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Extended reports: M M Haara, P Manninen, H Kröger, J P A Arokoski, A Kärkkäinen, P Knekt, A Aromaa, and M Heliövaara Osteoarthritis of finger joints in Finns aged 30 or over: prevalence, determinants, and association with mortality Ann Rheum Dis 2003; 62: 151-158 [Abstract] [Full text] [PDF]

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Mikko M Haara, Pirjo Manninen, Heikki Kröger, Jari Arokoski, Alpo Kärkkäinen, Paul Knekt, Arpo Aromaa, and Markku Heliövaara.   (31 March 2003)

Osteoarthritis and cardiovascular death

Karl A Grindulis, Gurbir Bhatia, Russell Davis, Michael Sosin, Derek Connolly, and Fazal Khattak   (17 February 2003)

Authors' reply 31 March 2003
Mikko M Haara, MD Department of Public Health and General Practice University of Kuopio, Finland, Pirjo Manninen, Heikki Kröger, Jari Arokoski, Alpo Kärkkäinen, Paul Knekt, Arpo Aromaa, and Markku Heliövaara. Send letter to journal: Re: Authors' reply mhaara{at}hytti.uku.fi Mikko M Haara, et al.	Dear Editor We are grateful for the thoughtful comments by Grindulis et al.[1] concerning osteoarthritis (OA) as a predictor of cardiovascular mortality.[2] We agree that our results could have been presented in more detail. A priori, however, we had focused our comprehensive study on the prevalence of finger OA, on its risk determinants and on its association with total mortality. Interestingly, we observed that finger OA in men, in particular, predicts cardiovascular deaths.[2] As a respose to Grindulis et al.[1], we wish to present an ad hoc analysis. To emphasise the etiological approach, we entered more potential confounders into the survival analysis and excluded the subjects who were diagnosed as having a cardiovascular disease at the baseline survey (Table 1). Grindulis et al. claimed that the association between finger OA and cardiovascular death can be mediated by an effect of social class.[1] It is true that manual workers whose jobs demand higher physical input tend to be poorly paid compared to professionals. But we found that further adjustment for household income, in addition to educational level and history of workload, did not alter the results. The three indicators of socio-economical status rather suppressed the association between finger OA and cardiovascular mortality (Table 1). Grindulis et al. also suggested that disability caused by OA may increase the risk of cardiovascular disease.[1] This comment was well founded, because we had not adjusted the association between finger OA and cardiovascular mortality for physical activity at leisure. However, entering this potential factor into the Cox model did not alter our results. Further adjustment for well established risk factors, such as systolic and diastolic pressures, serum HDL and total cholesterol, body mass index, diabetes and smoking history did not weaken the association between finger OA and cardiovascular mortality (Table 1). Again, the modelling rather suggested suppression than confounding. We conclude that physical activity, social class or the conventional risk factors for coronary heart disease are unlikely to explain the increased cardiovascular mortality in the presence of finger OA. We therefore suggest a metabolic or genetic factor or their interaction as the mechanism of the association between OA and cardiovascular death. A circulating endogenous factor leading to OA may exist.[3] Previous studies suggest that hypertension, hypercholesterolemia and raised blood glucose are associated with both unilateral and bilateral knee OA independently of obesity [4] and that patients with non-insulin dependent diabetes mellitus have more often bilateral knee or hip OA.[5] Insulin-like growth factor I (IGF-I) may also play a role in such mechanism.[6] References (1) Grindulis KA, Bhatia G, Davis R, Sosin M, Connolly D, Khattak F. Osteoarthritis and cardiovascular death [electronic response to Haara MM et al. Osteoarthritis of finger joints in Finns aged 30 or over: prevalence, determinants, and association with mortality] annrheumdis.com 2003 http://ard.bmjjournals.com/cgi/eletters/62/2/151#24 (2) Haara MM, Manninen P, Kröger H, Arokoski JPA, Kärkkäinen A, Knect P, et al. Osteoarthritis of finger joints in finns aged 30 years or over: prevalence, determinants and associations with mortality. Ann Rheum Dis 2003;62:151-158. (3) Felson DT, Chaisson CE. Understanding the relationship between body weight and osteoarthritis. Bailliére’s Clinical Rheumatology 1997;11:671-681. (4) Hart DJ, Doyle DV, Spector TD. Association between metabolic factors and knee osteoarthritis in women: the Chingford Study. J Rheumatol 1995;22:1118-1123. (5) Sturmer T, Brenner H, Brenner RE, Gunther KP. Non-insulin dependent diabetes mellitus (NIDDM) and patterns of osteoarthritis. The Ulm osteoarthritis study. Scand J Rheumatol 2001;30:169-171. (6) Denko CW, Malemud CJ. Metabolic disturbances and synovial joint responses in osteoarthritis. Front Biosci 1999;4:D686-693.   