Cardiovascular risk in ankylosing spondylitis and the effect of anti-TNF drugs: a narrative review

ABSTRACT

Introduction: Cardiovascular (CV) mortality is increased in patients with ankylosing spondylitis (AS), but little is known about CV morbidity beyond the fact that they have a two-fold higher prevalence of ischemic heart disease than controls due to the inflammatory pattern of the disease itself, and a higher prevalence of traditional CV risk factors than the general population. Anti-TNF drugs reduce inflammation and a number of studies have reported a reduction in sub-clinical atherosclerosis in AS patients treated with anti-TNF drugs, thus suggesting that inflammation contributes to their higher CV risk. Anti-TNF drugs also alter the lipid profiles of AS patients, although these changes may reflect their normalization secondary to inflammation control, and improve their other myocardial alterations.

Areas covered: This review concentrates on the risk of cardiovascular morbidity and mortality among AS patients and the effect of anti-TNF drugs on this risk, with particular emphasis on the putative causes involved and the aspects that are relevant in clinical practice.

Expert opinion: The growing evidence of CV disease in AS means that all clinicians need to know how to prevent it and treat patients appropriately. It is important to bear in mind the EULAR guidelines, which state that a rheumatologist is responsible for monitoring all AS patients for signs of CV involvement because this is essential in order to ensure that they are treated properly. As there is little clinical evidence concerning the effects of biological drugs other than anti-TNF agents, treatment should be decided on the basis of the clinical aspects of the type of AS and the CV co-morbidity: for example, patients who are hypertensive or dyslipidemic should immediately start treatment with an anti-hypertensive agent and/or a statin. All of the patients should be educated to prevent CV events by keeping to a balanced healthy diet, avoiding tobacco smoking, and maintaining normal blood pressure, LDL-cholesterol and glucose levels. Finally, all clinicians (but particularly rheumatologists) should always bear in mind CV complications in order to guarantee that the quality of life of AS patients is as good as possible.

KEYWORDS:

• Cardiovascular disease
• ankylosing spondylitis
• lipid profile
• noninvasive diagnostic techniques

Article Highlights

● This review shows that traditional CV risk factors are more prevalent in patients with all types of arthritis than in the general population, and this partially explains their increased risk of developing myocardial infarction.

● However, the increased risk of CV morbidity and mortality among patients with AS is likely to be due to the inflammatory nature of the diseases itself.

● All AS patients should be screened for traditional CV factors and a CV risk stratification score such as the Framingham risk score or the Systematic Coronary Risk Evaluation (SCORE) algorithm should be calculated.

Two-dimensional speckle tracking echocardiography (2D-STE) and magnetic resonance imaging (MRI) are more sensitive in detecting sub-clinical ventricular dysfunction in various clinical disorders.

● Anti-TNF drugs reduce inflammation and improve myocardial alterations, and a number of studies have shown a reduction in sub-clinical atherosclerosis in SpA patients treated with TNF inhibitors.

● They also increase TC, HDL-C and LDL-C levels in patients with AS, although these changes probably reflect normalisation secondary to inflammation control.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This study was not funded