R. Vera-Pineda

Comparison of statin eligibility according to the Adult Treatment Panel III, ACC/AHA blood cholesterol guideline, and presence of carotid plaque by ultrasound in Mexican mestizo patients with rheumatoid arthritis

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in rheumatoid arthritis (RA) patients. Guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) 2013 and the Adult Treatment Panel III (ATP-III) differ in their strategies to recommend initiation of statin therapy. The presence of carotid plaque (CP) by carotid ultrasound is an indication to begin statin therapy. We aimed to compare the recommendation to initiate statin therapy according to the ACC/AHA 2013 guidelines, ATP-III guidelines, and CP by carotid ultrasound. We then carried out an observational, cross-sectional study of 62 statin-naive Mexican mestizo RA patients, aged 40 to 75, who fulfilled the 1987 or 2010 ACR/European League Against Rheumatism (EULAR) classification criteria. CP was evaluated with B-mode ultrasound. Cohen’s kappa (k) was used to assess agreement between ACC/AHA 2013 guidelines, ATP-III guidelines, and the presence of CP, considering a p < 0.05 as statistically significant. Agreement was classified as slight (0.01–0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80), and an almost perfect agreement (0.81–1.00). Slight agreement (k = 0.096) was found when comparing statin recommendation between CP and ATP-III. Fair agreement (k = 0.242) was revealed between ACC/AHA 2013 and ATP-III. Comparison between ACC/AHA 2013 and CP showed moderate agreement (k = 0.438). ACC/AHA 2013 guidelines could be an adequate and cost-effective tool to evaluate the need of statin therapy in Mexican mestizo RA patients, with moderate agreement with the presence of CP by ultrasound.

Periodontal Disease, Systemic Inflammation and the Risk of Cardiovascular Disease

Periodontal and cardiovascular disease are both major health issues. Poor oral health has long been associated with the development of systemic diseases, with the typical example being the risk of endocarditis posterior to dental procedures. Through the years, the association of periodontal disease with other non-infectious systemic diseases has been brought to attention. One of the most interesting associations is the one that exists with the development of cardiovascular disease. Many studies, including systematic reviews and meta-analyses, suggest an important association between periodontal disease and ischaemic heart disease, cerebrovascular disease, heart failure, atrial fibrillation and peripheral artery disease. Among the proposed mechanisms of this relationship, systemic inflammation appears to play a major role. Evidence suggests that periodontal inflammation triggers a systemic inflammatory state that, added to the damage mediated by antibodies that cross react between periodontal pathogens and components of the intimal wall, and the direct lesion of the intima by bacteria entering the circulation, promotes atheroma plaque development and progression. There are other studies that show a clear relationship between periodontal disease severity, elevations of inflammatory markers, and the presence of atherosclerosis. Here, we give a review of the available evidence supporting this association, and the possible mechanisms involved.

SAT0142 Pulmonary hypertension among hispanic patients with rheumatoid arthritis: a case-control study

Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, multifactorial disease that mainly affects synovial joints. Pulmonary artery hypertension (PAH) can appear as a complication of connective tissue diseases. It is possible that pulmonary artery systolic pressure (PASP) in RA may be elevated due to interstitial lung disease, pulmonary vasculitis, pulmonary veno-occlusive disease, or cardiac disease (1). Although right heart catheterization is the gold standard, Doppler echocardiography has proved to be a reliable non-invasive method for detecting PAH (2). Objectives: To determine the prevalence of PAH in RA patients and compare it to matched controls. Methods: A case-control study with RA patients aged 40 to 75 years that fulfilled the 2010 ACR/EULAR criteria and matching controls were included. Exclusion criteria: poor acoustic window, absence of tricuspid regurgitation (TR), prior atherosclerotic cardiovascular (CV) disease and overlap syndromes. Patients were matched using age, sex and comorbidities. Transthoracic echocardiogram was performed by a board-certified cardiologist. PASP was calculated using the Bernoulli equation: TR velocity2 × 4 + right atrial pressure according to ASE’s guidelines. We used Denton’s definition of PAH on Doppler echocardiography as an estimated PASP≥30 mmHg (3). Results: A total of 76 RA patients and 52 matched controls were included. Demographic and clinical characteristics of both groups are shown on table 1. As shown on table 2, the mean PASP was higher RA patients (27.14±6.34 mmHg) than controls (24.68±5.44 mmHg) (P=0.024). PASP≥30 mmHg prevalence was significantly higher in RA patients (34.2% vs 11.5%; P=0.004).Table 1 Demographic characteristics RA Control P (n = 76) (n = 52) Women, n (%) 74 (97.4) 46 (88.5) 0.041 Age, mean±SD 55.71±8.84 53.86±6.14 0.195 BMI, mean±SD 29.11±5.42 28.31±4.37 0.343 Hypertension, n (%) 26 (34.2) 12 (23.1) 0.176 Type 2 Diabetes mellitus, n (%) 8 (10.5) 7 (13.5) 0.612 Active smoking, n (%) 6 (7.9) 6 (11.5) 0.487Table 2 Echocardiographic findings RA Control P (n = 76) (n = 52) TR Vmax (m/s), mean±SD 2.27±0.32 2.18±0.33 0.157 PASP (mmHg), mean±SD 27.14±6.34 24.68±5.44 0.024 PASP≥30 mmHg, n (%) 26 (34.2%) 6 (11.5%) 0.004 TR Vmax – Tricuspid regurgitation maximum velocity Conclusions: Elevated PASP, suggesting PAH, was more prevalent on RA patients than controls. A higher number of CV events that cannot be explained by traditional risk factors have been reported in RA patients; and it is possible that the elevation in the PASP could contribute to the problem. Prospective studies are needed to evaluate the role of elevated PASP in morbidity and mortality of RA patients. References [1]Panagiotidou E, et al. Rheumatoid arthritis associated pulmonary hypertension. Respir Med Case Reports2017;20:164–7. [2]Udayakumar N, et al. Pulmonary hypertension in rheumatoid arthritis-Relation with the duration of the disease. Int J Cardiol2008;127(3):410–2. [3]Denton CP, et al. Comparison of Doppler Echocardiography and Right Heart Catheterization To Assess Pulmonary Hypertension in Systemic Sclerosis. Br J Rheumatol1997;36:239–43. Disclosure of Interest: None declared

AB1317 Identification of cardiometabolic abnormalities in the first visit to a preventive cardio-rheuma clinic

Background Rheumatoid arthritis (RA) is a chronic, systemic and autoimmune disease with articular and extra-articular manifestations. RA is associated with increased prevalence of comorbidities and higher cardiovascular risk when compared to general population. Atherosclerotic cardiovascular (CV) events are the leading cause of death in RA. In a recent meta-analysis, hypertension, type 2 diabetes mellitus (T2DM) and hypercholesterolemia were shown to increase the risk of CV disease in this population.1 A study reported a prevalence of hypertension 29.8%; dyslipidemia 27.1% and T2DM 12.4% in Mexican-mestizo RA patients.2 The cardio-rheuma clinics were designed to provide healthcare for CV diseases in patients with rheumatic conditions. Specific guidelines recommendations have been published to enhance detection and management of specific comorbidities associated to RA.3 Objectives To identify the prevalence of unknown cardiometabolic risk factors in a Mexican-mestizo cohort with RA. Methods Cross-sectional, observational study. Patients who fulfilled the 1987 ACR and/or the 2010 ACR/EULAR classification criteria were consecutively recruited. Patients were divided in two groups, with and without history of cardiovascular comorbidities. Clinical history and physical exam were performed by a general physician in a cardio-rheuma clinic. Fasting blood glucose and lipid profile were performed on all subjects. Categorical variables are expressed as percentages and numerical variables as means±standard deviations. Results A total of 296 patients were included. Demographical characteristics are shown in Figure 1. Hypertension was the most frequent comorbidity (27.7%), followed by dyslipidemia (26.7%) and T2DM (13.5%). Many of the patients without history of cardiometabolic risk factor had important findings on baseline visit: 18.7% had altered blood pressure without history of hypertension, 76.5% had an abnormal lipid profile without history of dyslipidemia, and 21.5% had an altered fasting glucose without history of T2DM.Abstract AB1317 – Figure 1 *Altered lipid profile was defined as TC ≥200 mg/dL, HDL-C <50 mg/dL, TG ≥150 mg/dL, LDL-C ≥100 mg/dL. SD=Standard deviation; T2DM=Type 2 diabetes mellitus; bDMARDs=biological agents; DAS 28-CRP=Disease Activity Score 28 joints C-reactive protein. Conclusions In our cohort of Mexican-mestizo RA patients there is a high prevalence of cardiometabolic risk factors. An important amount of these were discovered in patients without previous diagnosis at their first visit to a cardio-rheuma clinic. References [1] Dougados, et al. (2014). Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Annals of the rheumatic diseases, 73(1), 62–68. [2] Galarza-Delgado, et al. (2017). Prevalence of comorbidities in Mexican mestizo patients with rheumatoid arthritis. Rheumatology international, 37(9), 1507–1511. [3] Perk, J., et al. (2012). European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Atherosclerosis, 223(1), 1–68. Acknowledgements None Disclosure of Interest None declared

