Chronic Heart Failure in Early Rheumatoid Arthritis Patients Prior to Basic Antirheumatic Therapy

Aim. To study the clinical manifestations and factors associated with the presence of chronic heart failure (CHF) in patients with early rheumatoid arthritis (RA) prior to anti-inflammatory therapy. Material and methods. The study included 74 patients with valid diagnosis of RA (criteria ACR/EULAR, 2010), 56 women (74%), median age – 54 [46;61] years, disease duration – 7 [4;8] months; seropositive for IgM rheumatoid factor (87%) and/or antibodies to cyclic citrullinated peptide (100%) prior to taking disease modifying anti-rheumatic drugs and glucocorticoids. CHF was verified in accordance with actual guidelines. The assessment of traditional risk factors for cardiovascular diseases, echocardiography, tissue Doppler imaging, carotid artery ultrasound, were carried out before the start of therapy in all patients with early RA. The concentration of NT-proBNP was determined by electrochemiluminescence. The normal range for NT-proBNP was less than 125 pg/ml.

Results. CHF was diagnosed in 24 (33%) patients: in 23 patients – CHF with preserved ejection fraction, in 1 patient – CHF with reduced ejection fraction. 50% of patients with RA under the age of 60 were diagnosed with CHF. NYHA class I was found in 5 (21%) patients, class II – in 15 (63%), class III – in 1 (4%). Positive predictive value of clinical symptoms did not exceed 38%. All patients with early RA were divided into two groups: 1 – with CHF, 2 – without CHF. Patients with RA+CHF compared with patients without CHF were older, had higher body mass index, frequency of carotid atherosclerosis, of ischemic heart disease (IHD), hypertension, C-reactive protein (CRP) levels and intima media thickness. Independent factors associated with the presence of CHF were identified by linear regression analysis: abdominal obesity, CRP level, systolic blood pressure, dyslipidemia, carotid intima thickness, IHD. The multiple coefficient of determination was R2=57.1 (R-0.76, p<0.001). Level of NT-proBNP in RA patients with CHF (192.0 [154.9; 255.7] pg/ml) was higher than in RA patients without CHF (77 [41.1; 191.2] pg/ml) and in control (49.0 [33.2; 65.8] pg/ml), p<0.0001 and p=0.01, respectively. To exclude CHF in patients with early RA, the optimal NT-proBNP level was 150.4 pg/ml (sensitivity – 80%, specificity – 79%), the area under the ROC curve = 0.957 (95% confidence interval 0.913-1.002, p<0.001).

Conclusion. CHF was detected in a third of RA patients at the early stage of the disease. Factors associated with the presence of CHF were abdominal obesity, CRP level, systolic blood pressure, dyslipidemia, intima media thickness, IHD.

[Level of N-terminal fragment of brain natriuretic peptide progenitor and atherosclerotic damage of brachocephalic arteries in patients with rheumatoid arthritis with inefficiency and/or injurability of basic anti - inflammatory treatment]

The high prognostic significance of the concentration of the N-terminal - pro-B-type natriuretic peptide (NT-proBNP) in the development of cardiovascular diseases (CVD) was identified for rheumatoid arthritis (RA) and general populations.

AIM

to investigate the significance of NT-proBNP level in patients (pts) with RA with the ineffectiveness and/or intolerance of basic anti - inflammatory therapy; compare the level of NT-proBNP with atherosclerotic lesion of the brachiocephalic arteries (BCA), traditional risk factors and inflammatory markers.

