Clinical Agreement between Nurses in the Ultrasound Measurement of Abdominal Aortic Diameter within a National Screening Programme.

BACKGROUND: Accurate measurement is central to abdominal aortic aneurysm screening, but information concerning differences between observers using modern ultrasound devices is lacking. Our aim was to assess clinical agreement among nurses within a national screening programme. METHODS: Between-observer repeatability was assessed among 2 pairs of nurses (A & B and C & D) screening a consecutive series of men at a single-community clinic in Grampian, Scotland. All 4 nurses used the same ultrasound device (GE-LOGIQe 1.5-4.6 MHz curvilinear probe) to measure maximal infrarenal inner-to-inner (ITI) anteroposterior diameter in longitudinal and transverse planes. Nurses alternated in their measurements and were blinded to their partners' measurements. Participants remained supine while "double-scanned." Clinical agreement was assessed as twice the standard deviation (2 SD) of mean differences. Analysis was undertaken using IBM-SPSS-Statistics (version 22) using the Bland-Altman "limits of agreement" (95% LoA) approach (mean difference ±2 SD) and related plots. RESULTS: A total of 63 consecutive men underwent assessment (30 men by nurses A & B; 33 men by nurses C & D). Mean age 65.5 years, brachial blood pressure 145/88 mm Hg, current smokers 14%, never smoked 41%, diabetic 18%, arterial disease 11%, daily aspirin 16%, antihypertensives 35%, and statin therapy 44%. Mean aortic diameter (ITI) was 1.81 centimeters (cm; range 1.28-2.45; SD 0.18). Pooled mean differences between nurses was 0.05 cm (95% confidence interval 0.02-0.08); 2 SD ± 0.23 with 95% LoA -0.18 to 0.28 cm. Repeatability was similar in both planes and for both pairs of nurses. CONCLUSIONS: Nurses can achieve a high level of agreement in the measurement of aortic diameter in a routine clinical setting.

Physical disease and resilient outcomes: a systematic review of resilience definitions and study methods.

BACKGROUND: Findings from physical disease resilience research may be used to develop approaches to reduce the burden of disease. However, there is no consensus on the definition and measurement of resilience in the context of physical disease. OBJECTIVE: The aim was to summarize the range of definitions of physical disease resilience and the approaches taken to study it in studies examining physical disease and its relationship to resilient outcomes. METHODS: Electronic databases were searched from inception to March 2013 for studies in which physical disease was assessed for its association with resilient outcomes. Article screening, data extraction, and quality assessment were carried out independently by 2 reviewers, with disagreements being resolved by a third reviewer. The results were combined using a narrative technique. RESULTS: Of 2280 articles, 12 met the inclusion criteria. Of these studies, 1 was of high quality, 9 were of moderate quality, and 2 were low quality. The common findings were that resilience involves maintaining healthy levels of functioning following adversity and that it is a dynamic process not a personality trait. Studies either assessed resilience based on observed outcomes or via resilience measurement scales. They either considered physical disease as an adversity leading to resilience or as a variable modifying the relationship between adversity and resilience. CONCLUSION: This work begins building consensus as to the approach to take when defining and measuring physical disease resilience. Resilience should be considered as a dynamic process that varies across the life-course and across different domains, therefore the choice of a resilience measure should reflect this.

Charlson index scores from administrative data and case-note review compared favourably in a renal disease cohort.

BACKGROUND: The Charlson index is a widely used measure of comorbidity. The objective was to compare Charlson index scores calculated using administrative data to those calculated using case-note review (CNR) in relation to all-cause mortality and initiation of renal replacement therapy (RRT) in the Grampian Laboratory Outcomes Mortality and Morbidity Study (GLOMMS-1) chronic kidney disease cohort. METHODS: Modified Charlson index scores were calculated using both data sources in the GLOMMS-1 cohort. Agreement between scores was assessed using the weighted Kappa. The association with outcomes was assessed using Poisson regression, and the performance of each was compared using net reclassification improvement. RESULTS: Of 3382 individuals, median age 78.5 years, 56% female, there was moderate agreement between scores derived from the two data sources (weighted kappa 0.41). Both scores were associated with mortality independent of a number of confounding factors. Administrative data Charlson scores were more strongly associated with death than CNR scores using net reclassification improvement. Neither score was associated with commencing RRT. CONCLUSION: Despite only moderate agreement, modified Charlson index scores from both data sources were associated with mortality. Neither was associated with commencing RRT. Administrative data compared favourably and may be superior to CNR when used in the Charlson index to predict mortality.