Table 1 Relative risk (RR) and 95% confidence interval (CI) of cardiovascular death by finger joint osteoarthritis in 945 men (72 deaths during 11,972 person-years) and 1,242 women (48 deaths during 16,343 person-years) who had been free from cardiovascular diseases at entry. Model   Men Women Both sexes* RR CI 95% RR CI 95% RR CI 95% Adjusted for age 2.01     1.09-3.68 1.98 0.76-5.11 1.98 1.19-3.29 Further adjusted for educational level, history of workload, and household income 2.06    1.12-3.79 1.92 0.75-4.93  2.02 1.22-3.36 Further adjusted for physical activity at leisure 2.10   1.14-3.89 1.92  0.75-4.95  2.07 1.24-3.45 Further adjusted for systolic and diastolic pressures, serum HDL and total cholesterol, body mass index, diabetes, and smoking history  2.52     1.34-4.74 2.02 0.75-5.43 2.24 1.33-3.79 *adjusted also for sex
Osteoarthritis and cardiovascular death 17 February 2003
Karl A Grindulis, Consultant Rheumatologist Sandwell & West Birmingham NHS Trust, West Bromwich, Gurbir Bhatia, Russell Davis, Michael Sosin, Derek Connolly, and Fazal Khattak Send letter to journal: Re: Osteoarthritis and cardiovascular death Karl.Grindulis{at}swbh.nhs.uk Karl A Grindulis, et al.	Dear Editor Haara et al. recently published a study assessing epidemiological aspects of osteoarthritis (OA) in Finland.[1] A finding of interest was their identification of OA (in any finger joint) as a predictor of cardiovascular death among men, with the authors suggesting an undetermined metabolic factor as a mechanism. It may be that the disability conferred by OA in the lower limbs delays presentation of patients with ischaemic heart disease due to lack of exertional symptoms. Thus treatment to reduce risk is delayed. Additionally, some patients who also have generalised OA and are less physically active may be at higher risk of cardiac events.[2] Occupation and levels of education have been used as surrogates of social class.[3] Certain jobs that require repetitive movements or heavier work intensity increase the risk of developing OA ,[4] although occupation is not always linked to the development of hand OA.[5] Generally, manual workers, whose jobs demand higher physical input, are poorly paid compared to professionals. Haara et al. found no link between duration of education and osteoarthritis of the fingers but the association between OA and earlier death may, nevertheless, be mediated by an effect of social class. Death due to coronary disease is known to be associated with lower socioeconomic groups. Another Finnish study noted higher incidence of myocardial infarction in those of lower income, with higher pre-hospital, 28 day and 12 month mortality rates.[6] These higher rates may reflect differences in prevalence and awareness of cardiac risk factors among the different socioeconomic groups, which may also contribute to higher cardiovascular death in men with OA. References (1) Haara MM, Manninen P et al. Osteoarthritis of finger joints in Finns aged 30 or over: prevalence, determinants, and association with mortality. Ann Rheum Dis 2003;62:151-8. (2) Wagner A, Simon C et al. Physical activity and coronary event incidence in N. Ireland and France. Circulation 2002;105:2247-52. (3) Davey Smith G, Hart C et al. Education and occupational social class: which is the more important indicator of mortality risk? J Clin Epidemiol Community Health 1998;52:153-60. (4) National Institutes of Health Conference. Osteoarthritis: new insights. Ann Intern Med 2000;133:635-46. (5) Jones G, Cooley HM, Stankovich JM. A cross sectional study of the association between sex, smoking and other lifestyle factors and osteoarthritis of the hand. J Rheumatology 2002;29:1719-24. (6) Salomaa V, Niemela M et al. Relationship of Socioeconomic Status to the Incidence and Prehospital, 28-Day, and 1-Year Mortality Rates of Acute Coronary Events in the FINMONICA Myocardial Infarction Register Study. Circulation 2000;101:1913-8.