MATERIALS AND METHODS

The investigation enrolled 28 pts (24women/4men) with the lack of efficacy/resistance and/or intolerance of basic anti - inflammatory drugs (DMARDs); median age was 55 [46; 61] years, median disease duration 114 [60; 168] month; DAS28 6,2 [5.1; 7.0]; SDAI 35.0[23.9; 51.0], CDAI 30.0[21.0; 42.0], serum positivity for rheumatoid factor (RF) (100%)/anti - cyclic citrullinated peptide antibodies (ACCP) (86%). The study did not include RA pts with congestive heart failure. High incidence of traditional risk factors was found in RA pts: arterial hypertension - in 75%, dyslipidemia - 61%, smoking - 17%, overweight - 61%, family history of cardiovascular diseases - 36%, hypodynamia - 68%. Coronary artery disease was diagnosed in 11% RA pts. Lack of efficacy of 3 or more DMARDs was found in 46% of pts, intolerance to previous therapy with DMARDs - in 54% pts. 47% were receiving methotrexate (20 [18; 25] mg/week), 11% - leflunomide, 7% - sulfasalazine, 46% - glucocorticoids, 75% - non - steroidal anti - inflammatory drugs. The control group consisted of 20 healthy donors, comparable to pts by age and sex. Serum levels of of NT-proBNP were measured using electrochemiluminescence method Elecsys proBNP II (Roche Diagnostics, Switzerland). The determination of the intima - media thickness (IMT) BCA were assessed from duplex scanning. Atherosclerotic lesion of BCA was assessed by the presence of atherosclerotic plaque (IMT ≥1.2 mm).

RESULTS

NT-proBNP concentrations in RA pts proved to be higher (78.7 [41.4; 101.3] pg/ml) than those in the control group (55.3 [36.6; 67.3] pg/ml, p100 pg/ml - 1 group (n=6) and ≤100 pg/ml - 2 group (n=22). Groups of RA pts did not differ in gender, age, activity of RA, frequency of detection of traditional risk factors. Atherosclerotic lesion of the BCA was detected in 3 (50%) pts of the 1 group and in 8 (36%) pts of the 2 group (p>0.05). In RA pts the level of NT-proBNP correlated with age (r=0.39; p.

[Independent risk factors for severe cardiovascular events in male patients with gout: Results of a 7-year prospective study]

AIM

To determine risk factors for severe cardiovascular (CV) events (CVEs) in male patients with crystal-verified gout.

SUBJECTS AND METHODS

251 male patients with crystal-verified gout were prospectively followed up in 2003 to 2013. The mean follow-up period was 6.9±2.0 years. New severe CVE cases and deaths were recorded. Logistic regression was used to analyze the impact of traditional and other risk factors and allopurinol use on the risk for severe CVEs.

RESULTS

32 patients died during the follow-up period. Severe CVEs were recorded in 58 (23.1%) patients; CVE deaths were notified in 22 (8.8%) patients. The risk of all severe CVEs was high for hypertension, increased serum high-sensitivity C-reactive protein (hs-CRP) level (>5 mg/l), ≥ stage III chronic kidney disease (CKD) (glomerular filtration rate, <60 ml/min/1.73 m2), alcohol intake (>20 g/day), coronary heart disease (CHD), and a family history of premature CHD. The risk of fatal CVEs was highest for elevated serum hs-CRP level, ≥ stage III CKD, a family history of premature CHD, hypercholesterolemia, upper quartile of serum uric acid levels (>552 µmol/l), and regular intake of allopurinol.

CONCLUSION

In addition to the traditional risk factors of CV catastrophes, the presence of chronic inflammation and the impact of high serum uric acid levels may explain the high frequency of CV catastrophes.

[Clinical and hemodynamic characteristics and possibilities for therapy in patients with severe (functional class IV) pulmonary arterial hypertension associated with diffuse connective tissue diseases]

AIM

To study the clinical and hemodynamic characteristics of a group of patients with Functional Class (FC) IV pulmonary arterial hypertension (PAH) developing in the presence of diffuse connective tissue diseases (DCTD) and to evaluate the efficacy of intravenous iloprost.

SUBJECTS AND METHODS

The study enrolled 59 patients with PAN-DCTD, including 7 who had FC IV and 8 who developed this condition during a follow-up. The diagnosis of PAH was based on pulmonary artery catheterization findings. FC IV was diagnosed using the conventional New York Heart Association classification. All the patients received PAH-specific therapy (bosentan, sildenafil); the patients with FC IV had combined therapy; 4 patients were treated with intravenous iloprost calculated with reference to 0.5-2.5 ng/kg/min for 15 days. In addition to the patients with FC IV, 3 patients with unstable FC Ill were given iloprost. Besides targeted therapy, all the patients received standard treatment, including diuretics, and ionotropic therapy.

