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*Only for medical professionals to read and refer to Spread the strongest rheumatism and create a new academic fashion.
The 2021 American College of Rheumatology (ACR) annual meeting has just ended.
As the most influential academic feast gathering the latest research on rheumatism and immunity, the ACR annual meeting is prepared Aroused attention at home and abroad, Professor Marina Magrey from the Cleveland Medical Center in the United States discussed the topic of "comorbidities of spondyloarthritis (SpA): focus on cardiovascular features"
.
The Medical Rheumatism Channel invited young members from the Chinese Society of Rheumatology to explain, in order to spread the strongest rheumatism and create a new academic fashion
.
In this issue, Director Wang Yu from Peking University First Hospital took us into ACR 2021 and further explained the cardiovascular complications of SpA in detail
.
"Multiple shadow clones" of SpA: classification, multiple clinical manifestations SpA is a group of chronic inflammatory rheumatic diseases with specific pathophysiological, clinical, radiological and genetic characteristics, and inflammatory low back pain with or without peripheral joints Inflammation, coupled with certain characteristic extra-articular manifestations, are the unique symptoms and signs of this type of disease
.
In 2009 and 2011, the International SpA Expert Evaluation Association (ASAS) successively proposed new SpA classifications.
According to the new classification method, SpA is mainly divided into two categories: axial spondyloarthritis (axSpA) refers to inflammation of the spine or pelvis.
It usually causes inflammatory back pain; peripheral spondyloarthritis (pSpA) refers to inflammation of the spine and joints or tendons other than the sacroiliac joints
.
axSpA includes: ①Radiologically positive axSpA, also known as ankylosing spondylitis, with characteristic joint damage or fusion visible on X-rays; ②Radiologically negative axSpA (nr-axSpA)
.
pSpA usually involves the hands, wrists, elbows, shoulders, knees, ankles and foot joints
.
Inflammation of the tendon may occur in the fingers or toes (dactylitis) or tendon attachments (enthesitis)
.
Psoriatic arthritis, reactive arthritis, enteropathic arthritis and undifferentiated arthritis belong to this category
.
Figure 1 Classification of SpA At the same time, Director Wang Yu pointed out that although SpA has so many classifications, it is not uncommon for patients with multiple classifications to overlap
.
axSpA has a variety of symptoms and is often difficult to identify, leading to delayed diagnosis, missed diagnosis, or misdiagnosis
.
Director Wang Yu pointed out that in addition to the typical symptoms of musculoskeletal (such as inflammatory low back pain, tendon attachment inflammation, and finger/toe inflammation), extra-articular symptoms (such as iridocyclitis or psoriasis) may be the first Symptoms
.
Figure 2 Clinical manifestations of SpA These clinical manifestations of SpA include inflammatory low back pain, peripheral arthritis, dactylitis, foot attachment inflammation, arthritis of the spine, family history, effective use of non-steroidal drugs, iris ciliary Psoriasis, psoriasis, inflammatory bowel disease, HLA-B27 positive, and elevated C-reactive protein
.
The imaging manifestations of the sacroiliac joint include sacroiliac arthritis, accompanied by erosion, sclerosis, widening (or stenosis), and rigidity
.
Director Wang Yu added that early patients can see the edema of the sacroiliac joint from MRI
.
Leakage in the house is always rainy night: SpA comorbidities, focus on cardiovascular diseases Early
.
Figure 3 Comorbidities of axSpA.
The five comorbidities with the highest incidence are hypertension (22.
3%), infection (18.
3%), hyperlipidemia (17.
1%, 14.
6%), obesity (13.
5%), and cardiovascular disease (12.
3%)
.
Director Wang Yu pointed out that these comorbidities are similar to the comorbidities of the general population and other people with joint diseases, and may be related to the increasing incidence of metabolic syndrome and cardiovascular diseases in the population
.
A number of large-sample studies have shown that compared with the normal population, patients with ankylosing spondylitis have stroke, myocardial infarction, heart failure, peripheral vascular disease, ischemic heart disease, aortic valve heart disease, pulmonary valve heart disease, etc.
The risk of vascular disease is significantly increased
.
Figure 4 The risk of cardiovascular disease in patients with ankylosing spondylitis, but there is no statistical difference in the incidence of cardiovascular disease in patients with ankylosing spondylitis and nr-axSpA
.
There was no statistical difference in the incidence of comorbidities between male and female axSpA patients
.
Director Wang Yu pointed out that this suggests that clinicians also need to pay attention to comorbidities such as cardiovascular disease of radiology-negative axSpA, because there is no difference in the incidence of comorbidities with ankylosing spondylitis
.
To study the disease burden of SpA comorbidities, a large cross-sectional ASAS-COMOSPA study involving 3370 patients in 22 countries showed that the higher the Bath Ankylosing Spondylitis Function Index (BASFI), the higher the patient’s work absenteeism and the quality of life.