Relationship of EQ-5D quality of life with the presence of co-morbidity and extra-articular features in patients with rheumatoid arthritis.

PURPOSE: Rheumatoid arthritis (RA) is associated with extra-articular features (ExRA) and other co-morbidities. The aim of this study is to quantify their relative contribution to quality of life (QOL) in patients with RA. METHODS: A consecutive series of 114 ambulatory RA patients aged between 40 and 65 years were assessed by a research nurse on a single occasion. Assessment included a patient questionnaire (including EQ-5D), medication review and fasting venous blood sample. Medical records were reviewed by a rheumatologist for co-existing conditions. Multiple linear regression was used to adjust mean differences in EQ-5D in the presence/absence of co-existing conditions for age, sex, university education, arthritis duration, rheumatoid factor, erythrocyte sedimentation rate, current disease-modifying drug therapy, previous hand joint erosions and joint surgery. RESULTS: Mean age was 54 years (82% female) and median arthritis duration 10 years. Unadjusted EQ-5D was -0.09 (95% CI -0.18 to -0.01) lower in patients with any co-existing condition. EQ-5D scores were inversely correlated with the overall number of co-existing conditions (Spearman's ρ -0.31, p = 0.001), number of co-morbidities (ρ -0.22, p = 0.02) and number of ExRA features (ρ -0.22, p = 0.02). There was a linear trend of lower EQ-5D with increasing number of co-existing conditions (p = 0.003). EQ-5D was -0.18 (95% CI -0.33 to -0.02) lower in the presence of more than two co-existing conditions compared to none. Co-morbidity and ExRA features were associated with comparable adjusted reductions (-0.05 vs. -0.06) in EQ-5D scores. CONCLUSION: A wide range of co-existing conditions are associated with poorer QOL in patients with RA.

Aldosterone glucuronidation inhibition as a potential mechanism for arterial dysfunction associated with chronic celecoxib and diclofenac use in patients with rheumatoid arthritis.

OBJECTIVES: Adverse cardiovascular (CV) effects of non-steroidal anti-inflammatory drugs (NSAIDs) are largely independent of their cyclooxygenase (COX) enzyme selectivity, but could be a consequence of aldosterone 18ß-glucuronidation inhibition (AGI), which varies between NSAIDS. This study assesses the chronic effects of celecoxib (selective COX-2 inhibitor) versus diclofenac (non-selective NSAID) therapy on arterial dysfunction in patients with rheumatoid arthritis (RA). METHODS: AGI was assessed in vitro using human kidney cortical microsomes. Arterial function was measured clinically as the extent (augmentation index, AIX%) and timing (reflected wave transit time, RWTT, msec) of arterial wave reflection using radial applanation pulse wave analysis (SphygmoCor PWA device) in 39 RA patients without overt CV disease aged 40-65. A higher AIX% (and lower RWTT) indicates arterial dysfunction. Clinical assessment on a single occasion included a fasting blood sample, patient questionnaire and medical record review. Multivariable analysis was used to adjust for sex, mean blood pressure, arthritis duration, cumulative ESR-years and current DMARD therapy. RESULTS: The inhibition constant (Ki) for celecoxib was lower than that of diclofenac (Ki, 3.5 vs. 8.4 µM). Chronic celecoxib use was associated with a higher AIX% (34.8 vs. 32.3) and lower RWTT (130.1 vs. 132.7 msec) compared with diclofenac. Adjusted mean differences were AIX% 4.7 (95%CI 0.6 to 8.9; p=0.03) and RWTT -3.6 (95%CI -10.0 to 2.7; p=0.26). CONCLUSIONS: Celecoxib has a greater potency for AGI than diclofenac and its use is associated with a significantly higher AIX%. Our findings support AGI as a plausible mechanism for the CV toxicity of NSAIDs.

