Federica Ognibeni

Clinical profile and outcome of patients with rheumatoid arthritis and abnormally high aortic stiffness

Objectives Ascending aorta has an increased stiffness (AoSI) in rheumatoid arthritis (RA) patients due to their chronic inflammatory status. We assessed prevalence and factors associated with increased AoSI and its prognostic role in a large cohort of RA patients. Methods We prospectively analysed 226 RA patients without overt cardiac disease compared with 226 non-RA patients matched for cardiovascular risk factors (non-RA controls). Abnormally high AoSI was diagnosed if AoSI > 6.07% (95th percentile of the AoSI detected in our reference healthy population). AoSI was assessed at the level of the aortic root by two-dimensional guided M-mode evaluation as part of a thorough echocardiography performed in all patients. Results AoSI was significantly higher in the RA patients than non-RA controls (6.3 ± 4.5% vs. 4.6 ± 3.5%, p < 0.001); it was related to older age, higher systolic blood pressure and RA disease. Predictors of AoSI in RA patients were older age, higher systolic blood pressure and the non-prescription of non-steroidal anti-inflammatory drug and/or immunomodulatory/anti-cytotoxic agents. Abnormally high AoSI was diagnosed in 41% RA patients and 21% non-RA controls (p < 0.001). The RA phenotype with abnormally high AoSI was a > 60 years old subject with systolic blood pressure > 129 mmHg, mitral annular calcification who was not receiving non-steroidal anti-inflammatory drug. By multivariate Cox regression analysis abnormally high AoSI independently predicted death or all-cause hospitalization (hazard ratio 2.85 (95% confidence interval 1.03–7.85)) at 12-month follow-up. Conclusions Increased AoSI is common, can be predicted by an ordinary clinical assessment and is a strong predictor of adverse clinical outcome at mid-term follow-up in patients with RA.

Traditional cardiovascular risk factors or inflammation: Which factors accelerate atherosclerosis in arthritis patients?

Patients with chronic inflammatory arthritis experience an increased incidence of cardiovascular (CV) events. In addition to visualizing atherosclerotic plaques, ultrasound examinations (USs) of the carotid arteries permit the measurement of subclinical markers of atherosclerosis, such as intima-media thickness (cIMT) and carotid segmental distensibility (cDC). The aims of the study were to identify the determinants of atherosclerosis acceleration (plaques, cIMT and cDC) in a sample of patients suffering from chronic arthritis and to compare these patients with a control group of people with ≤1 traditional risk factor (TRF) for CV disease. METHODS We recruited 137 patients with rheumatoid arthritis (RA), 43 patients with psoriatic arthritis (PsA), 28 patients with ankylosing spondylitis (AS) and 48 healthy volunteers without histories of previous CV events. These patients underwent carotid artery US examinations using dedicated hardware. RESULTS Regression and multivariate analyses demonstrated that only age (p<0.001) was consistently associated with cDC, cIMT and atherosclerotic plaques, both in the entire sample of patients with arthritis and in the subgroup of patients with RA. Among modifiable TRFs for cardiovascular disease, only hypertension, diabetes mellitus and smoking exhibited associations with some carotid phenotypes, with borderline significance. When patients with RA carrying ≤1 TRF were compared with control subjects carrying ≤1 TRF, only cDC was slightly lower in the RA group than in the control group. CONCLUSIONS Age is the major determinant of subclinical atherosclerosis in patients with different types of arthritis, as the contributions of other TRFs and disease activity and duration indices to the disease seem to be limited.

Combined circumferential and longitudinal left ventricular systolic dysfunction in patients with asymptomatic aortic stenosis.

Early detection of left ventricular (LV) systolic dysfunction is pivotal in the management of patients with aortic stenosis (AS). LV circumferential and/or longitudinal shortening may be impaired in these patients despite LV ejection fraction is preserved. We focused on prevalence and factors associated with combined impairment of circumferential and longitudinal shortening (C&L) in asymptomatic AS patients.

