Cardiovascular events in ankylosing spondylitis: An updated meta-analysis
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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