Rheumatoid Arthritis: A Disease Associated with Accelerated Atherogenesis

https://doi.org/10.1016/j.semarthrit.2005.03.004Get rights and content

Objectives

Rheumatoid arthritis (RA) is a systemic inflammatory disease associated with an increased prevalence of coronary heart disease and a high cardiovascular (CV) mortality. In this article, a review of mechanisms implicated in the development of accelerated atherogenesis in RA was performed. The potential role of treatment to reduce the incidence of CV events in RA was also discussed.

Methods

Retrospective review of the literature. The potential mechanisms implicated in the development of accelerated atherogenesis in RA, information on carotid ultrasonography, and the potential implication of treatment to prevent accelerated atherogenesis in individuals with RA were examined.

Results

Endothelial dysfunction, which is an early step in the development of atherosclerosis, has been observed in patients with RA. Deleterious effects resulting from persistent chronic inflammation may lead to endothelial dysfunction, insulin resistance, and a dyslipidemic pattern in these patients. Other mechanisms different from those related to classic atherogenesis risk factors, such as hyperhomocysteinemia and increased oxidative stress, are considered to be implicated in the pathogenesis of atherosclerosis in RA. Increased carotid intima-media thickness and carotid plaques have been found in RA patients compared with matched controls. Active MTX treatment of the disease has been associated with decreased CV mortality. Additional drugs such as statins may be considered in the management of these patients.

Conclusions

The increased prevalence of CV mortality rate in RA cannot only be explained by the presence of traditional atherosclerotic risk factors. A chronic inflammatory response may promote the development of accelerated atherogenesis in these patients. Active treatment of the disease is required to reduce the risk of developing CV complications in individuals with RA.

Section snippets

Methods

In this article we have examined: (1) potential mechanisms implicated in the development of atherogenesis in RA; (2) information on carotid ultrasonography in RA, a reliable and noninvasive method to detect macrovascular disease; and (3) a potential therapeutic approach to prevent accelerated atherogenesis in RA.

A literature review was conducted using a MEDLINE database search from 1982 through 2004. Articles discussing relevant, and when available, updated information on atherosclerosis and CV

Endothelial Dysfunction: An Early Step in the Development of Atherosclerosis

The endothelium plays an important role in the regulation of vascular tone, platelet activity, and thrombosis. The properties of normal endothelium make possible that an antithrombotic and anticoagulant balance may be maintained.

Vascular endothelial injury is the primary event in atherosclerosis (10) and has been associated with endothelial dysfunction (11). This may be determined as an impaired ability of the artery to dilate in response to physical and chemical stimuli due to a reduced nitric

Discussion and Conclusions

Patients with RA have an increased prevalence of coronary heart disease and a high CV mortality rate which cannot be explained only by the presence of traditional atherosclerotic risk factors.

A chronic inflammatory response may promote the development of accelerated atherogenesis in these patients. Proinflammatory cytokines, in particular TNF-α, lead to proatherogenic changes that include endothelial dysfunction, insulin resistance, a characteristic dyslipidemia, prothrombotic effects, and

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