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Autoimmune rheumatic diseases may induce premature atherosclerosis

Stephen Padilla
17 Dec 2020

Patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are more likely to develop premature and extremely premature atherosclerotic cardiovascular disease (ACVD), according to an analysis from the Veterans with Premature Atherosclerosis (VITAL) registry.

“The presence of these rheumatic diseases, especially SLE and RA, was independently associated with a higher likelihood of both premature and extremely premature ACVD,” the researchers said.

Using the VITAL registry, the researchers assessed age at the time of first cardiovascular event to compare patients with premature (n=135,703) and those with extremely premature ACVD (n=7,716), with age-matched patients without ACVD (nyoung=1,153,535, nextremely young=441,836).

They also investigated whether SLE, RA, psoriatic arthritis, and ankylosing spondylitis independently correlated with premature and extremely premature ACVD.

The prevalence of all rheumatic diseases was higher among patients with premature and extremely premature ACVD than age-matched patients without ACVD. [Am J Med 2020;133:1424-1432.E1]

Fully adjusted models showed the association of SLE (odds ratio [OR], 1.69, 95 percent confidence interval [CI], 1.56–1.83) and RA (OR, 1.72, 95 percent CI, 1.63–1.81) with a higher likelihood of premature ACVD. Patients with SLE (OR, 3.06, 95 percent CI, 2.38–3.93) and RA (OR, 2.39, 95 percent CI, 1.85–3.08) also had higher odds of extremely premature ACVD.

“Consistent with well-established pathways associated with chronic inflammation and rheumatic diseases, our results provide further clinical evidence supporting its association in patients with premature and extremely premature atherosclerosis,” the researchers said. [Scand J Rheumatol 2008;37:1-5; Arthritis Rheum 2009;60:2870-2879; J Rheumatol 2007;34:2388-2394]

“In addition to cytokine and oxidative-stress–mediated endothelial dysfunction, patients with chronic inflammation secondary to rheumatic diseases may experience changes in arterial stiffness, lipid-salvage mechanisms, and destabilization of plaques, resulting in … atherosclerosis in various vascular beds,” they noted. [Best Pract Res Clin Rheumatol 2016;30: 851-869; Ann Rheum Dis 2012;71:1157-1162]

The findings of the current study also suggested that similar pathways, which have been examined in patients with RA and SLE, might be at play in those with psoriatic arthritis and ankylosing spondylitis. [Arthritis Res Ther 2009;11:217]

Of note, there was a higher prevalence of all traditional atherosclerotic risk factors in patients with premature and extremely premature ACVD.

“Even though the existing knowledge highlights a synergistic mechanism between traditional atherosclerotic risk factors such as tobacco use and inflammation for the progression from pathogenesis to development of clinical ACVD, our results suggest that presence of rheumatic diseases may confer a higher risk for premature ACVD, which is independent of these risk factors,” the researchers said. [Nat Rev Rheumatol 2015;11:693; Autoimmun Rev 2013;12:1004-1015; Current Rheumatol Rep 2018;20:81]

“Given the elevated risk of early-onset ACVD, which was independent of traditional atherosclerotic risk factors, interventions for primary prevention of ACVD in such patients require further in-depth analysis and dissemination into clinical practice,” they added.

“Initiatives spearheading multidisciplinary care and collaboration between cardiovascular and rheumatology specialists may also prove fruitful,” the researchers said.

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