Routine pharmacological venous thromboembolism prophylaxis in frail older hospitalised patients: where is the evidence?

It has been claimed that there are over 25,000 preventable in-hospital deaths from venous thromboembolism annually in the UK. NICE and SIGN guidelines therefore recommend that all hospitalised patients are risk assessed for venous thromboembolism. The guidelines would recommend using pharmacological thromboprophylaxis for all patients aged 60 and above with reduced mobility and acute medical illness unless obvious contra-indications exist. Meta-analysis data regarding pharmacological thromboprophylaxis for medical patients demonstrate reductions in asymptomatic deep vein thrombosis (DVT) rather than fatal pulmonary embolism and mortality. There is also the potential for increased bleeding risk with this approach. Evidence for older medical in-patients, particularly those aged over 75, is more limited being derived from subgroup analyses of larger clinical trials. In addition, based on exclusion criteria such as increased bleeding risk, frailer older adults were unlikely to have been included within such trials. This commentary will (i) critically appraise available data on the incidence of DVT and PE in older hospitalised patients; (ii) review the evidence available from meta-analyses and subgroup analyses in older medical in-patients for the use of venous thromboembolism prophylaxis; (iii) discuss those situations out-with the guidelines where venous thromboprophylaxis may not be appropriate and even potentially harmful in this patient group and (iv) suggest future research directions.

Relationship between arterial dysfunction and extra-articular features in patients with rheumatoid arthritis.

Systemic inflammation may be a common process that underpins both atherosclerosis and extra-articular features (ExRA) of rheumatoid arthritis (RA). We evaluated the relationship between ExRA and arterial dysfunction in 114 consecutive patients with RA (82% women) without overt arterial disease aged 40-65 years. A trained research nurse undertook 'SphygmoCor' pulse wave analysis (PWA) using radial applanation tonometry to measure the extent (augmentation index, AIX%) and timing (reflected wave transit time, RWT, msec) of aortic wave reflection. Assessment included fasting blood sample, patient questionnaire and medical record review. Mean differences were adjusted for age, sex, mean blood pressure, smoking pack-years, fasting cholesterol, Stanford HAQ score and erythrocyte sedimentation rate. Mean age was 54 (SD 7) and median RA duration 10 (IQR 4-17) years. There was a trend for arterial dysfunction (higher AIX%; lower RWT) to increase as the number of ExRA features rose, but no difference in AIX% (-0.5, 95%CI -2.8 to 1.8, P = 0.65) or RWT (0.3 ms, 95%CI -3.6 to 4.2, P = 0.86) between 'any ExRA' and 'no ExRA'. Arterial dysfunction was not associated with the presence of rheumatoid nodules, Sjogren's syndrome or carpal tunnel syndrome. Our study was too small to determine whether severe ('Malmo') ExRA (vasculitis, pericarditis, episcleritis) was truly associated with a higher AIX% (3.8, 95%CI -2.3 to 9.9, P = 0.22) and lower RWT (-5.5 ms 95%CI -13.1 to 2.1, P = 0.16). While arterial dysfunction may be associated with the number of ExRA features and severe ExRA, it does not appear to be associated with other ExRA features.

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study.

