Qing Shang

Increased arterial stiffness correlated with disease activity in systemic lupus erythematosus

To evaluate the relationships between arterial stiffness, disease activity and end-organ damage in systemic lupus erythematosus (SLE), non-invasive vascular assessments were made on 32 female SLE patients and 32 female normal controls. The patients had significantly increased brachial-ankle pulse wave velocity (PWV) (13.06 ± 1.79 vs. 11.50 ± 1.00 m/s; P < 0.001), heart-ankle PWV (8.98 ± 1.16 vs. 7.88 ± 0.73 m/s; P < 0.001), carotid augmentation index (AI) (21.6 ± 17.2% vs. 5.4 ± 14.0%; P = 0.001) and carotid intima-medial thickness (IMT) (0.753 ± 0.132 vs. 0.644 ± 0.092 mm; P = 0.002) when compared with controls. The disease activity and organ damage were evaluated by SLE disease activity index (SLEDAI) and systemic lupus international collaborating clinics (SLICC) damage index. Patients with active disease (SLEDAI ≥ 3) had significantly higher carotid AI (34.4 ± 9.7% vs. 17.8 ± 17.3%, P < 0.05) than stable ones (SLEDAI < 3) and those with organ damage (SLICC ≥ 1) had significantly higher heart-ankle PWV (9.69 ± 1.13 vs. 8.61 ± 1.02 m/s, P < 0.05) than those with SLICC = 0. After making adjustments for age, body mass index (BMI) and blood pressure, carotid AI was found to show correlation with SLEDAI and haPWV with SLICC. A carotid AI value of 33.3% identified SLEDAI ≥ 3 with a sensitivity of 83% and a specificity of 80%, whereas a heart-ankle PWV value of 9.0 m/s identified SLICC ≥ 1 with a sensitivity of 91% and a specificity of 67%. In conclusion, SLE was an independent risk factor of sub-clinical atherosclerosis and arterial stiffness may identify the presence of active disease.

A prospective cohort study of the long-term effects of CPAP on carotid artery intima-media thickness in Obstructive sleep apnea syndrome

ObjectiveTo examine the long-term effect of CPAP on carotid artery intima-media thickness (IMT) in patients with Obstructive sleep apnea syndrome(OSAS).MethodsA prospective observational study over 12 months at a teaching hospital on 50 patients newly diagnosed with OSAS who received CPAP or conservative treatment (CT). Carotid IMT was assessed with B-mode Doppler ultrasound from both carotid arteries using images of the far wall of the distal 10 mm of the common carotid arteries at baseline, 6 months and 12 months.Measurements and results [mean (SE)]Altogether 28 and 22 patients received CPAP and CT respectively without significant differences in age 48.8(1.8) vs 50.5(2.0)yrs, BMI 28.2(0.7) vs 28.0(1.2)kg/m2, ESS 13.1(0.7) vs 12.7(0.6), AHI 38(3) vs 39(3)/hr, arousal index 29(2) vs 29(2)/hr, minimum SaO2 75(2) vs 77(2)% and existing co-morbidities. CPAP usage was 4.6(0.3) and 4.7(0.4)hrs/night over 6 months and 1 year respectively. Carotid artery IMT at baseline, 6 months, and 12 months were 758(30), 721(20), and 705(20)micron for the CPAP group versus 760(30), 770(30), and 778(30)micron respectively for the CT group, p = 0.002.Among those free of cardiovascular disease(n = 24), the carotid artery IMT at baseline, 6 months and 12 months were 722(40), 691(40), and 659(30)micron for the CPAP group (n = 12) with usage 4.5(0.7) and 4.7(0.7) hrs/night over 6 months and 12 months whereas the IMT data for the CT group(n = 12) were 660(20), 685(10), and 690(20)micron respectively, p = 0.006.ConclusionsReduction of carotid artery IMT occurred mostly in the first 6 months and was sustained at 12 months in patients with reasonable CPAP compliance.

