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Patients with AS exhibit lower left ventricular myocardial function
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Patients with ankylosing spondylitis have lower left ventricular systolic myocardial function, as determined by global longitudinal strain, independent of cardiovascular risk factors, according to data published in Arthritis Care & Research.
“Cardiovascular (CV) factors like hypertension, diabetes and metabolic syndrome are prevalent in AS patients, and have been suggested to largely explain the increased risk of CV disease in AS patients,” Helga Midtbø MD, PhD, of Haukeland University Hospital in Norway, and colleagues wrote. “However, it is well known that presence of subclinical cardiac dysfunction like left ventricular myocardial dysfunction measured by global longitudinal strain, predicts increased CV risk independent of risk factors in unselected cardiac populations.”
To analyze and describe the presence and cofounders of subclinical left ventricular systolic myocardial function, as determined by global longitudinal strain, among patients with AS, the researchers recruited patients from an established cohort at Diakonhjemmet Hospital rheumatology department, in Oslo, Norway. Of the 257 patients with AS initially invited to participate, the researchers included 106 for their study, after excluding the others for established CV disease or because their echocardiographic images were of insufficient quality.
Each participant — as well as 106 matched controls randomly selected by Statistics Norway — underwent conventional and speckle tracking echocardiography. Midtbø and colleagues assessed left ventricular systolic myocardial function using peak systolic global longitudinal strain. A lower negative systolic global longitudinal strain indicated lower function.
According to the researchers, CV disease risk factors were similarly distributed among the control participants and patients with AS. However, more control participants used statin therapy (P = .05). Global longitudinal strain was significantly lower in patients with AS (–17.7 ± 2.5%) compared with controls (–18.4 ± 2.3%) (P = .03). Among the total study population, after univariable linear regression analyses, lower global longitudinal strain was associated with AS, male sex, higher BMI, left ventricular mass index and lower left ventricular ejection fraction (all P < .05).
In addition, among patients with AS, lower global longitudinal strain was independently associated with larger aortic root diameter (P = .02). The researchers found no association with AS disease activity, duration or use of antirheumatic medication.
“Patients with AS had lower [left ventricular] systolic myocardial function assessed by [global longitudinal strain] than controls independent of CV risk factors, ejection fraction and [left ventricular] mass index,” Midtbø and colleagues wrote. “Lower [global longitudinal strain] was particularly associated with larger aortic root diameter in AS patients. The current results add to previous documentation on increased prevalence of subclinical cardiac disease in AS patients, which may contribute to the increased CV risk observed in AS patients.” – by Jason Laday
Disclosure: Midtbø reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Grace C. Wright, MD, PhD
Ankylosing spondylitis (AS) is a member of the spondyloarthritis family of inflammatory arthritides, and is known to be associated with cardiovascular disease and abnormalities of the aortic root and aortic valve. Traditional cardiovascular risk factors such as hypertension, diabetes and metabolic syndrome are prevalent in patients with AS; however, subclinical cardiac dysfunction and its contribution to overall cardiovascular health in AS patients is less well characterized.
In this study by Midtbø and colleagues, cardiac dysfunction was analyzed by echocardiography with measurement of global longitudinal strain (GLS), which predicts increased CV risk independent of other conventional cardiac risk factors. Patients with AS had average disease durations of 22 years and moderate-to-high disease activity as measured by ASDAS and BASDAI scores. When compared to controls, patients with AS exhibited higher CRP levels, used less statin therapy and had equal prevalence of CV risk factor burden.
The prevalence of valvular regurgitation was also similar between groups, with at most mild-moderate aortic valve regurgitation. Mean left ventricular ejection fraction was also normal in patients with AS as well as controls. Hypertension was the most prevalent CV risk factor, present in 30% of patients with AS and 36% of control subjects (P=0.38).
Importantly, patients with AS without known CV disease had lower LV systolic myocardial function than controls measured by GLS, even after adjustment for CV risk factors and other confounders in multivariable analyses. Study limitations included a small sample size and insufficient power to detect differences between subsets of patients with AS.
However, this data adds to the emerging data highlighting undetected cardiovascular disease in patients with spondyloarthritis and may assist us in detecting unrecognized risk in this patient population. Further studies are needed to evaluate patients with shorter disease duration and lower disease activity.
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