OBJECTIVES: Multimorbidity is the coexistence of two or more health conditions in an individual. Multimorbidity in younger adults is increasingly recognised as an important challenge. We assessed the prevalence of secondary care multimorbidity in mid-life and its association with premature mortality over 15 years of follow-up, in the Aberdeen Children of the 1950s (ACONF) cohort. METHOD: A prospective cohort study using linked electronic health and mortality records. Scottish ACONF participants were linked to their Scottish Morbidity Record hospital episode data and mortality records. Multimorbidity was defined as two or more conditions and was assessed using healthcare records in 2001 when the participants were aged between 45 and 51 years. The association between multimorbidity and mortality over 15 years of follow-up (to ages 60-66 years) was assessed using Cox proportional hazards regression. There was also adjustment for key covariates: age, gender, social class at birth, intelligence at age 7, secondary school type, educational attainment, alcohol, smoking, body mass index and adult social class. RESULTS: Of 9625 participants (51% males), 3% had multimorbidity. The death rate per 1000 person-years was 28.4 (95% CI 23.2 to 34.8) in those with multimorbidity and 5.7 (95% CI 5.3 to 6.1) in those without. In relation to the reference group of those with no multimorbidity, those with multimorbidity had a mortality HR of 4.5 (95% CI 3.4 to 6.0) over 15 years and this association remained when fully adjusted for the covariates (HR 2.5 (95% CI 1.5 to 4.0)). CONCLUSION: Multimorbidity prevalence was 3% in mid-life when measured using secondary care administrative data. Multimorbidity in mid-life was associated with premature mortality.

Arterial stiffness and cumulative inflammatory burden in rheumatoid arthritis: a dose-response relationship independent of established cardiovascular risk factors.

OBJECTIVE: To quantify the relationship between arterial stiffness and cumulative inflammatory burden in patients with RA. METHODS: We recruited RA patients without overt arterial disease aged 40-65 years, attending hospital rheumatology outpatient clinics. Standardized research nurse assessment included blood pressure (BP), pulse wave analysis (PWA, SphygmoCor), BMI, fasting blood sample (lipids, glucose, RF and ESR), patient questionnaire (smoking, alcohol, diet, exercise, family history of premature coronary heart disease and Stanford HAQ), current medication and medical record review. Cumulative inflammatory burden was measured as ESR area-under-the-curve (ESR-years) extracted from medical records. Arterial stiffness was measured using PWA [aortic augmentation index (AIX@75)]. Multiple linear regression was used to adjust for age, sex and nine other cardiovascular risk factors. RESULTS: We recruited 114 RA patients (mean age 54 years, female 81%, current DMARD 90%, current NSAID 70%, ACR criteria 56%) comprising 1040 RA person-years. Cholesterol, glucose and BMI were similar in women and men. Women had a longer duration of arthritis (10 vs 7 years) and were more likely to be seropositive (85 vs 71%). BP, smoking and alcohol consumption were lower for women. On fully adjusted analysis, an increase of 100 ESR-years was associated with an increase in AIX@75 of 0.51 (95% CI 0.13, 0.88). On fully adjusted analysis restricted to women the increase was 0.43 (95% CI 0.01, 0.85). CONCLUSIONS: In RA patients free of overt arterial disease, a dose-response relationship exists between cumulative inflammatory burden and arterial stiffness. This relationship is independent of established CV risk factors.

Impact of educational attainment on the association between social class at birth and multimorbidity in middle age in the Aberdeen Children of the 1950s cohort study.

OBJECTIVE: Multimorbidity (the coexistence of two or more health conditions) is increasingly prevalent. No long-term cohort study has examined the impact of contemporaneously measured birth social class along with educational attainment on adult self-reported multimorbidity. We investigated the impact of educational attainment on the relationship between social class at birth and adult self-reported multimorbidity in the Aberdeen Children of the 1950s (ACONF) cohort. METHODS: A prospective cohort study using the ACONF cohort. ACONF included 12 150 individuals born in Aberdeen, Scotland 1950-1956. In 2001, 7184 (64%) responded to a questionnaire providing information including self-reported morbidity and educational attainment. The exposure was father's social class at birth from birth records and the outcome was self-reported multimorbidity.Logistic regression assessed the association between social class and multimorbidity with adjustment for gender, then by educational attainment and finally by childhood cognition and secondary school type. ORs and 95% CIs were presented. RESULTS: Of 7184 individuals (mean age 48, 52% female), 5.4% reported multimorbidity. Birth social class was associated with adult multimorbidity. For example, the OR of multimorbidity adjusted by gender was 0.62 (95% CI 0.39 to 1.00) in the highest social class group (I/II) in relation to the reference group (III (manual)) and was 1.85 (95% CI 1.19 to 2.88) in the lowest social class group. This was partially attenuated in all social class categories by educational attainment, for example, the OR was 0.74 (95% CI 0.45 to 1.21) in group I/II following adjustment. CONCLUSION: Lower social class at birth was associated with developing multimorbidity in middle age. This was partially mediated by educational attainment and future research should consider identifying the other explanatory variables. The results are relevant to researchers and to those aiming to reduce the impact of multimorbidity.

