ABSTRACT
OBJECTIVES: This study explored whether the excess cardiovascular (CV) disease (CVD) risk in RA could be ameliorated by suppression of inflammation using a treat-to-target (T2T) approach. We compared the CV event (CVE) incidence among ERA patients managed by a T2T strategy with a CV risk factor-matched non-RA population and a historical RA cohort (HRA). METHODS: This was an observational study using the city-wide hospital data and the ERA registry. ERA patients received T2T management while HRA patients received routine care. Each ERA/HRA patient was matched to three non-RA controls according to age, gender and CV risk factors. Patients on antiplatelet/anticoagulant agents, with pre-existing CVD, chronic kidney disease or other autoimmune diseases were excluded. All subjects were followed for up to 5 years. The primary end point was the first occurrence of a CVE. RESULTS: The incidence of CVE in the ERA cohort (n = 261) and ERA controls were similar with a hazard ratio of 0.53 (95% CI 0.15, 1.79). In contrast, the incidence of CVE in the HRA cohort (n = 268) was significantly higher than that of the HRA controls with a hazard ratio of 1.9 (95% CI 1.16, 3.13). The incidence of CVE in the ERA cohort was significantly lower than that of the HRA cohort and the difference became insignificant after adjusting for inflammation, the use of methotrexate and traditional CV risk factors. CONCLUSION: ERA patients managed by a T2T strategy did not develop excess CVE compared with CV risk factor-matched controls over 5 years.
Subject(s)
Arthritis, Rheumatoid , Cardiovascular Diseases , Humans , Case-Control Studies , Arthritis, Rheumatoid/complications , Arthritis, Rheumatoid/drug therapy , Arthritis, Rheumatoid/epidemiology , Methotrexate/therapeutic use , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Inflammation/complications , Risk FactorsABSTRACT
OBJECTIVES: This study aimed to assess the performance of carotid ultrasound (US) parameters alone or in combination with Framingham Risk Score (FRS) in discriminating patients with psoriatic arthritis (PsA) with and without coronary artery disease (CAD). METHODS: Ninety-one patients with PsA (56 males; age: 50±11 years, disease duration: 9.4±9.2 years) without overt cardiovascular (CV) diseases were recruited. Carotid intima-media thickness (cIMT), the presence of plaque and total plaque area (TPA) was determined by high-resolution US. CAD was defined as the presence of any coronary plaque on coronary CT angiography (CCTA). Obstructive-CAD (O-CAD) was defined as >50% stenosis of the lumen. RESULTS: Thirty-five (38%) patients had carotid plaque. Fifty-four (59%) patients had CAD (CAD+) and 9 (10%) patients had O-CAD (O-CAD+). No significant associations between the presence of carotid plaque and CAD were found. However, cIMT and TPA were higher in both the CAD+ and O-CAD+ group compared with the CAD- or O-CAD- groups, respectively. Multivariate logistic regression analysis revealed that mean cIMT was an independent explanatory variable associated with CAD and O-CAD, while maximum cIMT and TPA were independent explanatory variables associated with O-CAD after adjusting for covariates. The optimal cut-offs for detecting the presence of CAD were FRS >5% and mean cIMT at 0.62 mm (AUC: 0.71; sensitivity: 67%; specificity: 76%), while the optimal cut-offs for detecting the presence of O-CAD were FRS >10% in combination with mean cIMT at 0.73 mm (AUC: 0.71; sensitivity: 56%; specificity: 85%). CONCLUSION: US parameters including cIMT and TPA may be considered in addition to FRS for CV risk stratification in patients with PsA.
