while immunization with killed virus was below the recommended level.

[Multimorbidity in elderly rheumatic patients part 2]

While diseases, such as cardiovascular diseases and osteoporosis in the elderly are categorized as comorbidities of rheumatoid arthritis, elderly rheumatic patients are often additionally affected by thyroid dysfunctions and diabetes mellitus type 2, so that the risk of multimorbidity (coexistence of at least two chronic and/or acute diseases) will increase significantly in elderly patients already suffering from systemic rheumatic diseases. Restricted cognition, adherence or compliance may additionally complicate the treatment of elderly rheumatic patients. Furthermore, the pharmacokinetics of the elderly is another challenging task. Referring to selected aspects of geriatric pharmacotherapy, the use of certain substance classes is described in this context.

Progression of coronary artery atherosclerosis in rheumatoid arthritis: comparison with participants from the Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

In cross-sectional studies, patients with rheumatoid arthritis (RA) have higher coronary artery calcium (CAC) than controls. However, their rate of progression of CAC and the predictors of CAC progression have heretofore remained unknown.

METHODS

Incidence and progression of CAC were compared in 155 patients with RA and 835 control participants. The association of demographic characteristics, traditional cardiovascular risk factors, RA disease characteristics and selected inflammatory markers with incidence and progression of CAC were evaluated.

RESULTS

The incidence rate of newly detected CAC was 8.2/100 person-years in RA and 7.3/100 person-years in non-RA control subjects [IRR 1.1 (0.7-1.8)]. RA patients who developed newly detectable CAC were older (59 ± 7 vs. 55 ± 6 years old, p=0.03), had higher triglyceride levels (137 ± 86 vs. 97 ± 60 mg/dL, p=0.03), and higher systolic blood pressure (129 ± 17 vs. 117 ± 15 mm Hg, p=0.01) compared to those who did not develop incident CAC. Differences in blood pressure and triglyceride levels remained significant after adjustment for age (p<=0.05). RA patients with any CAC at baseline had a median rate of yearly progression of 21 (7-62) compared to 21 (5-70) Agatston units in controls. No statistical differences between RA progressors and RA non-progressors were observed for inflammatory markers or for RA disease characteristics.

CONCLUSIONS

The incidence and progression of CAC did not differ between RA and non-RA participants. In patients with RA, incident CAC was associated with older age, higher triglyceride levels, and higher blood pressure, but not with inflammatory markers or RA disease characteristics.

The association between n-3 polyunsaturated fatty acid levels in erythrocytes and the risk of rheumatoid arthritis in Korean women

BACKGROUND

Rheumatoid arthritis (RA) is one of the most common autoimmune diseases that result in chronic inflammation of the joints. n-3 polyunsaturated fatty acids (PUFAs) have been suggested to play a role in the pathogenesis and clinical course of RA. The purpose of the present study was to investigate whether erythrocyte levels of n-3 PUFA are associated with an increased risk of RA and whether this could potentially serve as an indicator of RA disease activity in Korean women.

METHODS

A total of 100 female RA patients and 100 healthy women were enrolled into this study. Erythrocyte fatty acid composition and RA disease activity were evaluated in all patients.

RESULTS

Erythrocyte levels of α-linolenic acid (ALA; 18:3n3), eicosapentaenoic acid (EPA; 20:5n3), and the omega-3 index [EPA + docosahexaenoic acid (DHA)] were significantly lower in RA patients than in healthy controls. Multivariable-adjusted regression analysis showed that the levels of ALA, EPA, and the ratio of EPA to arachidonic acid were negatively associated with the risk of RA after adjusting for body weight and smoking status. Additionally, the concentration of prostaglandin E2 was significantly decreased with increased levels of erythrocyte DHA among RA patients.

CONCLUSIONS

Erythrocyte levels of EPA and ALA were negatively associated with the risk of RA in Korean women, which may be related to eicosanoid metabolism.

Carotid atherosclerosis in patients with rheumatoid arthritis and rheumatoid nodules

OBJECTIVE

To determine whether an association exists between the presence of rheumatoid nodules and thickening of the intima-media and plaque of the carotid artery, which is evidence of atherosclerosis.