Gender bias in the clinical management of women with angina: another look at the Yentl syndrome.

BACKGROUND: Woman with heart disease may receive lower levels of clinical care than men. We assessed whether the Yentl syndrome (women receive equivalent care to men only when they demonstrate that they are like men by having a heart attack) operates in the management of angina pectoris in primary care. METHODS: The study design is a cross-sectional survey of 1162 angina patients (552 women) managed in eight sentinel centers serving 15% of the population of Liverpool. Data were extracted by specially trained data managers. Analysis included directly age-standardized proportions and male/female adjusted odds ratios (AOR), adjusted for age, disease duration, physician consultation rate, and age at diagnosis. RESULTS: All aspects of care were higher for men with angina-previous myocardial infarction (MI) than for women with angina-previous MI. Risk factor recording was an absolute 8% higher (95% CI 1%-17%), secondary prevention 9% higher (95% CI 1%-17%), cardiac investigation 10% higher (95% CI 1%-20%), and revascularization 13% higher (95% CI 4%-22%). Men with angina-previous MI consistently received the highest level and women with angina the lowest level of risk factor recording (AOR 1.79, 95% CI 1.21-2.66), secondary prevention (AOR 2.24, 95% CI 1.47-3.40), cardiac investigation (AOR 2.21, 95% CI 1.56-3.13), and revascularization (AOR 4.67, 95% CI 3.03-7.18). The provision of care to men with angina alone and women with angina-previous MI fell between these two extremes. CONCLUSIONS: A gender-based clinical hierarchy operates in the clinical management of angina pectoris in primary care. The Yentl syndrome did not apply, however, as women with angina received less intensive clinical care than similar men irrespective of prior MI.

Measurement of aortic augmentation index in pregnant women with raised blood pressure and subsequent outcomes: a preliminary prospective cohort study.

OBJECTIVE: Preeclampsia is associated with arterial dysfunction and augmentation index (AIX%) is an established indicator of arterial dysfunction. Our aim was to investigate the relationship of AIX% with time-to-delivery and other outcomes in women admitted to an antenatal triage unit. METHODS: We recruited 28 women with singleton pregnancies attending antenatal triage ward for assessment of hypertension. After 10 min rest, seated brachial blood pressure (Omron HEM-757) and AIX% (SphygmoCor applanation tonometry pulse wave analysis, PWA) were measured by a single investigator; other clinicians remained blinded to PWA results. Routine assessment included cardiotocography, urine analysis and blood tests. Subsequent outcomes were extracted from the obstetric records. RESULTS: Mean AIX% was 19.7% (SD 11.5; range -4% to +36%), maternal age 31 years, gestation 37 weeks, brachial BP 145/95, proteinuria 39%. Nine women had preeclampsia at assessment and six subsequently developed preeclampsia. Median time-to-delivery was 10 d (IQR 1.6-25 d) and was shorter for AIX% ≥ 20% (median 8.9 versus 19.8 d). AIX% was higher with preeclampsia (24.0%; SD 9.5) versus gestational hypertension (15.2%; SD 12.4); absolute difference 8.8% (95%CI 0.1-17.5; p = 0.05). A one-point higher AIX% (adjusted for age, urate and gestation) was associated with 0.3 d (95%CI -0.5 to 0.0; p = 0.06) reduced time-to-delivery. A higher AIX% was also associated with induction for preeclampsia, severe preeclampsia, peripartum-anti-hypertensives and discharge-on-anti-hypertensives. Area under the curve (AUC) for AIX% predicting preeclampsia was 0.80 (95%CI 0.59-1.00; p = 0.04). CONCLUSION: AIX% is associated with time-to-delivery and other outcomes in pregnancy.