Subject(s)
Arthritis, Psoriatic , Coronary Artery Disease , Arthritis, Psoriatic/complications , Arthritis, Psoriatic/diagnostic imaging , Arthritis, Psoriatic/epidemiology , Carotid Arteries/diagnostic imaging , Carotid Intima-Media Thickness , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/epidemiology , Humans , Infant, Newborn , Male , Risk Assessment , Risk FactorsABSTRACT
OBJECTIVE: PsA patients who achieved sustained minimal disease activity (sMDA) had less subclinical atherosclerosis progression. The vascular effects of achieving other potential treatment targets, including the PsA Disease Activity Score (PASDAS) and the Disease Activity in PsA (DAPSA) score, remained uncertain. This study aimed to compare the vascular effects of achieving different treatment targets in PsA patients. METHOD: This is a post hoc analysis of a 2 year treat-to-target study aimed at MDA. A total of 101 consecutive PsA patients without overt cardiovascular disease were recruited. High-resolution carotid ultrasound and arterial stiffness markers were assessed annually. Low disease activity (LDA) was defined as MDA, DAPSA ≤14 or PASDAS ≤3.2. Sustained disease control was defined as achieving these targets at each visit from month 12 until month 24. RESULTS: Ninety patients [52 male (57.8%), age 50 years (s.d. 11)] who completed 24 months of follow-up were included in this analysis. A total of 44%, 48% and 45% of patients achieved sustained DAPSA LDA (sDAPDA-LDA), sustained PASDAS LDA (sPASDAS-LDA) and sMDA, respectively. Patients who achieved sMDA had significantly less progression of carotid intima-media thickness than those who did not (P = 0.031). Using multivariate analysis, achieving sMDA and sPASDAS-LDA had a protective effect on plaque progression, less increase in total plaque area, reduced mean intima-media thickness and reduced augmentation index after adjusting for covariates. In contrast, no significant differences in the progression of vascular parameters were demonstrated between patients who did or did not achieve sDAPSA-LDA. CONCLUSION: Achieving sMDA/sDASPAS-LDA, but not sDAPSA-LDA, was associated with a protective effect in subclinical atherosclerosis and arterial stiffness progression. A multidimensional domain of disease control might be better in minimizing cardiovascular risk in PsA.
Subject(s)
Arthritis, Psoriatic/drug therapy , Atherosclerosis/drug therapy , Atherosclerosis/prevention & control , Carotid Intima-Media Thickness , Vascular Stiffness , Atherosclerosis/diagnostic imaging , Disease Progression , Female , Humans , Male , Middle Aged , Multivariate Analysis , Plaque, Atherosclerotic/diagnostic imaging , Remission Induction , Time FactorsABSTRACT
OBJECTIVE: To investigate the effects of achieving minimal disease activity (MDA) on the progression of subclinical atherosclerosis and arterial stiffness in patients with psoriatic arthritis (PsA). METHODS: A total of 101 consecutive patients with PsA were recruited for this prospective cohort study. All patients received protocolized treatment targeting MDA for a period of 2 years. High-resolution carotid ultrasound and arterial stiffness markers were assessed annually. The primary outcome measure was the effect of achieving MDA at 12 months (MDA group) on the progression of subclinical atherosclerosis over a period of 24 months. Secondary objectives were to compare the changes in arterial stiffness markers over 24 months between the MDA and non-MDA groups, as well as the changes in subclinical atherosclerosis and arterial stiffness markers in patients who achieved MDA at each visit from month 12 through month 24 (sustained MDA [sMDA]). RESULTS: Ninety PsA patients (mean ± SD age 50 ± 11 years, 58% male [n = 52]) who completed 24 months of follow-up were included in this analysis. Fifty-seven patients (63%) had achieved MDA at 12 months. Subclinical atherosclerosis and arterial stiffness outcomes were similar between the MDA and non-MDA groups. Forty-one patients (46%) achieved sMDA. As shown by multivariate analysis, achieving sMDA had a protective effect on plaque progression (odds ratio 0.273 [95% confidence interval 0.088-0.846], P = 0.024), and less of an increase in total plaque area, mean intima-media thickness, and augmentation index values after adjustment for covariates. CONCLUSION: Our results support the recommendation that once MDA is achieved, it should ideally be maintained for a prolonged period in order to prevent progression of carotid atherosclerosis and arterial stiffness in patients with PsA.
