EULAR Report: Dual Cause of Increased CV Risk in Ankylosing Spondylitis Needs Attention

The increased cardiovascular disease risk in patients with ankylosing spondylitis is explained both by traditional  cardiovascular risk factors as well as the underlying chronic inflammatory process. However, this dual etiology is not adequately addressed in clinical practice, according to a presentation on June 3 at the European Congress of Rheumatology (EULAR) annual meeting.

“The increased risk has a dual etiology. On one hand there is an approximately 50 percent increased risk for atherosclerotic disease. On the other hand, it is due to the so-called ankylosing spondylitis specific cardiovascular manifestations,” said Mike Nurmohamed, M.D., Ph.D., a professor at the Reade & VU University Medical Center in Amsterdam, the Netherlands. “The cardiovascular risk management is far from optimal.”

A previous population-based study in Canada that included over 21,000 people with ankylosing spondylitis found that vascular diseases are the primary cause of death, with an important part due to due to atherosclerosis. As atherosclerosis is now known as an inflammatory disease, the chronic inflammatory process in ankylosing spondylitis renders these patients more susceptible to accelerated atherosclerosis. Moreover, ankylosing spondylitis should be considered a new independent  cardiovascular risk factor for which cardiovascular risk management is necessary. A review by Dr. Nurmohamed, published in Expert Opinion on Biological Therapy last December, found a reduction in sub-clinical atherosclerosis in patients with ankylosing spondylitis who were treated with anti-tumor necrosis factor dugs.

Meanwhile, data from the CARDAS study, which Dr. Nurmohamed presented  at the annual meeting of the American College of Rheumatology last year, suggested an increased prevalence of diastolic dysfunction, aortic valve regurgitation, mitral valve regurgitation, and hypertension in Dutch ankylosing spondylitis patients compared to the general population. However, conduction disturbances occurred far less frequently than previously thought, suggesting that there is no need for routine electrocardiograms in patients with ankylosing spondylitis. Diastolic dysfunction and mitral valve insufficiency were not more frequent in patients with ankylosing spondylitis. There was a triple risk of aortic insufficiency in these patients, suggesting that echocardiography should be considered in elderly patients with ankylosing spondylitis.

To assess the management of cardiovascular disease risk in daily clinical practice, 254 patients  with ankylosing spondylitis were compared with the general population in the Netherlands. The prevalence of hypertension and smoking were higher in those with ankylosing spondylitis, but only 24 percent of the treatment targets for hypertension and/or hypercholesterolemia were reached. The study concluded that the cardiovascular risk management is far from optimal.

“An important point of the EULAR recommendation is that the rheumatologist is responsible for cardiovascular disease risk  management in ankylosing spondylitis, in the sense that he/she should coordinate it,” Dr. Nurmohamed said.

Under the EULAR guidelines, cardiovascular risk assessment is required every five years, lifestyle recommendations should be provided, and cardiovascular disease risk management should be carried out in accordance with national guidelines. Anti-inflammatory agents and/ or statins should be used in  patients with ankylosing spondylitis as with the general population. Treatment with anti-inflammatories and statins should only be initiated once a patient’s ten-year risk of cardiovascular disease has been calculated, such as  with the Framingham risk score, and is above 10 percent, in most cases.

Dr. Nurmohamed suggested that further research should look at the heart effects of anti-rheumatic therapies and imaging studies are needed to look at the effect on the vascular wall from drug tapering. Finally, strategies are needed to optimize cardiovascular risk implementation in daily clinical practice.

REFERENCE

Ankylosing spondylitis: the dual etiology of its increased cardiovascular risk. Mike Nurmohamed, M.D., Ph.D. 2:15 p.m., Wednesday, June 3. 2020 EULAR E-Congress