Round opacity as a presentation of pneumocystis jirovecii pneumonia in an HIV-infected patient

We present the case of a human immunodeficiency virus (HIV)-infected patient who arrived at our emergency department with fever, headache and exertional dyspnea. Throughout their stay, a chest x-ray was taken and a rounded opacity in his left lung was observed. CT images showed same abnormality and also ground glass opacities were seen. Symptoms and images strongly suggested a pulmonary infection due to pneumocystis jirovecii, however a presence of a round lesion should always lead to neoplasia being suspected. We empirically started treatment based on trimethoprim and sulfamethoxazole. Once available, flexible bronchoscopy and bronchoalveolar lavage was performed and stained preparations from his respiratory specimens confirmed the diagnosis of pulmonary pneumocystis infection. Finally, after 4 days of antibiotic therapy, an important clinical improvement was documented; a new chest x-ray was performed and the previous rounded opacity was absent. This finding strongly suggested a case of round pneumonia.

Thermal burn resulting from prolonged transcutaneous pacing in a patient with complete heart block

ABSTRACT Temporary transcutaneous pacing devices are used to treat symptomatic bradyarrhythmias that are unresponsive to medical therapy until it resolves or a more stable pacing device is established. Pain is the most common complication. Skin burns as a complication are uncommon. A female patient presented with a complete atrioventricular block that caused altered mental status and required orotracheal intubation. A temporary transcutaneous pacing device was used to treat the bradyarrhythmia and maintained for 12 h until a temporary transvenous pacemaker was placed. The patient developed a third degree skin burn in the area where the anterior pacing patch was placed. Bradycardia is a common complaint in the emergency department. Temporary transcutaneous cardiac pacing is a widely available treatment modality that serves as initial management for these cases and allows us to keep patients stable until a more stable pacing solution is available. Burns as a complication of transcutaneous pacing are uncommon.

Levocarnitine Decreases Intradialytic Hypotension Episodes: A Randomized Controlled Trial

Intradialytic hypotension is common complication in stage 5 chronic kidney disease patients on hemodialysis. Incidence ranges from 15 to 30%. These patients have levocarnitine deficiency. A randomized, placebo‐controlled quadruple‐blinded trial was designed to demonstrate the levocarnitine efficiency on intradialytic hypotension prevention. Patients were randomized into four groups, to receive levocarnitine or placebo. During the intervention period, levocarnitine and placebo was administered 0 and 30 min before each hemodialysis session, respectively. During the trial, 33 patients received 1188 hemodialysis sessions. We identified 239 (21.3%) intradialytic hypotension episodes. The intradialytic hypotension episodes were less frequent in the levocarnitine group (9.3%, 60 IH events) (P < 0.001). Hemodialysis is frequently perplexed by intradialytic hypotension episodes. Levocarnitine supplementation before each hemodialysis session efficiently diminishes the intradialytic hypotension episodes. This is a new application method that must be considered and explored.