Tumour necrosis factor alpha blockade is associated with sustained regression of carotid intima-media thickness for patients with active psoriatic arthritis: a 2-year pilot study

We have reported that psoriatic arthritis (PsA) patients without overt cardiovascular diseases have evidence of premature atherosclerosis as indicated by an increased carotid intima-media thickness (IMT).1 Whether an increase in IMT reflects current (but reversible) inflammation of the vessel wall rather than more permanent structural vessel changes in PsA has never been assessed. We undertook a prospective, observational study to determine whether a 12-week treatment of tumour necrosis factor alpha (TNFα) blockers may reduce IMT in patients with active PsA, and whether the changes in IMT can be sustained in patients who were continued on long-term TNFα blockers. Twenty consecutive PsA patients with active disease were recruited to receive TNFα blockers. After 12 weeks, nine patients continued (group 1) while 11 patients discontinued TNFα blockers due to financial constraints (group 2). Twenty PsA patients who were naive to TNFα blockers were recruited as controls (group 3). Patients …

Infliximab is associated with improvement in arterial stiffness in patients with early rheumatoid arthritis -- a randomized trial.

Objective. To determine the efficacy of methotrexate (MTX) with infliximab (IFX) compared with MTX alone in the prevention of atherosclerosis and arterial stiffness in patients with early rheumatoid arthritis (RA). Methods. A randomized, open-label study in which early RA patients with active disease were treated with MTX alone (n = 20) and MTX plus IFX (n = 20) for 6 months. Patients were assessed every 3 months. Patients from the MTX-alone group who failed to achieve 28-joint Disease Activity Score remission (DAS28 ≤ 2.6) at 6 months were permitted to escape to open-label IFX. Intima-media thickness (IMT), pulse wave velocity (PWV), and augmentation index (AIx) were measured at baseline, 6 months, and 12 months. Results. At 6 months, there was a significantly greater reduction in PWV in the MTX-alone group (0.18 ± 1.59 m/s) compared with the MTX plus IFX group (−0.78 ± 1.13 m/s; p = 0.044), accompanied by significantly greater reduction in patient’s global assessment, number of swollen joints, C-reactive protein, and DAS28 in the MTX plus IFX group compared to the MTX-alone group. The changes in IMT and AIx were similar between the 2 groups. At 12 months, there was a trend favoring early combination treatment with regard to the reduction in PWV (p = 0.06). Conclusion. MTX plus IFX causes a more significant reduction in PWV than MTX alone in patients with early RA after 6-month treatment, and further improvement may be achieved in patients who continued on longterm tumor necrosis factor-α blockers, suggesting that early, effective suppression of inflammation may prevent progression of atherosclerosis by improving vascular function.

High Prevalence of Subclinical Left Ventricular Dysfunction in Patients with Psoriatic Arthritis

Objective. Endothelial dysfunction and early atherosclerosis have been found in patients with psoriatic arthritis (PsA) without cardiovascular disease (CVD) risk factors. Few studies have investigated whether there is any early impairment of myocardial function. The aims of our study were to determine the prevalence of subclinical left ventricular (LV) dysfunction in PsA patients and the disease-related risk factors. Methods. Ninety-four PsA patients without clinical evidence of CVD and 63 healthy subjects were enrolled. All underwent conventional echocardiography and tissue Doppler imaging. Results. Sixty-one (65%) patients with PsA had evidence of subclinical LV dysfunction as defined by mean myocardial peak systolic velocity (Sm) of basal 6 segments < 4.4 cm/s, lateral E’ < 11.5 cm/s, and/or lateral E/E’ > 10. Thirty-six (38%) patients had only diastolic dysfunction, 4 (4%) had only systolic dysfunction, and 21 (22%) had both systolic and diastolic dysfunction. PsA patients with subclinical LV dysfunction were older, had a higher age at diagnosis of PsA and of psoriasis, a longer disease duration, a higher prevalence of hypertension and hyperlipidemia, higher levels of serum creatinine, and more antihypertensive treatment than those with normal LV function. Multivariate regression showed that age at diagnosis of PsA > 40 years (OR 3.388, 95% CI 1.065–10.777, p = 0.039) and hypertension (OR 4.732, 95% CI 1.345–16.639, p = 0.015) were independent predictors of subclinical LV dysfunction. Conclusion. PsA patients without established CVD disease and in the absence of traditional CV risk factors have a high prevalence of subclinical LV dysfunction.