MATERIALS AND METHODS

Observational, cross-sectional study of 124 patients with rheumatoid arthritis from a University Hospital clinic from 2005 to 2006. We divided the patients into 2 groups, 62 with rheumatoid nodules and 62 without rheumatoid nodules, matched for age and sex. Medical history, erythrocyte sedimentation rate, anti-cyclic citrullinated peptide, rheumatoid factor, and a high resolution doppler ultrasound of the carotid arteries were performed.

RESULTS

Women comprised 89.5% of the patients. The prevalence of a carotid plaque was 57% in our population. The presence of a plaque was associated with age, arterial hypertension and abdominal circumference. Average intima-media thickness (IMT) in patients with a plaque was 0.085 cm (± 0.02). There was no correlation between laboratory parameters and thickening of the intima-media of the carotid artery. Subcutaneous nodules were present in 33 (47%) of the 70 patients with a carotid plaque and in 29 (54%) of patients without a carotid plaque (p=.471).

CONCLUSIONS

We did not find an association between rheumatoid nodules and the presence of a carotid plaque and thickening of the intima-media of the carotid in patients with rheumatoid arthritis.

Suboptimal cardiovascular risk factor identification and management in patients with rheumatoid arthritis: a cohort analysis

Introduction

Accelerated cardiovascular (CV) disease significantly contributes to increased mortality in rheumatoid arthritis (RA) patients, with a risk comparable to the one observed in patients with type 2 diabetes mellitus (DM). Part of this enhanced risk in RA is attributed to traditional cardiovascular risk factors (CRFs). The aims of this study were to determine how often traditional CRFs are identified and managed by (a) rheumatologists, compared with primary care physicians (PCPs) in RA patients; and (b) PCPs among patients with RA, DM, and the general population (GP).

Methods

A retrospective cohort study compared age/gender/ethnicity-matched patients from three groups: RA, DM, and GP (without RA or DM); n = 251 patients per group. Electronic patient records were reviewed during a continuous 12-month period between June 2007 and April 2011 to assess whether CRFs were identified and managed.

Results

In RA patients, PCPs managed obesity, BP, and lipids significantly more often than did rheumatologists. PCPs managed obesity, BP, and lipids significantly more often in diabetic patients than in the other two groups, and more often in the GP than in RA patients. In patients with elevated BMI, PCPs managed weight in 68% of the DM group, 46% of the GP, and 31% of the RA group (P < 0.0001 for all groups; P = 0.006 between RA and GP groups).

Conclusions

Rheumatologists identify and manage CRFs less frequently than PCPs. PCPs manage CRFs less frequently in RA patients, compared to the GP and DM. Given the increased CV risk associated with RA, physicians need to more aggressively manage CRFs in these patients.

Development and validation of a risk score for serious infection in patients with rheumatoid arthritis

OBJECTIVE

Infection risk is increased in patients with rheumatoid arthritis (RA), and accurate assessment of the risk of infection could inform clinical decision-making. This study was undertaken to develop and validate a score to predict the 1-year risk of serious infection in patients with RA.

METHODS

We studied a population-based cohort of Olmsted County, Minnesota residents with incident RA ascertained in 1955-1994 whose members were followed up longitudinally, via complete medical records, until January 2000. The validation cohort included residents with incident RA ascertained in 1995-2007. The outcome measure included all serious infections (requiring hospitalization or intravenous antibiotics). Potential predictors were examined using multivariable Cox models. The risk score was estimated directly from the multivariable model, and performance was assessed in the validation cohort using Harrell's C statistic.

RESULTS

Among the 584 RA patients in the original cohort (72% female; mean age 57.5 years), who were followed up for a median of 9.9 years, 252 had ≥ 1 serious infection (646 total infections). Components of the risk score included age, previous serious infection, corticosteroid use, elevated erythrocyte sedimentation rate, extraarticular manifestations of RA, and comorbidities (coronary heart disease, heart failure, peripheral vascular disease, chronic lung disease, diabetes mellitus, alcoholism). Validation analysis revealed good discrimination (C statistic 0.80).

CONCLUSION

RA disease characteristics and comorbidities can be used to accurately assess the risk of serious infection in patients with RA. Knowledge of risk of serious infection in RA patients can influence clinical decision making and inform strategies to reduce and prevent the occurrence of these infections.

The risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment

RA is known to be associated with an increased risk of serious infection. Even more than 50 years ago, observational studies showed a greater than 2-fold increased risk of serious infection in RA. This was reinforced by various subsequent cohort studies. The elevated susceptibility of patients with RA can be explained by the pathobiology of the disease itself, the impact of chronic comorbid conditions, as well as sequelae of immunosuppressive treatment. It has been suggested that premature ageing of the immune system in RA contributes to weakened protection against infectious organisms. In addition, chronic comorbid conditions such as diabetes or chronic lung or kidney disease, disease-related functional disability, as well as lifestyle factors such as smoking, increase the risk in individual patients. For a long time glucocorticoids (GCs) have been used as potent immunosuppressive drugs in RA. There is evidence that they increase the risk of serious infections up to 4-fold in a dose-dependent manner. TNF-α inhibitors increase the serious infection risk up to 2-fold. They have, however, the potential to outweigh their risk when higher GC doses can be tapered down. If patients need higher dosages of GCs in addition to treatment with biologic agents, their risk of infection is substantial. This combination should be used carefully and, if possible, avoided in patients with additional risk factors such as older age or comorbid conditions.

Prevalence of traditional modifiable cardiovascular risk factors in patients with rheumatoid arthritis: comparison with control subjects from the multi-ethnic study of atherosclerosis

OBJECTIVE

Despite the recognized risk of accelerated atherosclerosis in patients with rheumatoid arthritis (RA), little is known about cardiovascular risk management in contemporary cohorts of these patients. We tested the hypotheses that major modifiable cardiovascular risk factors were more frequent and rates of treatment, detection, and control were lower in patients with RA than in non-RA controls.

METHODS

The prevalence of hypertension, diabetes, elevated low-density lipoprotein (LDL) cholesterol, elevated body mass index, smoking, moderate-high 10-year cardiovascular risk and the rates of underdiagnosis, therapeutic treatment, and recommended management were compared in 197 RA patients and 274 frequency-matched control subjects, and their associations with clinical characteristics were examined.

RESULTS

Eighty percent of RA patients and 81% of control subjects had at least 1 modifiable traditional cardiovascular risk factor. Hypertension was more prevalent in the RA group (57%) than in controls [42%, P = 0.001]. There were no statistically significant differences in the frequency of diabetes, elevated body mass index, smoking, intermediate-high 10-year coronary heart disease risk, or elevated LDL in patients with RA versus controls. Rates of newly identified diabetes, hypertension, and hyperlipidemia were similar in RA patients versus controls. Rates of therapeutic interventions were low in both groups but their use was associated with well-controlled blood pressure (OR = 4.55, 95% CI: 1.70, 12.19) and lipid levels (OR = 9.90, 95% CI: 3.30, 29.67).

CONCLUSIONS

Hypertension is more common in RA than in controls. Other traditional cardiovascular risk factors are highly prevalent, underdiagnosed, and poorly controlled in patients with RA, as well as controls.

Myocarditis

Myocarditis is an underdiagnosed cause of acute heart failure, sudden death, and chronic dilated cardiomyopathy. In developed countries, viral infections commonly cause myocarditis; however, in the developing world, rheumatic carditis, Trypanosoma cruzi, and bacterial infections such as diphtheria still contribute to the global burden of the disease. The short-term prognosis of acute myocarditis is usually good, but varies widely by cause. Those patients who initially recover might develop recurrent dilated cardiomyopathy and heart failure, sometimes years later. Because myocarditis presents with non-specific symptoms including chest pain, dyspnoea, and palpitations, it often mimics more common disorders such as coronary artery disease. In some patients, cardiac MRI and endomyocardial biopsy can help identify myocarditis, predict risk of cardiovascular events, and guide treatment. Finding effective therapies has been challenging because the pathogenesis of chronic dilated cardiomyopathy after viral myocarditis is complex and determined by host and viral genetics as well as environmental factors. Findings from recent clinical trials suggest that some patients with chronic inflammatory cardiomyopathy have a progressive clinical course despite standard medical care and might improve with a short course of immunosuppression.

