Increased Risk of Aortic Regurgitation, Atrial Fibrillation in Patients With Radiographic Axial Spondyloarthritis

The European Alliance of Associations for Rheumatology (EULAR) recommends screening and early management of cardiovascular disease in patients with radiographic axial spondyloarthritis.

Patients with radiographic axial spondyloarthritis (r-axSpA) were shown to have an increased risk of both aortic regurgitation and atrial fibrillation, but not atrioventricular (AV) block II-III, when compared with controls, according to a study published in Therapeutic Advances in Musculoskeletal Disease.1

“Among extra-articular symptoms, cardiac manifestations are the most critical complication,” investigators started. “Furthermore, cardiovascular diseases (CVDs) are more frequent in r-axSpA patients than in the general population (GP), and combined CVD increases the risk of mortality in r-axSpA patients. Therefore, the European Alliance of Associations for Rheumatology recommends proper screening and early management of CVD in patients with r-axSpA.”

A total of 8877 patients with r-axSpA were age- and sex-matched with the GP (n = 26,631) and followed from August 2006 through December 2019 using data from the National Health Insurance Services (NHIS) of Korea. Information, such as inpatient and outpatient services, sociodemographic data, and diagnoses according to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were collected within the database, which covers 97.2% of the Korean population.

Rates and standardized incidence ratios (SIRs) of AF, aortic regurgitation, and AV block II-III were collected and compared between the 2 groups. Ten-year incidence rates and hazard ratios (HR) were calculated.

The mean follow-up duration was 9.04 years in the r-axSpA group and 9.35 years in the GP cohort. Most (73.5%) patients in the r-axSpA cohort were male.

In the r-axSpA group, incidence rates of AF, aortic regurgitation, and AV block II-III were 4.0, 0.42, and 0.21 per 1000 person-years (PYs), respectively. Aortic regurgitation rates were higher in the r-axSpA group when compared with the GP (0.42 vs 0.18 per 1000 PY, p < 0.001, respectively). AF rates were also higher (4.00 vs 3.13 per 1000 PYs, p < 0.001, respectively). The SIR for aortic regurgitation was highest among 40- to 49-year-old men in the r-axSpA group. Older age and those with combined dyslipidemia had a significantly higher risk of cardiac manifestations.

AV block II-III rates were comparable between r-axSpA patients and the GP (0.21 vs 0.14 per 1000 PYs, p = 0.222, respectively).

Multivariate analysis indicated that r-axSpA was linked with a higher hazard risk for developing both aortic regurgitation and AF (HR [95% confidence interval] = 2.55 [1.49–4.37] and 1.20 [1.04–1.39], respectively). However, the AV block II-III risks were insignificant (HR [95% confidence interval] = 1.17 [0.59–2.31]).

Diagnostic accuracy may be limited as diagnosis was calculated by ICD-10-CM codes within the NHIS database. However, as these patients are closely monitored, inaccuracies should be minimal. Another limitation is that investigators only included patients with r-axSpA. Other factors, such as r-axSpA-associated aspects, laboratory data, and biologic medications, which may influence the occurrence of cardiac issues, were not analyzed in the study because that information was not provided by the NHIS.

“The risks of these cardiac disorders were significantly increased in r-axSpA patients,” investigators concluded. “Regular echocardiography in a specific subgroup of r-axSpA patients, such as those who are older and male, may increase the early detection of aortic regurgitation.”


Min HK, Kim HR, Lee SH, et al. Increased risks of aortic regurgitation and atrial fibrillation in radiographic axial spondyloarthritis patients: a 10-year nationwide cohort study. Ther Adv Musculoskelet Dis. 2022;14:1759720X221088094. Published 2022 Mar 30. doi:10.1177/1759720X221088094