Chronic Rheumatic Inflammatory Conditions and Cardiovascular Health

Patients with chronic inflammatory rheumatic diseases (IRD), such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and spondyloarthritis (psoriatic arthritis and ankylosing spondylitis), have a higher risk of developing premature cardiovascular disease (CVD). The multi-factorial characteristic of this condition is thought to result from an interaction of inflammation, metabolic factors, therapy- and disease-related factor. Remarkably, patients with IRD have a higher vulnerability to atheromatous plaques. The risk of unstable plaques in RA patients is higher with respect to healthy controls. Vulnerability and rupture of plaques are often ascribed to disease activity, as well as thrombosis in IRD.

Standardized mortality ratios (SMRs) in patients with IRD are higher than those in the general population (1.3-2.3 in RA, 1.6-1.9 in AS, and 0.8-1.6 in PsA, respectively). This increased and commonly premature mortality is mainly due to CV events. Interestingly, this increased risk of CVD in RA is comparable to that observed in type 2 diabetes mellitus.

Patients with SLE have a 5–6 times increased risk of developing CVD compared to the general population, and the risk is particularly increased in young patients. Cardiovascular morbidity mainly involves conduction defects and aortic insufficiency in patients with ankylosing spondylitis (AS), but there is some evidence of an increased prevalence also of ischemic heart disease.

Dampening disease activity has been associated with reduction in the cardio vascular (CV) mortality of patients with IRD. Patients with RA in remission have lower values of laboratory markers of inflammation, lower blood pressure, and better arterial compliance. MTX has been associated with reductions in CVD in several studies.

TNF-a inhibitors may protect against CV events in patients with RA. In the CORRONA registry, which included 10,156 RA patients followed up for a mean of 22.9 months, the risk of CV events (MI, stroke, and death) was lower in the subgroup on TNF-a antagonists than in the subgroup receiving MTX or other DMARDs (HR 0.39)

European League Against Rheumatism's (EULAR) evidence-based recommendations for CV risk management in patients with RA and other forms of IRD strongly support the use of algorithms to stratify the CV risk of patients with inflammatory arthritis. Risk charts used to assess CV risk in the general population, such as the FRS, Reynolds equation, and Systematic Coronary Risk Evaluation (SCORE), can be applied to determine the CV risk of patients with IRD. However, these risk function charts underestimate the actual CV risk of patients with RA. The EULAR task force has attempted to solve this problem; they introduced some correction factors that are to be considered when the European algorithm SCORE is used. Briefly, the EULAR task force recommends a 1.5 multiplication factor in patients with RA who meet two of the three following criteria: disease duration longer than 10 years, presence of FR or anti-CCP antibodies, and extra-articular manifestations.

Better identification of the patients at high risk of CV events could benefit from the use of non-invasive surrogate markers of CVD, such as the carotid US, which could be considered in the strategy of CV risk stratification of these patients -particularly those included in the category of moderate CV risk according to risk chart algorithms. In addition to maintaining tight control of the rheumatic disease, looking for clinical remission and management of traditional CV risk factors such as dyslipidemia and hypertension should be routinely performed in patients with IRD.

The main aim of this Research Topic is to provide an overview of recent investigations in the field of cardiovascular health in rheumatic disease that advance our understanding of the mechanisms that trigger normal cardiovascular health functions and dysfunctions in patients with rheumatic disease.

Topics of interest to this Research Topic include, but are not limited to:

• Serum markers of endothelial health in rheumatoid arthritis

• Early vascular imaging and diagnostic score for cardiovascular disease in rheumatoid arthritis

• Reducing the cardiovascular burden in rheumatoid arthritis, TNF, IL-6, JAk

• Vitamin D, cardiovascular health and systemic lupus

• Interstitial lung disease and the cardiovascular risk in Sjogren and rheumatoid arthritis

• Pulmonary arterial hypertension and renal crisis in Systemic sclerosis: non-invasive markers

• Large vessel vasculitis: imaging and therapy for early and late cardiovascular complication.

• Thromboembolic risk in Behcet,

• Asymptomatic hyperuricemia, gout, and cardiovascular risk

• Osteoporosis and cardiovascular disease

• Cardiotoxicity and rheumatic therapy

• Thromboembolism in rheumatic disease

• Inflammation, antibodies and atherosclerosis