Systematic review and meta-analysis of methotrexate use and risk of cardiovascular disease

Inflammation predicts risk for cardiovascular disease (CVD) events, but the relation of drugs that directly target inflammation with CVD risk is not established. Methotrexate is a disease-modifying antirheumatic drug broadly used for the treatment of chronic inflammatory disorders. A systematic review and meta-analysis of evidence of relations of methotrexate with CVD occurrence were performed. Cohorts, case-control studies, and randomized trials were included if they reported associations between methotrexate and CVD risk. Inclusions and exclusions were independently adjudicated, and all data were extracted in duplicate. Pooled effects were calculated using inverse variance-weighted meta-analysis. Of 694 identified publications, 10 observational studies in which methotrexate was administered in patients with rheumatoid arthritis, psoriasis, or polyarthritis met the inclusion criteria. Methotrexate was associated with a 21% lower risk for total CVD (n = 10 studies, 95% confidence interval [CI] 0.73 to 0.87, p <0.001) and an 18% lower risk for myocardial infarction (n = 5, 95% CI 0.71 to 0.96, p = 0.01), without evidence for statistical between-study heterogeneity (p = 0.30 and p = 0.33, respectively). Among prespecified sources of heterogeneity explored, stronger associations were observed in studies that adjusted for underlying disease severity (relative risk 0.64, 95% CI 0.43 to 0.96, p <0.01) and for other concomitant medication (relative risk 0.73, 95% CI 0.63 to 0.84, p <0.001). Publication bias was potentially evident (funnel plot, Begg's test, p = 0.06); excluding studies with extreme risk estimates did not, however, alter results (relative risk 0.81, 95% CI 0.74 to 0.89). In conclusion, methotrexate use is associated with a lower risk for CVD in patients with chronic inflammation. These findings suggest that a direct treatment of inflammation may reduce CVD risk.

QT dispersion and cardiac involvement in patients with juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the commonest cause of chronic inflammatory arthritis in childhood. Cardiac involvement as pericarditis, myocarditis and valvular disease is known to occur in patients with JIA (JIA), as it does in adults with rheumatoid arthritis. There are, however, few descriptions concerning systolic and diastolic functions of the left ventricle (LV) in children with JIA. QT dispersion (QTd) is simple noninvasive arrhythmogenic marker that can be used to assess homogeneity of cardiac repolarization and which has not been studied in JIA patients before. A recent study found that rheumatoid arthritis patients had an abnormally longer QTd and corrected QT (cQTd) dispersion, markers for ventricular arrhythmogenicity. This study assessed QTd and cQTd and their relation with systolic and diastolic function of the LV in a group of children with JIA. We performed electrocardiography and Doppler echocardiography on patients and controls. Maximum QT (QTmax), minimum QT (QTmin), QTd, corrected QT, maximum corrected QT (cQTmax), minimum corrected QT (cQTmin) and cQTd intervals were measured from standard 12-lead electrocardiography. No statistically significant differences were found between the groups in QTd and cQTd. Among the diastolic parameters, increased late flow velocity, decreased early flow velocity and prolonged isovolumic relaxation time reflected an abnormal relaxation form of diastolic dysfunction. During 12 months of follow-up, no ventricular arrhythmias were documented in either group.

Lower gastrointestinal perforation in rheumatoid arthritis patients treated with conventional DMARDs or tocilizumab: a systematic literature review