Increase in ventricular–arterial stiffness in patients with psoriatic arthritis

OBJECTIVES Ventricular and arterial stiffness is an accepted cause of myocardial diastolic dysfunction. The aim of this study is to determine whether there is increased ventricular and arterial stiffness in patients with PsA and any relationship with disease-related risk factors. METHODS Seventy-three patients with PsA were divided into two subgroups based on the absence or presence of hypertension and/or left ventricular (LV) hypertrophy. Fifty healthy controls were enrolled for comparison. All participants underwent non-invasive assessments including conventional echocardiography with tissue Doppler imaging and pulse wave analysis. Ventricular stiffness was measured by ventricular end-systolic and diastolic elastance, whereas arterial stiffness was measured by total arterial compliance and aortic augmentation index. RESULTS There was significantly increased ventricular and arterial stiffness in patients with PsA (P < 0.001), even in those without hypertension and/or LV hypertrophy. Based on the cut-off points derived from the controls, 38.4% of PsA patients had increased LV stiffness including 31.5% in diastole and 17.8% in systole, and 15.1% had increased arterial stiffness. Multivariable logistic regression analysis showed that long PsA disease duration (>10 years) (odds ratio = 6.55, P = 0.001) was an independent risk factor for increased LV diastolic elastance after adjusting for age, gender and hypertension. CONCLUSION Patients with PsA may have increased ventricular and arterial stiffness even without evidence of LV remodelling, and those with long disease duration may be at a higher risk. Therefore, prolonged inflammatory burden may be an important cause of early cardiovascular disease in patients with PsA.

Disease chronicity and activity predict subclinical left ventricular systolic dysfunction in patients with systemic lupus erythematosus

Objective: This study investigates parameters that could predict subclinical cardiac dysfunction in systemic lupus erythematosus (SLE) in the absence of valvular, clinical coronary artery and pericardial disease. Design: A case-control trial. Setting: Rheumatology clinic, a university teaching hospital. Patients: Eighty-two female SLE patients (49 (SD 9) years) and 82 female normal subjects (49 (13) years) matched for age, body mass index, blood pressure and heart rate. Interventions: All underwent standard echocardiography and tissue Doppler imaging. Main outcome measures: Twenty-two (27%) patients had evidence of impaired left ventricular (LV) long-axis function with mean myocardial peak systolic velocity (Sm) of basal six segments <4.4 cm/s and also subnormal stress-corrected midwall fractional shortening. Thirty-four (42%) patients demonstrated impaired right ventricular (RV) long-axis function. These occurred in the presence of comparable normal LV ejection fraction, cardiac index, and RV fractional area change to the control group. Patients with subnormal mean Sm were older (49 (8) vs 44 (9); p = 0.043) and had a higher prevalence of hypertension (46% vs 22%; p = 0.034), longer disease duration >10 years (82% vs 50%, p = 0.01), higher disease activity score (73% vs 48% for Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)⩾1, p = 0.049) and end-organ damage index (64% vs 47% with Systemic Lupus International Collaborating Clinics Damage Index (SLICC)⩾1, p = 0.049) than those with normal values. Disease duration >10 years, disease activity index and increased arterial stiffness provided additional incremental predictive value of LV long-axis function. Conclusion: SLE patients have subclinical long and short-axis dysfunctions. Regular monitoring of cardiac function by tissue Doppler echocardiography may be indicated for patients who had SLE for >10 years, frequent flare or when arterial stiffening is demonstrated.

Difference in prevalence and pattern of mechanical dyssynchrony in left bundle branch block occurring in right ventricular apical pacing versus systolic heart failure.

BACKGROUND This study compared the prevalence and pattern of mechanical dyssynchrony in patients with normal heart and right ventricular apical (RVA) pacing versus patients with systolic heart failure (SHF) and spontaneous left bundle branch block (LBBB). METHODS A total of 112 patients having LBBB pattern on surface electrocardiogram were included (57 with ejection fraction>50% received RVA pacing; 55 had SHF with ejection fraction<35%). Using tissue Doppler imaging, systolic and diastolic dyssynchrony was defined by the standard deviation of the time to peak systolic and peak early diastolic velocity, respectively. RESULTS Despite comparable QRS duration and LBBB pattern, the prevalence of electromechanical dyssynchrony was significantly lower in the patients with RVA pacing (systolic: 54% vs 73%, chi2=4.058, P=.044; diastolic: 32% vs 61%, chi2=9.738, P=.002). The presence of coexisting systolic and diastolic dyssynchrony, isolated systolic dyssynchrony, isolated diastolic dyssynchrony, and no dyssynchrony also showed a different distribution between the 2 groups (RVA pacing: 14%, 40%, 18%, and 28%; SHF: 51%, 22%, 11%, and 16%; chi2=17.498, P=.001). Furthermore, the SHF group had a higher prevalence of medial wall (ie, septal, anteroseptal, and inferior) delay (56% vs 30%), whereas RVA pacing resulted in more free wall (ie, lateral, posterior and anterior) delay (44% vs 70%) (chi2=8.050, P=.005). CONCLUSIONS The prevalence of mechanical dyssynchrony is lower in patients with normal ejection fraction and RVA pacing when compared with patients with SHF and spontaneous LBBB. The pattern of delay in contraction also appears to be different between the 2 groups.