Repeatability of SphygmoCor pulse wave analysis in assessing arterial wave reflection in pregnancy using applanation tonometry.

OBJECTIVE: To estimate clinical agreement in relation to measuring aortic augmentation index (AIX-75) in pregnancy in a routine clinical setting. METHODS: A hospital-based clinical agreement study of 20 women in which two trained nurses alternated in measuring arterial function (AIX standardized to a heart rate of 75 beats-per-minute, AIX-75) on a single occasion in triplicate, after participants had rested semi-recumbent for 15 min. Right brachial blood pressure (BP) was measured using the Microlife 3BTO-A oscillometric device. Radial applanation pulse wave analysis (PWA) was undertaken according to current guidelines using the SphygmoCor device with a hand-held Millar tonometer applanated at the right radial artery. Each nurse was blinded to others PWA results. Observer agreement was assessed using the Bland-Altman "limits of agreement" (LOA, mean difference ±2 SD) approach. RESULTS: Median gestation was 37 weeks (range: 12-42), mean age 31 years, 30% nulliparous, mean brachial BP 128/79 mm Hg. Based on all six PWA measurements, mean AIX-75 was 11.7 (range: -18 to +35). The between-observer LOA was 0.1 ± 11.0 and the within-observer LOA's were 1 ± 10 and -2 ± 8 for the two nurses. Observer differences did not vary systematically with the magnitude of AIX-75. CONCLUSION: AIX-75 can be measured by nurses using PWA in pregnancy with a high level of observer agreement.

Gender differences in the extent and timing of the reflected arterial waveform in the presence of coronary artery disease.

BACKGROUND: The non-invasive assessment of arterial dysfunction may improve cardiovascular (CV) risk assessment. We studied the relationship of the reflected wave transit time (RWT) and augmentation index (AIX), both derived from pulse wave analysis (PWA), in the presence/absence of coronary artery disease (CAD), and compared PWA with the ankle-brachial index (ABI). METHODS: A trained research nurse measured PWA (radial applanation tonometry, SphygmoCor device) and ABI (hand-held Doppler) in a consecutive series of fasted patients resting supine prior to elective coronary angiography. Measurements were undertaken blind to other clinical information. Mean differences in RWT, AIX, and ABI in the presence of CAD were adjusted for age, height, mean BP, fasting cholesterol, ever smoked, and treated hypertension using multiple linear regression. RESULTS: We recruited 125 patients (49 women) with a mean age of 65 years, total cholesterol 4.4 mmol/l, BP 136/78, current smokers 22%, and previous myocardial infraction 30%. A statistically significant interaction between sex and CAD was present for both RWT (p = 0.003) and AIX (p = 0.03). No interaction was demonstrated for ABI (p = 0.21). Mean differences for men and women in the presence/absence of CAD were: RWT -10.1 vs. +5.2 milliseconds; AIX +1.2 vs. -5.4; ABI -0.02 vs. -0.10. Male and female area under receiver operating characteristic curves for CAD detection differed for RWT (0.33 vs. 0.67) and AIX (0.62 vs. 0.36), but were similar for ABI (0.40 vs. 0.34). CONCLUSION: The timing and extent of arterial wave reflections in the presence of CAD may differ in men and women.

Non-steroidal anti-inflammatory drug (NSAID) related inhibition of aldosterone glucuronidation and arterial dysfunction in patients with rheumatoid arthritis: a cross-sectional clinical study.