THU0140 Speckle tracking echocardiography evaluation of coronary territories in mexican mestizo patients with rheumatoid arthritis

Background The main cause of death in patients with rheumatoid arthritis (RA) is atherosclerotic cardiovascular disease. Speckle Tracking Echocardiography (STE) is an imaging technique that analyses the local and global myocardial function by assessing the myocardial deformation (strain). This technique is useful in addressing early alterations in ischemic pathologies (1,3). Objectives The aim of this study was to analyze if longitudinal strain abnormalities correspond with vascular territories, and compare the results between RA-patients and matched controls. Methods An observational cross-section case-control study was designed. Patients that fulfilled the 1987 ACR and/or 2010 ACR/EULAR classification criteria for RA, were 40–75 years old, with no overlap syndromes and no history of atherosclerotic cardiovascular disease were included. The control group was integrated by age- and sex-matched subjects, with no rheumatologic or cardiovascular diseases. A standard transthoracic echocardiogram was performed by a board-certified echocardiographer. Affection of coronary territories was compared between groups using longitudinal strain by speckle tracking according to the European Society of Cardiology and the American Society of Echocardiography recommendations. Results A total of 53 RA-patients and 24 control subjects were included. Demographic characteristics for each group are shown in table 1. There was no statistical difference in global longitudinal strain between RA-patients and controls (-20.86±2.82 vs -21.19±2.46, p=0.62). Comparison of longitudinal strain values of the three vascular territories evaluated between RA-patients and controls did not reach statistical difference (Table 2).Table 1. Demographic characteristics RA group (n=53) Control group (n=24) p Age, mean ± SD 55.54±9.11 52.81±6.61 0.172 Women, n (%) 51 (96.2) 26 (96.3) 0.988 Body Mass Index, mean ± SD 27.53±5.85 28.05±4.66 0.956 Hypertension, n (%) 18 (33.96) 5 (18.5) 0.149 Type 2 Diabetes mellitus, n (%) 7 (13.2) 4 (14.8) 0.844 Conclusions Contrary to previous published evidence (1, 2), there was no statistical difference in global longitudinal strain between RA patients and controls. Coronary territories are not affected in RA patients in comparison with controls. Further studies with a larger cohort are necessary to determine the usefulness of strain in the evaluation of subclinical cardiovascular disease. References Fine et al. Evaluation of myocardial function in patients with rheumatoid arthritis using strain imaging by speckle-tracking echocardiography, Ann Rheum Dis. 2014 Oct;73(10):1833–9. Sitia S, Tomasoni L, Cicala S, et al. Detection of preclinical impairment of myocardial function in rheumatoid arthritis patients with short disease duration by speckle tracking echocardiography. Int J Cardiol 2012;160:8–14. Batir et al, Herz. 2015 Jun;40(4):669–74. Preclinical impairment of myocardial function in rheumatoid arthritis patients. Detection of myocardial strain by speckle tracking echocardiography. Disclosure of Interest None declared

AB0310 Prevalence of comorbidities of rheumatoid arthritis in a mexican mestizo population

Background Patients with rheumatoid arthritis (RA) have an increased risk of developing comorbid conditions which are associated to increased mortality, hospital admissions, higher costs of care and inability to work (1, 2). Objectives To evaluate the prevalence of comorbidities in a Mexican mestizo population of RA patients. Methods We performed a cross-sectional study in which RA patients who were admitted to our outpatient clinic between August 2014 and December 2016 were consecutively enrolled. We collected data regarding demographics, disease characteristics (activity, severity, treatment), comorbidities (cardiovascular, infections, cancer, and osteoporosis), and performed blood tests at the time of the patients visit to the clinic. Results We analyzed 225 patients. Their characteristics are shown in Table 1. Age, 55.7±8.3 years (mean ± SD); disease duration, 9.5 (4 – 15.5) (median (IQR)); female gender, 93.7%; Disease Activity Score using 28 joints–C-reactive protein (DAS28-CRP), 3 (2 – 4) (median (IQR)); past or current methotrexate use, 84.9%; past or current use of any other conventional disease modifying anti-rheumatic drug (cDMARD), 52.4%; past or current use of biological agents, 8%. The most frequently associated diseases were: hypertension, 29.8%; dyslipidemia, 27.1%; osteoporosis, 19.1%; diabetes, 12.4%; hypothyroidism, 6.2%; solid malignancies (excluding basal cell carcinoma), 4.4%. Risk factors were also evaluated, the most prevalent was overweight (BMI ≥25 <30) present in 101 (44.9%) of our patients. A total of 71 (31.6%) had obesity (BMI ≥30). The systematic evaluation of our patients allowed us to detect abnormalities in vital signs, such as elevated blood pressure in 12.4%, and to identify conditions that manifest as laboratory test abnormalities, such as hyperglycemia in 27.1% and hyperlipidemia in 49.8%. Conclusions This study confirms the high prevalence of comorbidities in RA patients. Among our cohort, 63.5% had at least one comorbidity, being those associated with cardiovascular disease the most common. With a systematic assessment (3) including a thorough physical examination, vital signs and laboratory tests, it is possible to detect comorbid conditions that would otherwise remain unrecognized. References Dougados M, Soubrier M, Antunez A, Balint P, Balsa A, Buch MH, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73(1):62–8. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther. 2009;11(3):229. Baillet A, Gossec L, Carmona L, Wit M, van Eijk-Hustings Y, Bertheussen H, et al. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: a EULAR initiative. Ann Rheum Dis. 2016;75(6):965–73. Disclosure of Interest None declared