Tocilizumab, a monoclonal antibody targeting the IL-6 receptor, has recently been added to the therapeutic armamentarium against rheumatoid arthritis (RA). Despite its overall safety, concerns have been raised regarding diverticular perforation in patients receiving the drug. The aim of our research was to document the incidence of diverticular disease in RA patients treated in the pre-disease-modifying anti-rheumatic drug (DMARD) era, following treatment with conventional DMARDs, and subsequent to tocilizumab therapy. We performed a systematic literature review in MEDLINE, EMBASE, Conference Proceedings Citation Index-Science, Cochrane Central Register of Controlled Trials and Current Controlled Trials up to Nov. 2010. The publication titles and abstracts were independently assessed by two reviewers for relevance and quality, and the review was conducted following guidelines from the Centre for Reviews and Dissemination. In the pre-DMARD period of RA management, where patients were largely treated with NSAIDs and corticosteroids, gastrointestinal (GI) complications were a substantial cause of mortality with diverticulitis and colonic ulcers accounting for almost a third of GI-related deaths. In contrast, our search did not reveal any evidence of diverticular perforation in patients treated with conventional DMARDs. Eighteen cases of lower GI perforation (16 of whom had diverticulitis) have been documented in recent conference proceedings following tocilizumab treatment in clinical trials, with a lower GI perforation rate of 1.9 per 1,000 patient years (PY). This lies between the reported rate of GI perforations for corticosteroids and anti-TNF-α agents in the United Health Care database, with rates of 3.9 per 1,000 PY (95% CI 3.1-4.8) and 1.3 per 1,000 PY (95% CI 0.8-1.9), respectively. The majority of these patients were concurrently prescribed NSAIDs and/or long-term corticosteroids. Traditional DMARD therapy for RA appears not only to have modified the risk of lower GI perforation but prevented it. The risk of diverticular perforation may be slightly higher in patients treated with tocilizumab compared with conventional DMARDs or anti-TNF agents, but lower than that for corticosteroids. The mechanism of action of IL-6 antagonism in the pathophysiology of diverticular perforation has yet to be elucidated.

Carotid atherosclerosis predicts incident acute coronary syndromes in rheumatoid arthritis

OBJECTIVE

The role of atherosclerosis in the acute coronary syndromes (ACS) that occur in patients with rheumatoid arthritis (RA) has not been quantified in detail. We undertook this study to determine the extent to which ACS are associated with carotid atherosclerosis in RA.

METHODS

We prospectively ascertained ACS, defined as myocardial infarction, unstable angina, cardiac arrest, or death due to ischemic heart disease, in an RA cohort. We measured carotid atherosclerosis using high-resolution ultrasound. We used Cox proportional hazards models to estimate the association between ACS and atherosclerosis, adjusting for demographic features, cardiovascular (CV) risk factors, and RA manifestations.

RESULTS

We performed carotid ultrasound on 636 patients whom we followed up for 3,402 person-years. During this time, 84 patients experienced 121 new or recurrent ACS events, a rate of 3.5 ACS events per 100 patient-years (95% confidence interval [95% CI] 3.0-4.3). Among the 599 patients without a history of ACS, 66 incident ACS events occurred over 3,085 person-years, an incidence of 2.1 ACS events per 100 person-years (95% CI 1.7-2.7). The incidence of new ACS events per 100 patient-years was 1.1 (95% CI 0.6-1.7) among patients without plaque, 2.5 (95% CI 1.7-3.8) among patients with unilateral plaque, and 4.3 (95% CI 2.9-6.3) among patients with bilateral plaque. Covariates associated with incident ACS events independent of atherosclerosis included male sex, diabetes mellitus, and a cumulative glucocorticoid dose of ≥ 20 gm.

CONCLUSION

Atherosclerosis is strongly associated with ACS in RA. RA patients with carotid plaque, multiple CV risk factors (particularly diabetes mellitus or hypertension), many swollen joints, and a high cumulative dose of glucocorticoids, as well as RA patients who are men, are at high risk of ACS.

Pharmacotherapy: concepts of pathogenesis and emerging treatments. Optimising the strategy of care in early rheumatoid arthritis

In rheumatoid arthritis (RA), early use of disease-modifying anti-rheumatic drugs (DMARDs), intensive follow-up and 'treating to target' to achieve low disease activity produce significant improvements in measures of disease activity, functional impairment and retard erosive radiographic progression. Step-up, parallel and step-down regimens are all significantly more effective than sequential monotherapy; although the most effective regimen has not been established. Minimising the period of exposure to synovitis, by including a rapidly acting agent (e.g., corticosteroids or tumour necrosis factor alpha (TNFalpha) inhibitor), may slow radiographic progression further. Biologic therapies, especially TNFalpha inhibitors, are effective in early RA; however, their exact role is unclear. Current measures may overestimate the number of patients in clinical remission; therefore, musculoskeletal ultrasound and/or novel biomarkers may also have a role. Pre-clinical immunological markers could possibly be used to trigger pre-emptive treatment in asymptomatic, 'at risk' individuals. Potential treatment developments include combining biologic agents or targeting alternative immunological pathways.