RESULTS

Evaluation of hemodynamics in patients with different FCs revealed the most important differences in right atrial pressure, cardiac output, cardiac index, and pulmonary vascular resistance. A linear relationship was seen between the level of this indicator and FC, the closest correlation being for hemodynamic parameters characterizing right ventricular systolic function. There were no changes in mean pulmonary artery pressure; only the patients with FC IV were found to have its slight elevation (from 52 ± 15 to 55 ± 11 mm Hg). Pulmonary artery wedge pressure remained unchanged regardless of FC. Intravenous iloprost was noted to have an obvious positive effect on both clinical and hemodynamic parameters. Catheterization verified improvement in 6 out of the 7 patients; no hemodynamic changes were found in 1 patient during 15-day therapy.

CONCLUSION

The patients with FC IV PAH-DCTD have clinical and hemodynamic features responsible for a fatal prognosis. The results of using intravenous iloprost in patients with decompensated PAH associated with scleroderma systematica convince to use its PAH-specific tablets in cases of verified clinical deterioration when taking its dosage form.

[Left and right ventricular diastolic dysfunction in patients with early rheumatoid arthritis before prescribing disease-modifying antirheumatic therapy]

AIM

To estimate the rate of diastolic dysfunction (DD) of the left and right ventricles (LV and RV) in patients with early rheumatoid arthritis (RA) before using disease-modifying antirheumatic drugs (DMARDs) therapy and to investigate its association with traditional risk factors (TRFs) for cardiovascular diseases (CVD) and inflammatory markers.

SUBJECTS AND METHODS

The investigation enrolled 74 patients with a valid diagnosis of RA, including 56 (74%) women (median age, 54 years; disease duration, 7 months); the patients who were seropositive for rheumatoid factor (RF) (87%) and/or anti-cyclic citrullinated peptide (anti-CCP) antibodies (100%) who had not been on DMARDs or glucocorticosteroids. TRFs for CVD and carotid artery atherosclerosis were assessed from duplex scanning data and echocardiography was performed in all the patients with early RA before starting the therapy. The ratio of the maximum blood flow velocity during early diastolic filling (E) to that during atrial systole (A) was used as a criterion for LVDD and RVDD. There were 3 types of impaired ventricular filling: 1) E/A <1; 2) E/A = 1-2; 3) E/A > 2.

RESULTS

LVDD and RVDD were detected in 35 (48%) and 17 (23%) patients, respectively. RVDD was recorded only in conjunction with LVDD. Among LVDD and RVDD, the former was prevalent. All the patients with early RA were divided into 3 groups: 1) patients with LVDD and RVDD; 2) those with LVDD; 3) those without ventricular DD. All the three groups were matched for the level of DAS28, anti-CCP antibodies, and RF. The incidence of arterial hypertension, dyslipidemia, and abdominal obesity was higher in the patients of Groups 1 and 2 than in those of Group 3. There was a progressive decrease in high-density lipoprotein (HDL) cholesterol concentrations and increases in triglyceride (TG) levels and atherogenic index from Group 3 to Group 1, with the concentrations of total cholesterol and low-density lipoprotein cholesterol being similar in the 3 groups. Coronary heart disease was recorded more frequently in Group 2 than in Group 3. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) proved to be also significantly higher in the patients with DD than in those without DD. Correlations were found between LV E/A and ESR, CRP, HDL cholesterol, TG, RV E/A and ESR, DAS28, TG.

CONCLUSION

The patients with early-stage RA were found to have high incidence rates of LVDD and RVDD, which is related to the high prevalence of CVD, the high spread of TRF for CVD, and the high activity of an inflammatory process.