Prevalence and factors related to inappropriately high left ventricular mass in patients with rheumatoid arthritis without overt cardiac disease

Objectives: Due to the chronic inflammatory status, specific neuro-hormones and progression of arterial stiffness, patients with rheumatoid arthritis (RA) are exposed to the development of excessive left ventricular mass disproportionate to the need to compensate left ventricular load. This condition, named inappropriately high left ventricular mass (iLVM), is associated with unfavorable prognosis in patients with hypertension, aortic stenosis or diabetes. In this study, we assessed prevalence and factors associated with iLVM in a large cohort of patients with RA and tested the hypothesis that RA per se is a condition related to iLVM. Methods: We prospectively analyzed 235 RA patients without overt cardiac disease recruited between January and December 2014, who were compared with 235 controls matched for age, sex, BMI, prevalence of hypertension and diabetes. iLVM was defined as measured/predicted LVM ratio above 123%. LVM was predicted in each individual by using a simple equation considering height, sex and left ventricular work. Results: iLVM was detected in 150 RA patients (64%) and in 30 controls (15%; P < 0.001). In patients with RA, the variables independently associated with iLVM emerged by multivariate logistic regression analysis were left ventricular systolic dysfunction measured as mid-wall shortening and concentric left ventricular geometry. Considering both groups of patients with RA and matched controls, RA was the strongest variable related to iLVM (odds ratio 3.37, 95% confidence interval 1.37–8.31, P = 0.008). Conclusions: Two-thirds of patients with RA without overt cardiac disease have iLVM, which is associated with left ventricular systolic dysfunction and concentric geometry. RA per se is a condition closely related to iLVM.

Reasons why patients suffering from chronic heart failure at very high risk for death survive

BACKGROUND An accurate prognostic stratification is essential for optimizing the clinical management and treatment decision-making of patients with chronic heart failure (HF). Among the best available models, we used the Cardiac and Comorbid Conditions HF (3C-HF) Score, to predict all-cause mortality in patients with CHF. METHODS we selected and characterized the subgroup of patients at very high risk with the worst mid-term prognosis belonging to the highest decile of 3C-HF score with the aim to assess predictors of survival in subjects with an expected probability of 1-year mortality near to 45%. METHODS AND RESULTS We recruited 1777 consecutive chronic HF patients at 3 Italian Cardiology Units. Median age was 76 ± 10 years, 43% were female, and 32% had preserved ejection fraction. Subjects belonging to the highest decile of 3C-HF score were 246 (13.8% of total population). During a median follow-up of 21 [12-40] months, 110 of these patients (45%) survived and 136 (55%) died. The variables that contributed to survival prediction emerged by Cox regression multivariate analysis were the lower degree of renal dysfunction and higher body mass index. CONCLUSIONS The prognostic stratification of chronic HF patients allows in daily practice to select patients at different risk for death and identify prognosticators of survival in outliers at very high risk of death. The reasons why these patients outlive the matching part of subjects who expectedly die are related to the maintenance of a satisfactory renal function and body mass index.

Prognostic Role of Subclinical Left Ventricular Systolic Dysfunction Evaluated by Speckle-Tracking Echocardiography in Rheumatoid Arthritis

Background: Speckle‐tracking echocardiography allows early detection of subclinical left ventricular systolic dysfunction (LVSD) in patients with rheumatoid arthritis (RA). In this prospective study, we assessed the prevalence and the prognostic role of subclinical LVSD detected by speckle‐tracking echocardiography in RA patients. Methods: Two‐dimensional global longitudinal strain (GLS) and global circumferential strain (GCS) were measured in 209 RA patients without overt cardiac disease. LVSD was defined as low GLS (> −16.0%), low GCS (> −17.8%), or both. The primary end point was all‐causes hospitalization; the coprimary end point was hospitalization for cardiovascular causes. Results: The study population had a mean age of 58 ± 11 years; 67% were female, 52% had hypertension, and the RA duration was 14 ± 10 years. Low GLS was detected in 51 patients (24%), low GCS in 42 patients (20%), and combined low GLS and GCS in 18 patients (9%). During a median follow‐up time of 16 months (range, 10–21 months), a primary end point occurred in 50 patients (24%), and 25 patients were hospitalized for a cardiovascular event. Multiple Cox regression analyses revealed that combined low GLS and GCS was independently associated with the end point defined as all‐causes hospitalization together with higher aortic stiffness. Examined individually, neither low GCS nor low GLS showed an independent association with this typology of clinical outcome. Conversely, both low GCS and low GLS (examined individually or as combined low GLS and GCS) emerged as strong independent prognosticators of cardiovascular events. Conclusions: Subclinical LVSD defined as low GLS, GCS, or both is common in RA patients without overt cardiac disease and provides additional prognostic information in these individuals. HighlightsA significant proportion of asymptomatic rheumatoid arthritis patients without history of cardiac disease have subclinical left ventricular systolic dysfunction detected by speckle‐tracking echocardiography and defined as low global longitudinal strain (GLS) and/or low global circumferential strain (GCS).In rheumatoid arthritis subjects analyzed in primary prevention, all‐causes hospitalizations are independently related to the condition of combined low GLS and GCS.The combined low GLS and GCS status is characterized by older age, left ventricular diastolic dysfunction, and left ventricular hypertrophy, all of which are factors predisposing patients toward the development of overt heart failure.Low GCS, low GLS, and combined low GLS and GCS are strong independent predictors of cardiovascular events at mid‐term follow‐up.