Rapid increase in myocardial infarction risk following diagnosis of rheumatoid arthritis amongst patients diagnosed between 1995 and 2006

The risk of ischaemic heart disease (IHD), and in particular myocardial infarction (MI), is increased amongst patients with established rheumatoid arthritis (RA). Few studies have included contemporary patients with RA. We recently reported that the risk of IHD is not elevated before the onset of RA symptoms. However, when, in relation to RA diagnosis, the risk is increased is unknown.

OBJECTIVE

To assess the risk of MI and other IHD events amongst patients diagnosed with RA during the last decade and within 18 months following RA symptom onset, compared to the general population, by time since RA diagnosis, year of RA diagnosis and by rheumatoid factor (RF) status.

METHODS AND PATIENTS

A Swedish inception cohort of RA (n = 7469) diagnosed between 1995 and 2006 and a matched general population comparator cohort (n = 37,024), was identified and linked to national registers of morbidity and mortality from IHD. Relative risks (RRs) of MI and other IHD events were estimated using Cox regression.

RESULTS

During follow-up, 233 patients with RA and 701 controls developed a first MI, corresponding to an overall RR of MI of 1.6 (95% confidence interval 1.4, 1.9). Increased risks of MI were already detected within 1-4 years following RA diagnosis, as well as in patients diagnosed with RA during the last 5 years, in RF-negative patients and for transmural as well as nontransmural MIs.

CONCLUSIONS

MI risk increases rapidly following RA diagnosis, suggesting the importance of additional mechanisms other than atherosclerosis. The elevated short-term risk is present amongst patients diagnosed in recent years, underscoring the importance of MI prevention from the time of RA diagnosis.

Tumour necrosis factor antagonists and the risk of cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review

OBJECTIVES

RA is associated with early ischaemic heart disease. This appears to be driven largely by the presence of chronic inflammation. Studies suggest that treatment with disease-modifying drugs such as MTX may reduce the incidence of cardiovascular events in RA. Anti-TNF therapies significantly reduce inflammation in RA. However, the extent to which these agents also reduce cardiovascular disease (CVD) is uncertain. The purpose of this study was to explore the effect of anti-TNF agents on CVD in RA using a systematic literature review.

METHODS

We searched for studies of adults with RA treated with TNF antagonists where cardiovascular outcomes were recorded using MEDLINE, EMBASE, Cochrane Database, Database of Abstracts and Reviews of Effects, Health Technology Appraisal, Science Citation Index and Clinical Evidence from 1989 to 2010. Conference proceedings for the British Society of Rheumatology, ACR and EULAR between 2005 and 2009 were hand searched. Two reviewers assessed abstracts for inclusion and then quality of selected papers was assessed.

RESULTS

A total of 1840 abstracts were identified and 20 articles were suitable for inclusion. Information was obtained on the effect of TNF antagonists on overall CVD events, myocardial infarction, strokes and heart failure.

CONCLUSION

In many studies, TNF antagonists appear to reduce the likelihood of CVD in individuals with RA. Reassuringly, there does not appear to be an increased risk of cardiac failure. However, the reduction in CVD is not as consistently seen as with studies of MTX.

Cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment

Morbidity and mortality rates are higher in individuals with rheumatoid arthritis (RA) than in the general population. Ischemic heart disease and heart failure now represent one of the most common causes of death in RA. Indeed, RA appears to represent an independent risk factor for ischemic heart disease, similar to diabetes mellitus. However, no clear guidelines with regard to cardiovascular disease diagnosis and prevention in RA have been developed. This review highlights recent investigations on the assessment, prevention, and treatment of cardiovascular disease in RA.

Mortality in Psoriatic Arthritis – A Single-center Study from the UK

Objective.

To determine whether the mortality in a cohort of patients with psoriatic arthritis (PsA) from a single center in the UK is significantly different from the general UK population.

Methods.

Patients who were entered onto the PsA database at the Royal National Hospital for Rheumatic Diseases, Bath, between 1985 and 2007 were included in this study. Information on patient deaths was collected retrospectively. The National Health Service (NHS) Strategic Tracing Service was used to establish which patients were alive and which had died. Date and cause of death were confirmed by death certificates from the Registry of Births, Marriages and Deaths. A standardized mortality ratio (SMR) was calculated by matching the patient data to single-year, 5-year age-banded England and Wales data from the Office of National Statistics.

