Increased Cardiovascular and Cerebrovascular Mortality in Ankylosing Spondylitis

In one of the first large-scale studies designed to assess the risk of vascular mortality in patients with ankylosing spondylitis, researchers have found that patients with ankylosing spondylitis have a significantly higher risk for vascular death as compared to healthy populations. The findings are especially unique to men. Ankylosing spondylitis has long been associated with cardiovascular disease, but the science has been less clear on cerebrovascular mortality. In this population-based study of 21,473 men and women, researchers found that ankylosing spondylitis was associated with a higher cardiovascular and cerebrovascular mortality, according to a study published in the Aug. 11, 2015 online issue of Annals of Internal Medicine. 

• Non-steroidal anti-inflammatory drugs and statins significantly reduced vascular mortality. 
• Dementia, low income, male sex and increasing age were risk factors for vascular mortality.
• This was the first large population-based study on vascular mortality in ankylosing spondylitis. 
• Smoking and alcohol use was not available in the administrative database.  

The researchers, led by Nigil Haroon, MD, PhD, of Toronto Western Hospital in Ontario, Canada, compared 21,473 patients with ankylosing spondylitis to a population of 86,606 men and women without ankylosing spondylitis. The patients were on average 46 years old and 53% were male. The adjusted hazard ratios for vascular death were 1.36 (95% confidence interval,1.13 to 1.65) for all patients. However, the hazard ratio for men was 1.46 (CI, 1.13 to 1.87), which was statistically significant, but for women it was 1.24 (CI, 0.92 to 1.67) which was not statistically significant. The study is based on data from the provincial health administrative data in Ontario. Significant risk factors for vascular death were age, male sex, lower income, dementia, chronic kidney disease, peripheral vascular disease and (in patients age ≥65) absence of nonsteroidal anti-inflammatory drugs and statins, they wrote. Men had almost twice the risk as women. The risk increased by 12% with each year of age.  [[{"type":"media","view_mode":"media_crop","fid":"40514","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_8913470117840","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4166","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.0080003738403px; line-height: 1.538em; float: left;","title":" ","typeof":"foaf:Image"}}]]“Several factors may explain the elevated risk for vascular death in patients with ankylosing spondylitis,” the authors wrote. “Chronic inflammation, especially when untreated owing to delayed diagnosis, could contribute to endothelial damage, diastolic dysfunction and accelerated atherosclerosis. Patients with AS have also been shown to have increased risk for dyslipidemia, diabetes and the metabolic syndrome.” The researchers wrote that although the use of some traditional NSAIDs and COX-2 inhibitors have been linked to vascular disease, “NSAIDs might be beneficial in inflammatory diseases by reducing the overall vascular risk imposed by inflammation.” The study showed that the risk for vascular mortality was decreased with traditional non-steroidal anti-inflammatory drugs (hazard ratio 01 [CI 0.01to 0.61]) and statins (hazard ratio 0.25 [CI 0.13 to 0.51]).  “Studies are needed on the effect of therapeutic interventions and optimal control of inflammation in preventing the enhanced vascular mortality in patients with ankylosing spondylitis,” the researchers wrote. “On the basis of our findings, a comprehensive strategy should be developed to screen and treat modifiable risk factors for vascular disease in patients with ankylosing spondylitis.” A major limitation of the administrative database, and of the study, was that it lacked information on smoking and alcohol status, diet, physical activity, lipid levels, and (in patients age <65) prescription data.  

References:

Haroon NN, Paterson JM, Li P, et al. Patients With Ankylosing Spondylitis Have Increased Cardiovascular and Cerebrovascular Mortality: A Population-based Study. Annals of Internal Medicine. Published online August 11, 2015 doi: 10.7326/M14-2470