Cardiovascular events in ankylosing spondylitis: An updated meta-analysis

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Abstract

Objectives

Rheumatoid arthritis is associated with increased cardiovascular risk. In the guidelines, ankylosing spondylitis (AS) is considered to have an equally high cardiovascular risk. The literature findings remain controversial. This study aims to assess the risk of myocardial infarction (MI) and stroke in AS patients.

Methods

An updated meta-analysis with a new systematic literature review using PubMed was conducted up to January 2014. Incidence of MI or stroke was calculated by metaproportion.

Results

In addition to the 11 previously included studies, six new studies assessed the occurrence of MI or stroke in AS patients.

(1) MI. A total of 2131 MI were reported in AS patients (n = 27,532) over a mean follow-up of 15 years: incidence 5.3% (1.6%–11.0%), i.e., 0.36/100 pyrs. Seven studies revealed 17,410 MI [2.5% (95% CI: 1.8%–3.4%)] in the control group (n = 1,349,964). Meta-analysis of the seven longitudinal studies showed a significant increase in MI [OR = 1.60 (95% CI: 1.32–1.93)] in AS patients. (2) Stroke. In 11 longitudinal studies (n = 51,990), 1807 strokes were reported in AS patients over 17.6 years of follow-up: incidence 3.6% (1.5%–6.5%), i.e., 0.24/100 pyrs. Three studies reported 22,899 strokes in controls (n = 1,239,041), giving an incidence of 1.78% (1.75%–1.80%). A significant increase in stroke [OR = 1.50 (95% CI: 1.39–1.62)] in AS patients was found.

Conclusion

AS patients appear to have a higher risk of MI and stroke. Management of cardiovascular risk factors and control of systemic inflammation should be taken into account in AS to decrease this high cardiovascular risk.

Introduction

Evidence of increased cardiovascular risk in rheumatoid arthritis (RA) is now well-recognized with a significant number of published articles [1]. European rheumatological guidelines recommend taking into account this higher cardiovascular risk, controlling disease activity, and lowering cardiovascular risk factors [2]. In these guidelines, ankylosing spondylitis (AS) is also considered to have higher cardiovascular risk. Patients with AS need to be monitored to lower cardiovascular risk insofar as possible. Higher cardiovascular risk has been reported in AS patients [3], [4]. However, opinions still differ on the association between atherosclerosis and AS, largely due to lack of evidence and controversial findings [5]. In 2011, we published a meta-analysis in the Arthritis Care & Research journal finding a higher but non-significant risk of myocardial infarction [6]. Other studies have since assessed cardiovascular risk in AS patients. Some reported an increased occurrence of cardiovascular events in AS patients compared with controls, whilst others found no difference between patients and controls [7], [8].

We decided to update our previous meta-analysis including the recent findings of previous studies and, focusing on the most relevant data, the occurrence of cardiovascular events, i.e., myocardial infarction (MI) and stroke. We did not focus on cardiovascular risk factors, as we did before.

Section snippets

Methods

We followed the same methodology as that previously published [6]. However, we decided not to focus on cardiovascular risk factors, as we did before. All the items required in the PRISMA checklist were filled in our previous study [6].

Eligible studies

In addition to the 11 previously included studies, we found six studies that assessed the occurrence of MI or stroke in AS patients, giving a total of 51,894 AS patients and 1,349,964 controls [7], [10], [11], [12], [13] (Fig. 1) (Supplementary File 1). Overall, 12 longitudinal cohort studies assessed the occurrence of myocardial infarction and 11 that of stroke in AS patients. Of these, seven reported the occurrence of MI in both patients and controls and three reported the occurrence of

Discussion

In this updated meta-analysis, a higher risk of myocardial infarction or stroke was found in AS patients compared with controls [OR = 1.60 (95% CI: 1.32–1.93) and OR = 1.50 (95% CI: 1.39–1.62), respectively]. In the guidelines, AS is also considered to have a higher cardiovascular risk. In 2008, Lévy et al. [14] reported an increased risk of myocardial infarction of about 1.63 in RA patients. This meta-analysis found a similarly increased MI risk in AS patients. More recently, Szabo et al.

Conclusion

AS patients appear to have a higher risk of MI compared to controls. This could be due to the atherogenic profile or systemic inflammation. Management of cardiovascular risk factors and control of systemic inflammation should be taken into account in AS to decrease this high cardiovascular risk, as recommended in the guidelines.

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