Results.

In this cohort of 453 patients with PsA (232 men, 221 women), there were 37 deaths. Sixteen men and 21 women died. The SMR for the men was 67.87% (95% CI 38.79, 110.22), and for the women, 97.01% (95% CI 60.05, 148.92) and the overall SMR for the PsA cohort was 81.82% (95% CI 57.61, 112.78). The leading causes of death in this cohort were cardiovascular disease (38%), diseases of the respiratory system (27%), and malignancy (14%).

Conclusion.

These results suggest that mortality in our single-center PsA cohort is not significantly different from the general UK population. No increased risk of death was observed in this cohort.

High risk of clinical cardiovascular events in rheumatoid arthritis: Levels of associations of myocardial infarction and stroke through a systematic review and meta-analysis

BACKGROUND

While there are convergent data suggesting that overall cardiovascular mortality is increased in patients with rheumatoid arthritis, the relative contributions of myocardial infarction and stroke remain unclear.

AIMS

We sought to clarify this issue by conducting a meta-analysis of cohort studies on myocardial infarction and stroke in patients with rheumatoid arthritis.

METHODS

A MEDLINE search from January 1960 to September 2009 and abstracts from international conferences from 2007 to 2009 were searched for relevant literature. All cohort studies reporting on standardized mortality ratio or incidence rate ratio of myocardial or stroke associated with rheumatoid arthritis, with available crude numbers, were included. STATA meta-analysis software was used to calculate pooled risk estimates.

RESULTS

Seventeen papers fulfilled the inclusion criteria, corresponding to a total of 124,894 patients. Ten studies reported on standardized mortality ratio for fatal myocardial infarction, which ranged from 0.99 to 3.82. The overall pooled estimate was 1.77 (95% confidence interval [CI] 1.65-1.89). Incidence rate ratio for myocardial infarction was reported in five studies; the pooled estimate was 2.10 (95% CI 1.52-2.89). Nine studies reported on fatal stroke, with standardized mortality ratio ranging from 1.08 to 2.00; the pooled estimate was 1.46 (95% CI 1.31-1.63). The pooled incidence rate ratio for stroke (three studies) was 1.91 (95% CI 1.73-2.12).

CONCLUSION

Our results show that risks of myocardial infarction and stroke are increased in patients with rheumatoid arthritis. In addition, both account for the observed increased mortality in individuals with rheumatoid arthritis.

The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review

OBJECTIVES

Patients with RA have an increased prevalence of cardiovascular disease (CVD). This is due to traditional risk factors and the effects of chronic inflammation. MTX is the first-choice DMARD in RA. We performed a systematic literature review to determine whether MTX affects the risk of CVD in patients with RA.

METHODS

We searched Medline, Embase, Cochrane database, database of abstracts of reviews of effects, health technology assessment and Science Citation Index from 1980 to 2008. Conference proceedings (British Society of Rheumatology, ACR and EULAR) were searched from 2005 to 2008. Papers were included if they assessed the relationship between MTX use and CVD in patients with RA. Two reviewers independently assessed each title and abstract for relevance and quality.

RESULTS

A total of 2420 abstracts were identified, of which 18 fulfilled the inclusion criteria. Two studies assessed the relationship between MTX use and CVD mortality, one demonstrated a significant reduction in CVD mortality and the second a trend towards reduction. Five studies considered all-cause CVD morbidity. Four demonstrated a significant reduction in CVD morbidity and the fifth a trend towards reduction. MTX use in the year prior to the development of RA decreased the risk of CVD for 3-4 years. Four studies considered myocardial infarction, one demonstrated a decreased risk and three a trend towards decreased risk with MTX use.

CONCLUSION

The current evidence suggests that MTX use is associated with a reduced risk of CVD events in patients with RA. This suggests that reducing the inflammation in RA using MTX not only improves disease-specific outcomes but may also reduce collateral damage such as atherosclerosis.

