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OBJECTIVE: We assessed whether features of metabolic syndrome (MetSyn) were risk factors for subclinical atherosclerosis independent of previously identified determinants of cardiovascular disease in 74 patients with rheumatoid arthritis (RA). We further evaluated the clinical utility of currently recommended MetSyn definitions in the identification of RA patients with subclinical atherosclerosis. METHODS: We investigated the associations of MetSyn features and MetSyn definitions with ultrasonographically determined common carotid artery intima-media thickness (CCA-IMT) and plaque, with adjustment for age, radiographic scores (cumulative inflammation), polymorphonuclear cell counts (current inflammation), or hypothyroidism. RESULTS: The Quantitative Insulin Sensitivity Check Index (QUICKI) (partial R = -0.24 to -0.26, p = 0.04 to 0.02), log triglycerides (partial R = 0.23 to 0.30, p = 0.05 to 0.01), and systolic blood pressure (partial R = 0.22 to 0.30, p = 0.06 to 0.002) were consistently associated with the log CCA-IMT. Log triglycerides (OR 1.04, 95% CI 1.01-1.08, p = 0.02) and the QUICKI (OR 0.22, 95% CI 0.05-0.91, p = 0.03) were associated with plaque after adjusting for cumulative inflammation. Hypertension (blood pressure > or = 130/85 mm Hg or drug treatment for hypertension) was consistently associated with CCA-IMT (p = 0.05 to 0.0003) and plaque (p = 0.03 to 0.006). The WHO-defined MetSyn was associated with CCA-IMT (p = 0.08 to 0.04) but not with plaque (p > or = 0.1). The National Cholesterol Education Program-defined MetSyn was not associated with CCA-IMT or plaque (p > or = 0.3). CONCLUSION: In this RA cohort, the MetSyn features of hypertension, insulin resistance, and triglycerides were risk factors for subclinical atherosclerosis, independent of previously identified determinants of cardiovascular disease. Individual MetSyn features were more strongly associated with subclinical atherosclerosis than were currently recommended MetSyn definitions.