The lower the (EuroQol 5-domain questionnaire score), the higher the Rheumatism Complication Index (RDCI), and the greater the burden of disease
.
Therefore, Director Wang Yu pointed out that for patients with ax-SpA, we must not only focus on the functional status of the spine and joints, but also pay more attention to cardiovascular and cerebrovascular diseases, which are the main reasons for the decrease in the quality of life of patients and the increase in disease burden.
.
Disruption and disorder: SpA inflammation and cardiovascular disease pathogenesis SpA has chronic low-level inflammation, interleukin 17 (IL-17), high-sensitivity C-reactive protein (hsCRP), and interleukin 6 (IL) in the body.
-6), interleukin-1 (IL-1) and tumor necrosis factor (TNF) increase, causing endothelial cell activation and dysfunction, leading to classic atherosclerosis, plaque rupture, thrombosis, and ultimately cardiovascular events
.
Figure 5 The mechanism of SpA causing cardiovascular disease Director Wang Yu explained this process in more detail for us
.
The genetic background of SpA (such as genes HLA-B27, HLA-B40, ERAP1) and later environmental factors (such as infection, stress) promote the activation of the innate or adaptive immune system in the body, and activate Th17, Th1 and other cells.
Promote the release of TNF, IL-1, IL-6 and other inflammatory factors
.
And IL-17, IL-6, IL-1, TNF and other cytokines are related to increased cardiovascular risk
.
For example, IL-17 and IL-6 in the plasma of patients with unstable angina and myocardial infarction increase, and IL-1 and TNF are related to atherosclerosis
.
Underestimated players: Cardiovascular risk assessment of SpA patients Take real cases as an example to discuss the cardiovascular risk assessment of SpA patients
.
Studies have shown that patients with ankylosing spondylitis have a higher cardiovascular risk, which is twice that of patients with hypertension; compared with patients with rheumatoid arthritis, women with ankylosing spondylitis have an increased waist circumference
.
However, the risk of cardiovascular death in SpA patients is often underestimated
.
A Danish study showed that compared with patients with rheumatoid arthritis, the risk of cardiovascular death in patients with ankylosing spondylitis is often underestimated within 10 years
.
This is a wake-up call for clinicians.
Does the existing cardiovascular risk assessment formula need to be updated? Is it necessary to strengthen the assessment of cardiovascular risk in SpA patients? Jenna, female, 36 years old
.
Back pain for many years, was diagnosed as nr-axSpA last year, extra-articular manifestations include psoriasis and heel pain
.
Do not smoke
.
The initial cardiovascular risk is assessed as low risk
.
The disease activity is low and can be controlled with non-steroidal anti-inflammatory drugs (NSAIDs)
.
Director Wang Yu mentioned that regular cardiovascular risk assessment for patients with axSpA is important and necessary
.
The assessment content needs to include blood pressure, cholesterol, blood sugar, and creatinine
.
In the United States, 37% of SpA patients undergo an annual cardiovascular risk factor assessment, which is below the global average of 50%
.
Cardiovascular diseases affect SpA treatment decisions, and rheumatologists are in an advantageous position in cardiovascular risk management
.
The European Union Against Rheumatism (EULAR) recommends cardiovascular risk management for SpA patients.
According to national guidelines, cardiovascular risk assessments for low-to-medium risk patients are carried out every 5 years, and cardiovascular risk assessments for intermediate risk patients are carried out more frequently; Suggested methods: exercise, healthy diet, and quit smoking; long-term treatment of glucocorticoids should be controlled at the minimum dose; disease activity should be controlled while considering the risks and benefits of existing treatments to patients' cardiovascular risks
.
Summary SpA, as a chronic inflammatory rheumatic disease, not only has joint and extra-articular clinical manifestations, but its comorbidities, especially cardiovascular diseases, also cause a heavier disease burden on patients
.
Director Wang Yu is in line with the world, listening to cutting-edge voices, focusing on SpA cardiovascular comorbidities, proposing that the pathogenesis of SpA cardiovascular comorbidities may be chronic low-grade inflammation driven by inflammatory mediators, and further pointed out the importance of regular assessment of SpA comorbidities And SpA cardiovascular risk management method, pointed out the direction for clinicians and patients
.
Expert introduction Wang Yu, deputy director of Peking University First Hospital Division of Rheumatology, MD, PhD
.
The second prize of Beijing Health Science Popularization Competition, and obtained the qualification of science popularization experts
.
He is currently the Youth Committee of the Chinese Society of Rheumatology, the Vice Chairman of the Youth Committee of the Beijing Medical Association Rheumatology Society, and the expert member of the Rheumatology and Immunology and Chronic Disease Management Group of the Cross-Strait Medical and Health Exchange Association
.