Causes of death in patients with rheumatoid arthritis from 1971 to 1991 with special reference to autopsy

Rheumatoid arthritis (RA) patients have premature mortality, mostly attributed to cardiovascular diseases (CVDs). We studied causes of death (CoDs) and contribution of autopsy to them in RA patients treated at a single hospital responsible for primary to tertiary RA treatment in Helsinki. In 1971-1991, 960 RA patients died. The leading CoDs were CVDs, RA, and infections. Over 1971-1991, RA and renal deaths declined, but other CoDs showed no change. Autopsied patients died more frequently than nonautopsied of coronary heart disease (CHD) and gastrointestinal disorders, but less frequently of RA, renal, and endocrinologic diseases. Our finding of autopsied patients having CHD more frequently as a CoD may indicate that CHD, which may be asymptomatic in RA, may be overlooked during lifetime.

Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies

OBJECTIVE

To determine the magnitude of risk of cardiovascular mortality in patients with rheumatoid arthritis (RA) compared with the general population through a meta-analysis of observational studies.

METHODS

We searched Medline, EMBase, and Lilacs databases from their inception to July 2005. Observational studies that met the following criteria were assessed by 2 researchers: 1) prespecified RA definition, 2) clearly defined cardiovascular disease (CVD) outcome, including ischemic heart disease (IHD) and cerebrovascular accidents (CVAs), and 3) reported standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs). We calculated weighted-pooled summary estimates of SMRs (meta-SMRs) for CVD, IHD, and CVAs using the random-effects model, and tested for heterogeneity using the I(2) statistic.

RESULTS

Twenty-four studies met the inclusion criteria, comprising 111,758 patients with 22,927 cardiovascular events. Overall, there was a 50% increased risk of CVD death in patients with RA (meta-SMR 1.50, 95% CI 1.39-1.61). Mortality risks for IHD and CVA were increased by 59% and 52%, respectively (meta-SMR 1.59, 95% CI 1.46-1.73 and meta-SMR 1.52, 95% CI 1.40-1.67, respectively). We identified asymmetry in the funnel plot (Egger's test P = 0.002), as well as significant heterogeneity in all main analyses (P < 0.0001). Subgroup analyses showed that inception cohort studies (n = 4, comprising 2,175 RA cases) were the only group that did not show a significantly increased risk for CVD (meta-SMR 1.19, 95% CI 0.86-1.68).

CONCLUSION

Published data indicate that CVD mortality is increased by approximately 50% in RA patients compared with the general population. However, we found that study characteristics may influence the estimate.

Amyloidosis is frequently undetected in patients with rheumatoid arthritis

Prevalence of AA amyloid in rheumatoid arthritis (RA) is still unclear. The objective of this retrospective study was whether dedicated re-examination of autopsy tissues from RA patients increases the detection rate of amyloid compared to routine examination. Amyloid was re-examined in tissue samples and detection rate compared with original reports of 369 consecutively autopsied RA patients and 370 non-RA patients matched for sex, age, and year of autopsy between 1952 and 1991. Re-examination of 90% of the 739 cases showed doubling of the prevalence of amyloid compared with the original reports: from 18 to 30% in RA and from 2 to 4% in non-RA patients. In RA patients, cardiac amyloid was as frequent as renal amyloid. In RA patients with amyloid at re-examination, amyloidosis had been diagnosed before autopsy in 37%, and these patients had more inflammation and longer disease duration than RA patients without amyloid. Only 56% of RA patients with renal amyloid were known to have proteinuria. In conclusion, this autopsy study shows that amyloid in RA is a common finding which remains frequently undetected. In patients with active and long-lasting RA, a systematic search for amyloid may enable early diagnosis of amyloidosis, which will require effective suppression of inflammation.

Limiting cardiovascular risk in Irish rheumatoid arthritis patients

BACKGROUND

Patients with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease and premature death.

OBJECTIVES

Our aims were: (1) to assess how thoroughly RA patients were being screened for cardiovascular risk factors in our outpatient population and (2) to evaluate the benefit of introducing a shared care cardiovascular booklet.

METHODS

We assessed 80 patients who attend our service with RA. Our initial audit revealed that 80% of patients had not been thoroughly assessed for basic cardiovascular risk. Based on these findings, we created a shared care booklet.

RESULTS

On re-auditing our service, we found a significant improvement in the assessment of cardiovascular risks.

CONCLUSION

There is currently a low level of screening for cardiovascular risks in busy outpatient clinics. We felt the introduction of a shared care booklet allowed an increased level of screening in our clinics and also acted as a tool for doctor and patient education.