IL-33 and soluble ST2 levels as novel predictors for remission and progression of carotid plaque in early rheumatoid arthritis: A prospective study

OBJECTIVES To study the association between the baseline IL-33 and soluble ST2 (sST2) levels with disease remission and progression of carotid atherosclerosis in early rheumatoid arthritis (ERA) patients. METHODS A total of 98 ERA patients were enrolled. Disease activity and the presence of carotid plaque were evaluated at baseline and 12 months later. Plasma IL-33 and sST2 levels were determined using enzyme-linked immunosorbent assay kits. RESULTS Baseline IL-33 and sST2 levels were associated with inflammatory markers and cardiovascular (CV) risk factors. Overall, 44(45%), 18(18%), and 21(21%) patients achieved remission based on 28-joint disease activity score (DAS28), Boolean, and simplified disease activity score (SDAI) criteria at 12 months, respectively. Patients with detectable IL-33 at baseline were less likely to achieve DAS28 (P = 0.010) and SDAI remission (P = 0.021), while a lower baseline sST2 level was able to predict DAS28, Boolean, and SDAI remission (P = 0.005, 0.001, and <0.001, respectively). Using multivariate analysis, a lower baseline sST2 level independently predict Boolean (OR = 0.789; P = 0.005) and SDAI remission (0.812; P = 0.008). Regarding carotid atherosclerosis, 9/98(9.2%) patients had plaque progression at 12 months. Baseline IL-33 was detectable in 8/9(89%) and 42/83(51%) of patients with and without plaque progression respectively (P = 0.029). Baseline detectable IL-33 was an independent predictor for plaque progression after adjusting for traditional CV risk factors (P = 0.017). CONCLUSIONS Lower baseline sST2 levels independently predict disease remission and baseline detectable IL-33 independently predicts carotid plaque progression in ERA patients. This study suggests that inflammation induced by the IL-33/ST2 axis may play a significant role in the development of cardiovascular disease in RA.

Relation of Left Ventricular Systolic Dyssynchrony in Patients With Heart Failure to Left Ventricular Ejection Fraction and to QRS Duration

Left ventricular (LV) systolic dyssynchrony is an important pathologic mechanism in patients with heart failure (HF). However, the prevalence of intraventricular dyssynchrony in patients with different LV ejection fractions (EFs) is unknown. This study evaluated 402 consecutive patients with HF (mean age 64.99 +/- 13.15 years, 72.4% men) and 120 healthy controls. Dyssynchrony indexes included the SD of the time to peak systolic velocity (Ts) in ejection phase in the 12-segmental model (Ts-SD) and the difference in Ts between basal septal and basal lateral segments (Ts-Septal-Lateral) using tissue Doppler imaging. Patients were divided into 3 groups according to LVEF (LVEF <20%, >20% to 35%, and >35% to 50%) and compared with healthy controls. Both indexes were significantly higher in all 3 LVEF groups compared with controls (p <0.0001). Based on the established cut-off values, systolic dyssynchrony was equally prevalent in all 3 LVEF groups and was 67%, 62%, and 55% using Ts-SD and 38%, 36%, and 35% using Ts-Septal-Lateral, respectively. However, the prevalence of systolic dyssynchrony was higher using Ts-SD than Ts-Septal-Lateral (chi-square = 94.43, p <0.001). Conversely, the prevalence of electrical dyssynchrony, defined as a >120-ms QRS duration, decreased significantly with increasing LVEF (44%, 35%, and 16%; chi-square 5.60, p <0.001). In conclusion, the prevalence of mechanical systolic dyssynchrony was independent of severity of LV systolic dysfunction. This may implicate the potential role of cardiac resynchronization therapy for those with LVEF of 35% to 50%, in particular when systolic dyssynchrony is present.