The 2021 American College of Rheumatology (ACR) annual meeting has just ended.
As the most influential academic feast gathering the latest research on rheumatism and immunity, the ACR annual meeting is prepared Aroused attention at home and abroad, Professor Marina Magrey from the Cleveland Medical Center in the United States discussed the topic of "comorbidities of spondyloarthritis (SpA): focus on cardiovascular features"
.
The Medical Rheumatism Channel invited young members from the Chinese Society of Rheumatology to explain, in order to spread the strongest rheumatism and create a new academic fashion
.
In this issue, Director Wang Yu from Peking University First Hospital took us into ACR 2021 and further explained the cardiovascular complications of SpA in detail
.
"Multiple shadow clones" of SpA: classification, multiple clinical manifestations SpA is a group of chronic inflammatory rheumatic diseases with specific pathophysiological, clinical, radiological and genetic characteristics, and inflammatory low back pain with or without peripheral joints Inflammation, coupled with certain characteristic extra-articular manifestations, are the unique symptoms and signs of this type of disease
.
In 2009 and 2011, the International SpA Expert Evaluation Association (ASAS) successively proposed new SpA classifications.
According to the new classification method, SpA is mainly divided into two categories: axial spondyloarthritis (axSpA) refers to inflammation of the spine or pelvis.
It usually causes inflammatory back pain; peripheral spondyloarthritis (pSpA) refers to inflammation of the spine and joints or tendons other than the sacroiliac joints
.
axSpA includes: ①Radiologically positive axSpA, also known as ankylosing spondylitis, with characteristic joint damage or fusion visible on X-rays; ②Radiologically negative axSpA (nr-axSpA)
.
pSpA usually involves the hands, wrists, elbows, shoulders, knees, ankles and foot joints
.
Inflammation of the tendon may occur in the fingers or toes (dactylitis) or tendon attachments (enthesitis)
.
Psoriatic arthritis, reactive arthritis, enteropathic arthritis and undifferentiated arthritis belong to this category
.
Figure 1 Classification of SpA At the same time, Director Wang Yu pointed out that although SpA has so many classifications, it is not uncommon for patients with multiple classifications to overlap
.
axSpA has a variety of symptoms and is often difficult to identify, leading to delayed diagnosis, missed diagnosis, or misdiagnosis
.
Director Wang Yu pointed out that in addition to the typical symptoms of musculoskeletal (such as inflammatory low back pain, tendon attachment inflammation, and finger/toe inflammation), extra-articular symptoms (such as iridocyclitis or psoriasis) may be the first Symptoms
.
Figure 2 Clinical manifestations of SpA These clinical manifestations of SpA include inflammatory low back pain, peripheral arthritis, dactylitis, foot attachment inflammation, arthritis of the spine, family history, effective use of non-steroidal drugs, iris ciliary Psoriasis, psoriasis, inflammatory bowel disease, HLA-B27 positive, and elevated C-reactive protein
.
The imaging manifestations of the sacroiliac joint include sacroiliac arthritis, accompanied by erosion, sclerosis, widening (or stenosis), and rigidity
.
Director Wang Yu added that early patients can see the edema of the sacroiliac joint from MRI
.
Leakage in the house is always rainy night: SpA comorbidities, focus on cardiovascular diseases Early
.
Figure 3 Comorbidities of axSpA.
The five comorbidities with the highest incidence are hypertension (22.
3%), infection (18.
3%), hyperlipidemia (17.
1%, 14.
6%), obesity (13.
5%), and cardiovascular disease (12.
3%)
.
Director Wang Yu pointed out that these comorbidities are similar to the comorbidities of the general population and other people with joint diseases, and may be related to the increasing incidence of metabolic syndrome and cardiovascular diseases in the population
.
A number of large-sample studies have shown that compared with the normal population, patients with ankylosing spondylitis have stroke, myocardial infarction, heart failure, peripheral vascular disease, ischemic heart disease, aortic valve heart disease, pulmonary valve heart disease, etc.
The risk of vascular disease is significantly increased
.
Figure 4 The risk of cardiovascular disease in patients with ankylosing spondylitis, but there is no statistical difference in the incidence of cardiovascular disease in patients with ankylosing spondylitis and nr-axSpA
.
There was no statistical difference in the incidence of comorbidities between male and female axSpA patients
.
Director Wang Yu pointed out that this suggests that clinicians also need to pay attention to comorbidities such as cardiovascular disease of radiology-negative axSpA, because there is no difference in the incidence of comorbidities with ankylosing spondylitis
.
To study the disease burden of SpA comorbidities, a large cross-sectional ASAS-COMOSPA study involving 3370 patients in 22 countries showed that the higher the Bath Ankylosing Spondylitis Function Index (BASFI), the higher the patient’s work absenteeism and the quality of life.