[Clinical significance of the assessment of cardiac rhythm variability in patients with rheumatoid arthritis]

The study included 128 patients below 55 years of age with confirmed diagnosis of rheumatoid arthritis (RA) and 30 age and sex-matched healthy volunteer comprising the control group. They were examined for clinical manifestations and severity of RA, cardiovascular risk factors (smoking, body mass index (BMI), blood lipid level), and serum inflammation markers. Intima-media thickness (IMT) was measured in common carotid arteries by duplex scanning. 24 hour ECG monitoring was performed using a three-channel Astrokard monitor, Meditex, with HRV analysis. HRV values in RA patients proved significantly lower than in healthy subjects. The patients showed inverse correlation of HRV with RA duration and severity, HAQ index, X-ray stage, articular dysfunction, and maximum dose of corticosteroids. Also, HRV values negatively correlated with traditional risk factors (age, systolic and diastolic AP, smoking, and IMT. HRV was reduced in AR patients with high and low BMI compared with patients with normal weight. HRV negatively correlated with inflammation markers (leukocytes, ESR, C-reactive protein). It is concluded that concomitant measurement of HRV and inflammation markers in RA patients taking into account severity of the disease and traditional risk factors may be useful for prognosis of cardiovascular death among patients with RA.

[Clinical implication of assessment of heart rate variability in patients with psoriatic arthritis]

AIM

To evaluate clinical significance of heart rate variability (HRV) in patients with psoriatic arthritis (PsA).

MATERIAL AND METHODS

HRV was investigated by means of time-domain analysis of 24 h ECG ambulatory recording in 113 PsA (70 female) patients < 55-years-old and 65 age-matched healthy subjects. We assessed the presence of standard cardiovascular risk factors, performed carotid and femoral ultrasound with measurement of intima-medial thickness (IMT) in PsA patients. Inflammatory markers (CRP, fibrinogen) were detected in all the patients.

RESULTS

Significantly lower values of HRV parameters adjusted by Mean NN (SDNNn%, SDNNIN%) were detected in PsA men and women when compared to the control group. There was a significant negative correlation between HRV and disease duration, PsA activity (DAS4, Ritchi index), swollen and tender joint counts, femoral IMT, CRP in PsA males (p < 0.05). SDNNin% was lower in PsA male smokers than in non-smokers (p = 0.03). There was a significant negative correlation between HRV and age, systolic blood pressure, dyslipidemia, body mass index, carotid IMT, CRP, fibrinogen in PsA women.

CONCLUSION

Reduced HRV reflects sympatho-vagal imbalance in PsA patients associated with the disease duration and activity, smoking, femoral IMT, markers of inflammation (CRP) in males; with standard cardiovascular risk factors, fibrinogen, CRP, carotid IMT in women, and may be identified as a risk factor for cardiovascular morbidity and mortality in further studies.

[Clinical significance of heart rate variability in patients with systemic lupus erythematosus]

AIM

To evaluate clinical significance of heart rate variability (HRV) in patients with systemic lupus erythematosus (SLE).

MATERIAL AND METHODS

HRV was investigated by means of time-domain analysis of 24 hour ambulatory ECG of 122 SLE patients under 55 years of age and 32 age-matched healthy controls. In addition to clinical manifestations and activity of SLE, we assessed the presence of basic conventional cardiovascular risk factors (hypertension, smoking, body mass index, dyslipidemia), performed common carotid duplex scanning with measurement of intima-medial thickness (IMT). Inflammatory markers (ESR, CRP, IL-6) were assessed in all the patients.

RESULTS

Significantly lower HRV and the trend to tachycardia were detected in SLE patients when compared to the control group. There was a significant positive correlation between HRV and a cumulative dose of cyclophosphamide, a high density lipoprotein cholesterol level, a negative correlation between HRV and cumulative dose of azathioprine, standard risk factors (hypertension, smoking, body mass index, triglyceride level), markers of inflammation (ESR, CRP, IL-6) and IMT.

CONCLUSION

Measurement of HRV in combination with routine cardiovascular risk factors and level of inflammatory markers can be used for identification of subjects at risk for faster progression of atherosclerosis in SLE patients.