OBJECTIVE: Patients with rheumatoid arthritis (RA) are at increased risk of cardiovascular (CV) disease and are also commonly prescribed non-selective non-steroidal anti-inflammatory drugs (ns-NSAIDs). New in vitro evidence suggests that this increased CV risk may be mediated through aldosterone glucuronidation inhibition (AGI), which differs between NSAIDs (diclofenac>naproxen>indomethacin>ibuprofen). Our aim was to explore the association between ns-NSAID-related AGI and arterial dysfunction. METHODS: The extent (augmentation index, AIX%) and timing (reflected wave transit time, RWT, ms) of aortic wave reflection (measured using radial applanation pulse wave analysis, PWA, SphygmoCor device) were assessed on a single occasion in 114 consecutive RA patients without overt CV disease aged 40-65 years. A higher AIX% and lower RWT indicate arterial dysfunction. Assessment included a fasting blood sample, patient questionnaire and medical record review. Multivariate analysis was used to adjust for age, sex, mean blood pressure, smoking, cumulative erythrocyte sedimentation rate (ESR-years) and Stanford disability score. RESULTS: We identified 60 patients taking ns-NSAIDs and 25 non-users. Using a ns-NSAID with the highest AGI was associated with a higher AIX% (and lower RWT) versus treatment with a ns-NSAID with the lowest AGI (diclofenac AIX% 32.3, RWT 132.7 ms vs ibuprofen AIX% 23.8, RWT 150.9 ms): adjusted mean differences AIX% 6.5 (95% CI 1.0 to 11.9; p=0.02); RWT -14.2 ms (95% CI -22.2 to -6.3; p=0.001). Indomethacin demonstrated an intermediate level of arterial dysfunction. In relation to arterial dysfunction, both indomethacin and naproxen were more similar to diclofenac than to ibuprofen. CONCLUSIONS: ns-NSAID-related AGI is associated with arterial dysfunction in patients with RA. These findings provide a potentially novel insight into the CV toxicity of commonly used ns-NSAIDs. However, the findings are limited by the small number of patients involved and require further replication in a much larger study.

Relationship between arterial stiffness and Stanford Health Assessment Questionnaire disability in rheumatoid arthritis patients without overt arterial disease.

OBJECTIVE: To quantify the relationship between Stanford Health Assessment Questionnaire (HAQ) disability and arterial stiffness in patients with rheumatoid arthritis (RA). METHODS: A consecutive series of 114 patients with RA but without overt arterial disease, aged 40-65 years, were recruited from rheumatology clinics. A research nurse measured blood pressure (BP), arterial stiffness (heart rate-adjusted augmentation index), fasting lipids, glucose, erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF). A self-completed patient questionnaire included HAQ, damaged joint count, EuroQol measure of health outcome, and Godin physical activity score. Multiple linear regression (MLR) adjusted for age, sex, smoking pack-years, cholesterol, mean arterial BP, physical activity, daily fruit and vegetable consumption, arthritis duration, ESR, and RA criteria. RESULTS: Mean age was 54 years (81% women) with a median HAQ of 1.13 (interquartile range 0.50; 1.75). Median RA duration was 10 years, 83% were RF-positive, and median ESR was 16 mm/h. Mean arterial stiffness was 31.5 (SD 7.7), BP 125/82 mm Hg, cholesterol 5.3 mmol/l, and 24% were current smokers. Current therapy included RA disease-modifying agents (90%), prednisolone (11%), and antihypertensive therapy (18%). Arterial stiffness was positively correlated with HAQ (r = 0.42; 95% CI 0.25 to 0.56). On MLR, a 1-point increase in HAQ disability was associated with a 2.8 increase (95% CI 1.1 to 4.4; p = 0.001) in arterial stiffness. Each additional damaged joint was associated with a 0.17 point increase (95% CI 0.04 to 0.29; p = 0.009) in arterial stiffness. The relationship between EuroQol and arterial stiffness was not statistically significant. CONCLUSION: In patients with RA who are free of overt arterial disease, higher RA disability is associated with increased arterial stiffness independently of traditional cardiovascular risk factors and RA characteristics.