Prevalence and Factors Associated with Subclinical Left Ventricular Systolic Dysfunction Evaluated by Mid-Wall Mechanics in Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) have an increased cardiovascular event rate, mainly due to the arterial stiffness which leads to coronary atherosclerosis and concentric left ventricular (LV) geometry. These conditions predispose to LV systolic dysfunction (LVSD), which can be detected by stress‐corrected mid‐wall shortening (sc‐MS), an early prognosticator of cardiovascular events in asymptomatic patients with arterial hypertension and/or diabetes. In these subjects, sc‐MS is frequently impaired even though LV ejection fraction (LVEF) is preserved. In this study, we analyzed the prevalence and the factors associated with asymptomatic LVSD measured by sc‐MS among patients with RA and verified whether RA per se was independently related to LVSD.

Disease activity and left ventricular systolic function in rheumatoid arthritis

We have read with interest the recent paper by Midtbo et al .1 The authors evaluated 119 patients with rheumatoid arthritis (RA), and found that patients with RA active disease (Simplified Disease Activity Index (SDAI) >3.3) compared with those in remission (SDAI<3.3) had lower left ventricular (LV) systolic myocardial function, assessed by stress-corrected mid-wall shortening (scMWS) and global longitudinal strain (GLS). Data from Midtbo et al are in line with our previous work, in which we demonstrated that RA per se is a condition closely related to LV systolic dysfunction (LVSD) assessed by scMWS.2 Furthermore, similar to other pathophysiological models (systemic hypertension, diabetes mellitus and aortic stenosis), we showed that the LVSD in patients with RA is closely …

High prevalence of occult heart disease in normotensive patients with rheumatoid arthritis

Due to chronic inflammatory status, rheumatoid arthritis (RA) patients are exposed to changes in left ventricular (LV) geometry and function. We assessed prevalence, factors associated with, and prognostic role of concentric LV geometry and systolic dysfunction (LVSD) detected by echocardiography in a large cohort of patients with RA and normal blood pressure.

[PP.36.01] TRADITIONAL CARDIOVASCULAR RISK FACTORS ARE MAJOR FACTORS IN ACCELERATION OF ATHEROSCLEROSIS IN ARTHRITIS PATIENTS

Objective: Patients with chronic inflammatory arthropathy have an increased incidence of cardiovascular events (CV) due to acceleration of atherosclerosis. The echo-color Doppler examination of the carotid arteries can be useful in detection of pre-clinical atherosclerosis, such as intimal-medial thickness (IMT) and carotid segmental distensibility (DC), indices of subclinical atherosclerosis. As a whole the echo-color Doppler of the carotid arteries could allow a better stratification of cardiovascular risk in patients with chronic arthritis and may have immediate clinical utility. The aim of the study was to evaluate in a group of patients with rheumatoid arthritis prevalence of atherosclerotic plaques, and the values of carotid DC and IMT, comparing them with a population of healthy subjects. Design and method: The series consists of 219 subjects, including 163 patients with arthritis and 56 healthy volunteers, who did not have a history of CV events. All subjects were enrolled at the operating unit complex of Rheumatology of Verona in the period from March 2014 to October 2015. The patients were examined by echo-color Doppler of the carotid arteries to detect atheromatous plaques and the values of carotid IMT and DC. Results: Patients with rheumatoid arthritis don’t showed a IMT significantly increased compared to the population of healthy subjects (mean ± SD patients vs. controls 0,78 ± 0.20 s 0,73 ± 0,19, p = 0.074) but have an increased frequency of carotid plaques than controls (37% vs 20%; p = 0.020). No differences were found for DC in the two groups. The association have however shown that the differences are due primarily to age and traditional cardiovascular risk factors rather than to inflammation, disease state or anti-inflammatory drugs. Conclusions: Our study found the association between arthritis and chronic subclinical atherosclerosis emphasizing that the classic cardiovascular risk factors, potentially present in higher prevalence in this population, are major factors in the acceleration of this process. In patients with chronic arthritis its fundamental to be aggressive in identifying these factors to counteract quickly and effectively their deleterious effects on the cardiovascular system.