The lower the (EuroQol 5-domain questionnaire score), the higher the Rheumatism Complication Index (RDCI), and the greater the burden of disease
.
Therefore, Director Wang Yu pointed out that for patients with ax-SpA, we must not only focus on the functional status of the spine and joints, but also pay more attention to cardiovascular and cerebrovascular diseases, which are the main reasons for the decrease in the quality of life of patients and the increase in disease burden.
.
Disruption and disorder: SpA inflammation and cardiovascular disease pathogenesis SpA has chronic low-level inflammation, interleukin 17 (IL-17), high-sensitivity C-reactive protein (hsCRP), and interleukin 6 (IL) in the body.
-6), interleukin-1 (IL-1) and tumor necrosis factor (TNF) increase, causing endothelial cell activation and dysfunction, leading to classic atherosclerosis, plaque rupture, thrombosis, and ultimately cardiovascular events
.
Figure 5 The mechanism of SpA causing cardiovascular disease Director Wang Yu explained this process in more detail for us
.
The genetic background of SpA (such as genes HLA-B27, HLA-B40, ERAP1) and later environmental factors (such as infection, stress) promote the activation of the innate or adaptive immune system in the body, and activate Th17, Th1 and other cells.
Promote the release of TNF, IL-1, IL-6 and other inflammatory factors
.
And IL-17, IL-6, IL-1, TNF and other cytokines are related to increased cardiovascular risk
.
For example, IL-17 and IL-6 in the plasma of patients with unstable angina and myocardial infarction increase, and IL-1 and TNF are related to atherosclerosis
.
Underestimated players: Cardiovascular risk assessment of SpA patients Take real cases as an example to discuss the cardiovascular risk assessment of SpA patients
.
Studies have shown that patients with ankylosing spondylitis have a higher cardiovascular risk, which is twice that of patients with hypertension; compared with patients with rheumatoid arthritis, women with ankylosing spondylitis have an increased waist circumference
.
However, the risk of cardiovascular death in SpA patients is often underestimated
.
A Danish study showed that compared with patients with rheumatoid arthritis, the risk of cardiovascular death in patients with ankylosing spondylitis is often underestimated within 10 years
.
This is a wake-up call for clinicians.
Does the existing cardiovascular risk assessment formula need to be updated? Is it necessary to strengthen the assessment of cardiovascular risk in SpA patients? Jenna, female, 36 years old
.
Back pain for many years, was diagnosed as nr-axSpA last year, extra-articular manifestations include psoriasis and heel pain
.
Do not smoke
.
The initial cardiovascular risk is assessed as low risk
.
The disease activity is low and can be controlled with non-steroidal anti-inflammatory drugs (NSAIDs)
.
Director Wang Yu mentioned that regular cardiovascular risk assessment for patients with axSpA is important and necessary
.
The assessment content needs to include blood pressure, cholesterol, blood sugar, and creatinine
.
In the United States, 37% of SpA patients undergo an annual cardiovascular risk factor assessment, which is below the global average of 50%
.
Cardiovascular diseases affect SpA treatment decisions, and rheumatologists are in an advantageous position in cardiovascular risk management
.
The European Union Against Rheumatism (EULAR) recommends cardiovascular risk management for SpA patients.
According to national guidelines, cardiovascular risk assessments for low-to-medium risk patients are carried out every 5 years, and cardiovascular risk assessments for intermediate risk patients are carried out more frequently; Suggested methods: exercise, healthy diet, and quit smoking; long-term treatment of glucocorticoids should be controlled at the minimum dose; disease activity should be controlled while considering the risks and benefits of existing treatments to patients' cardiovascular risks
.
Summary SpA, as a chronic inflammatory rheumatic disease, not only has joint and extra-articular clinical manifestations, but its comorbidities, especially cardiovascular diseases, also cause a heavier disease burden on patients
.
Director Wang Yu is in line with the world, listening to cutting-edge voices, focusing on SpA cardiovascular comorbidities, proposing that the pathogenesis of SpA cardiovascular comorbidities may be chronic low-grade inflammation driven by inflammatory mediators, and further pointed out the importance of regular assessment of SpA comorbidities And SpA cardiovascular risk management method, pointed out the direction for clinicians and patients
.
Expert introduction Wang Yu, deputy director of Peking University First Hospital Division of Rheumatology, MD, PhD
.
The second prize of Beijing Health Science Popularization Competition, and obtained the qualification of science popularization experts
.
He is currently the Youth Committee of the Chinese Society of Rheumatology, the Vice Chairman of the Youth Committee of the Beijing Medical Association Rheumatology Society, and the expert member of the Rheumatology and Immunology and Chronic Disease Management Group of the Cross-Strait Medical and Health Exchange Association
.