Subject(s)
Antirheumatic Agents/therapeutic use , Arthritis, Psoriatic/drug therapy , Atherosclerosis/diagnostic imaging , Carotid Artery Diseases/diagnostic imaging , Radial Artery/physiopathology , Vascular Stiffness/physiology , Adult , Arthritis, Psoriatic/epidemiology , Asymptomatic Diseases , Atherosclerosis/epidemiology , Carotid Artery Diseases/epidemiology , Carotid Intima-Media Thickness , Cohort Studies , Disease Progression , Female , Humans , Male , Middle Aged , Multivariate Analysis , Prospective Studies , Pulse Wave Analysis , Treatment Outcome , UltrasonographyABSTRACT
Context: Measurement of areal bone mineral density (aBMD) by dual-energy x-ray absorptiometry (DXA) was able to predict fracture risk. High-resolution peripheral quantitative computed tomography (HR-pQCT) yields additional information about volumetric bone mineral density (vBMD), microarchitecture, and strength that may increase our understanding of fracture susceptibility. Objective: To ascertain whether vBMD, microarchitecture, and estimated bone strength derived from HR-pQCT can discriminate vertebral fractures in patients with glucocorticoid-induced osteoporosis (GIOP) independent of aBMD. Design: A cross-sectional case-control study. Setting: Seven regional hospitals in Hong Kong. Patients: A total of 110 patients on long-term glucocorticoids with vertebral fracture, determined radiographically, and 110 patients on long-term glucocorticoids without fracture. Main Outcome Measures: We assessed vBMD, microarchitecture, and bone strength; aBMD; and fracture risk assessment tool (FRAX). Results: Patients with vertebral fracture had lower total vBMD and a thinner cortex at the distal tibia after adjustment for age, sex, and aBMD or FRAX. In the antiresorptive treatment-naive subgroup, patients with vertebral fracture also had lower total vBMD at both the distal radius and the tibia after adjustment for covariates. Lower total vBMD and a thinner cortex were also noticed in the nonosteoporotic or FRAX score of <10% subgroups with vertebral fracture and were also associated with increasing prevalence of vertebral fracture. Conclusion: Patients with GIOP and vertebral fracture have a significant reduction in total vBMD and cortical thinning independent of aBMD and FRAX. These changes may help identify high-risk patients in the subgroups currently considered to have low fracture risk as assessed by DXA or FRAX.
Subject(s)
Bone Density , Glucocorticoids/adverse effects , Osteoporosis/physiopathology , Spinal Fractures/etiology , Tomography, X-Ray Computed/methods , Absorptiometry, Photon , Adult , Aged , Case-Control Studies , Cortical Bone/diagnostic imaging , Cortical Bone/physiopathology , Cross-Sectional Studies , Female , Hong Kong , Humans , Male , Middle Aged , Osteoporosis/chemically induced , Osteoporosis/complications , Prevalence , Radius/diagnostic imaging , Radius/physiopathology , Risk Factors , Spinal Fractures/epidemiology , Tibia/diagnostic imaging , Tibia/physiopathology , Time FactorsABSTRACT
OBJECTIVE: To evaluate disease activity in early rheumatoid arthritis patients in daily practice 1 year after applying a tight control treatment strategy aimed at lowering disease activity (Disease Activity Score 28, ≤ 3.2). DESIGN: Single-arm open trial with historical controls. SETTING: Regional hospital, Hong Kong. PATIENTS: All new rheumatoid arthritis patients (onset < 2 years) attending the tight control clinic from October 2008 to October 2009 were recruited. All the patients were followed up every 3 to 6 weeks and clinically assessed using the Disease Activity Score 28. Disease-modifying agent treatment was stepped up according to a preset protocol ladder and patient tolerance. The treatment target was to achieve a Disease Activity Score 28 of 3.2 or below (low disease activity). These patients were compared to matched historical controls in the rheumatology clinic. RESULTS: Twenty patients in the tight control early rheumatoid arthritis clinic were recruited. Their disease activities were brought into better control than historical control patients who were followed up every 12 weeks. At week 52, clinical variables showed greater improvements in the intensive care group; respective mean scores (based on the Disease Activity Score 28 system) were 2.7 versus 4.2 (P<0.001); respective mean Health Assessment Questionnaire scores were 0.2 versus 1.3 (P<0.001). CONCLUSION: Outcomes of patients attending our locally adapted tight control clinic were consistent with previous reports in the literature. The clinic reduced rheumatoid arthritis activity faster and better. It entailed more frequent follow-up and monitoring, however. To address this strategy more objectively, a randomised trial with parallel controls is necessary.