Target organ damage in patients with rheumatoid arthritis: The role of blood pressure and heart rate
Introduction
One of the individualized cardiovascular risk assessment tools is the cardiovascular continuum which was originally proposed by Dzau et al. [1]. This “cardiovascular disease (CVD) ladder” extends from the well established CVD risk factors (hypertension, dyslipidemia, obesity, smoking, diabetes) to intermediate phenotypes such as endothelial dysfunction and target organ damage (TOD), to established, clinically overt CVD. By TOD, most authorities refer to subclinical injury or dysfunction of different organs, including the heart and kidneys. Left ventricular hypertrophy (LVH) is one of the earlier manifestations of TOD and constitutes a powerful predictor of cardiovascular events [2]. Microalbuminuria, an integrated marker of cardiovascular risk, has also been added to the CVD risk factor panel [3], [4] and constitutes another element of TOD.
The main drive for TOD in the general population is hypertension [5], diabetes mellitus, obesity [6] and the other components of the metabolic syndrome [7]. Pulse pressure [8] and serum uric acid levels [9] have also been implicated as markers of subclinical TOD in hypertensive subjects. Of note, several studies have shown an association between increased heart rate and hypertension [10], showing that central influences act consensually on the heart and the arterioles and prevail over homeostatic mechanisms. Sympathetic overactivity, which is reflected by increased heart rate, has also been implicated in the pathogenesis of several cardiovascular risk factors (hypertension, dyslipidaemia, insulin resistance) and the evolution of cardiovascular hypertrophy [10]. A study by Marinakis et al. [11] has demonstrated a relationship between heart rate variability and TOD, thus highlighting its importance in the genesis of subclinical CVD. Recently [12], inflammation, and in particular tumor necrosis factor-α (TNF-α), has been implicated in the cascade leading to TOD in patients with essential hypertension [12].
Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterised by erosive symmetrical polyarthritis and associated systemic features involving other organs. RA is the most common inflammatory arthritis, affecting 0.8% of the adult population in the UK [13], and has been associated with subclinical atherosclerosis (aortic pulse wave velocity [14], carotid intima media thickness [15]). Despite the increased prevalence [16] and poor control of hypertension in RA [17], no studies exist in the literature assessing the prevalence and associations of TOD. Furthermore, patients with RA are characterised by increased systemic inflammation [18] and increased sympathetic drive [19], factors that could contribute to an increased incidence of TOD.
The present study aimed to investigate the prevalence and associations of TOD in patients with RA.
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Patients and methods
In the present study, we assessed a subgroup of the Dudley Rheumatoid Arthritis Comorbidity COhort (DRACCO), detailed characteristics of which have been described in previous papers [17], [20]. All patients of the cohort, without established cardiovascular or renal disease as defined by the European guidelines for the management of hypertension [21] were included in this study (N = 251).
Blood pressure (BP) was the mean of three measurements taken at 5-min intervals on the right arm with the
Results
Two hundred and fifty-one patients with RA fulfilled the inclusion criteria of the present study. Mean age was 59.5 ± 12.5 years and 78.5% (197/251) were females. TOD was present in 23.5% of the studied population (59/251). The prevalence of LVH was 12.4% (31/251), of mild renal impairment 4.8% (12/251) and of microalbuminuria 12% (30/251). Of the 59 RA patients with prevalent TOD, 7 (11.9%) had their HT optimally controlled, 6 (10.2%) had normal blood pressure, 27 (45.8%) had poorly controlled
Discussion
The present study suggests a high prevalence of TOD amongst patients with RA who have no overt cardiovascular or renal disease. However, almost 80% of RA patients with TOD had either undiagnosed or uncontrolled HT, highlighting the importance of early recognition and treatment of high blood pressure in this patient group. In the univariable analysis TOD associated with hypertension indices, heart rate, SUA levels, type 2 DM, while a trend was present for the use of oral glucocorticosteroids.
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2016, Obesity Research and Clinical PracticeCitation Excerpt :Urate has proinflammatory effects on vascular cells that seem to be mediated by intracellular redox pathways [16]. Urate mediated inflammation enhances sympathetic activity by impacting on the autonomic nervous system [8,15]. Then, sympathetic nerve activation is causally related to insulin resistance as both a cause and a consequence [10].
Autonomic function and rheumatoid arthritis-A systematic review
2014, Seminars in Arthritis and RheumatismCitation Excerpt :Rheumatoid arthritis (RA) is a chronic inflammatory condition predominantly affecting the synovial joints but leading to extra-articular manifestations. The increased cardiovascular mortality in RA patients (by up to 50%) [1–4] is not fully explained by the presence of traditional risk factors and remains an important research focus [3,5–13]. The autonomic nervous system (ANS) plays a critical role in the normal regulation of cardiovascular disease through its effects on the heart, peripheral vasculature and kidneys (Fig. 1) [14].