FRI0141 Left ventricular concentric remodeling is more prevalent in rheumatoid arthritis: a case-control study

Background Patients with rheumatoid arthritis (RA) have a higher risk to develop cardiovascular complications than general population (1), leading to a decrease in life expectancy of 3 to 10 years (2). RA is associated to increased left ventricle mass, pericardial effusion and diastolic dysfunction (3). Objectives The aim of this study was to assess the structure and function of the left ventricle in patients with RA and compare the results with matched controls. Methods We designed an observational cross-section case-control study. Patients diagnosed with RA according to the 1987 ACR and/or 2010 ACR/EULAR classification criteria, 40–75 years old, with no overlap syndromes, atherosclerotic cardiovascular disease or hypertension were included. Subjects for the control group were matched by sex, age and comorbidities. A board-certified cardiologist performed a transthoracic echocardiogram. Results We included a total of 44 RA-patients and 26 control subjects. Table 1 summarizes the demographic characteristics for each group. Left ventricular concentric remodeling (LVCR), defined as a relative wall thickness (RWT) >0.42 cm and a left ventricular mass index (LVMI) ≤95 gm/m2 in women and ≤115 gm/m2 in men, was found in 14 patients (32.6%) of the RA-group and 2 subjects (8%) of the control group; this difference was statistically significant (p=0.021). When we analyzed general abnormalities of left ventricle (either LVCR or left ventricular concentric hypertrophy [RWT >0.42 cm and LVMI >95 gm/m2 in women, >115 gm/m2 in men]) we found 15 RA patients (34.1%) with abnormalities and 3 subjects in the control group (11.5%) (p=0.037). There were no statistically significant differences among the groups in LVMI, diastolic dysfunction, global longitudinal strain or ejection fraction.Table 1. Demographic characteristics RA group (n=44) Control group (n=26) p Age, mean ± SD 52.35±7.34 53.94±6.81 0.371 Disease duration (years), mean ± SD 10.682±8.3321 – – DAS-28 CRP, mean ± SD 3.36±1.42 – – Women, n (%) 43 (97.7) 24 (92.3) 0.279 Body Mass Index, mean ± SD 26.98±6.13 28.3±4.12 0.956 Active smoking, n (%) 4 (9.1) 0 (0) 0.113 Type 2 Diabetes mellitus, n (%) 2 (4.5) 2 (7.7) 0.584 DAS-28 CRP - Disease activity score 28 using C-reactive protein. Conclusions Left ventricle concentric remodeling is more prevalent in RA-patients when compared to controls. Further research is needed to determine the impact of these findings in the clinical prognosis of RA-patients. References Solomon DH, Curhan GC, Rimm EB, Cannuscio CC, Karlson EW. Cardiovascular risk factors in women with and without rheumatoid arthritis. Arthritis & Rheumatism. 2004;50(11):3444–9. Myasoedova E, Davis JM, Crowson CS, Gabriel SE. Epidemiology of Rheumatoid Arthritis: Rheumatoid Arthritis and Mortality. Current Rheumatology Reports. 2010;12(5):379–85. Corrao S, Messina S, Pistone G, Calvo L, Scaglione R, Licata G. Heart involvement in Rheumatoid Arthritis: Systematic review and meta-analysis. International Journal of Cardiology. 2013;167(5):2031–8. Disclosure of Interest None declared