Elsevier

Atherosclerosis

Volume 196, Issue 1, January 2008, Pages 306-312
Atherosclerosis

Impaired coronary microvascular and left ventricular diastolic functions in patients with ankylosing spondylitis

https://doi.org/10.1016/j.atherosclerosis.2006.11.003Get rights and content

Abstract

Background

It has been shown that the patients with inflammatory rheumatic diseases such as systemic lupus erythematosus and rheumatoid arthritis have an increased risk of developing atherosclerosis. However, the association of ankylosing spondylitis (AS) to atherosclerosis and related diseases is still controversial. Accordingly, we investigated coronary flow reserve (CFR) and left ventricular (LV) diastolic function in patients with AS using transthoracic Doppler echocardiography.

Methods

CFR and LV diastolic function were studied in 40 patients with AS (38.9 ± 10.2 years, 26 males) and 35 healthy volunteers (37.5 ± 6.4 years, 23 males). Coronary diastolic peak flow velocities (DPFV) were measured at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline DPFV. LV diastolic function was assessed by both standard and tissue Doppler imaging.

Results

Demographic features and coronary risk factors except diastolic blood pressure were similar between the groups. CFR were significantly lower in the AS group than in the control group (2.20 ± 0.46 versus 3.02 ± 1.50, P < 0.0001). Reflecting LV diastolic function mitral A-wave and E/A ratio were borderline significant, and mitral E-wave deceleration time and isovolumic relaxation time were significantly different between the groups. Serum hsCRP and TNF-α levels were significantly higher in the patients with AS, and hsCRP and TNF-α levels independently correlated with CFR.

Conclusion

These findings show that CFR reflecting coronary microvascular function and LV diastolic function are impaired in patients with AS, and severity of these impairments correlate well with hsCRP and TNF-α. These results suggest that impaired CFR may be an early manifestation of cardiac involvement in patients with AS.

Introduction

Ankylosing spondylitis (AS) is a chronic inflammatory disease with predilection for the sacroiliac joints and spine. Patients with AS are known to have an average mortality of approximately 1.6–1.9-fold that of the general population [1]. In addition, mortality from cardiovascular (CV) disease has been found to be increased [2]. It has been shown that the patients with inflammatory rheumatic diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis have an increased risk of developing atherosclerosis [3], [4]. However, the association between atherosclerosis and related diseases and AS is still a controversy [5].

It has been previously demonstrated that left ventricular diastolic dysfunction is associated with coronary flow reserve (CFR) impairment and/or coronary microvascular dysfunction even in the absence of left ventricular hypertrophy [6], [7], [8]. CFR measurement is used both to assess epicardial coronary arteries and to examine the integrity of coronary microvascular circulation. Impairment of endothelial function and reduced CFR, which reflects coronary microvascular function, has been shown to be early manifestation of atherosclerosis and coronary artery disease [9], [10]. Recently, Britten et al. [9] emphasized the prognostic importance of CFR with respect to atherosclerosis in subjects with normal coronary arteries or mildly diseased coronary arteries. Although Britten et al. used coronary Doppler to measure CFR, in recent years, using second harmonic transthoracic Doppler echocardiography (TTDE) for evaluating CFR has become very popular, and in several studies its feasibility has been validated in evaluating CFR in the middle to distal portion of the LAD [9], [11], [12].

Therefore, in the present study we aimed to investigate CFR reflecting coronary microvascular function in patients with AS using TTDE.

Section snippets

Study population

Forty patients with AS were included in this study. The patients who fulfilled the modified New York criteria for AS [13] were selected from the rheumatology out-patient clinic. A complete physical examination was performed, with particular attention to peripheral arterial pulses and carotid bruits. Thirty-five healthy volunteers matched for age, sex and body mass index (BMI) were also included as control. Each subject was questioned about major CV risk factors including family history of

Clinical characteristics of the study population

The general characteristics and risk factors for coronary artery disease of the study population are presented in Table 1. All patients were receiving non-steroidal anti-inflammatory drugs, and 32 patients (80%) were also on sulphasalazine treatment at study inclusion. However, the drugs were discontinued 48-h before the procedure. Age, sex, BMI, heart rate, systolic blood pressure (BP), lipid profiles, and fasting glucose levels were similar between the groups. However, diastolic BP and hsCRP

Discussion

The present study showed that the patients with AS had significantly lower CFR compared to healthy subjects using second harmonic TTDE for CFR determination.

Impairment of endothelial function and reduced CFR, which reflects coronary microvascular function, has been shown to be early manifestation of atherosclerosis and CAD [17], [18]. Previous experimental and clinical studies have shown that early stage coronary atherosclerosis is frequently associated with abnormal resistance of the

Study limitations

TTDE does not measure the absolute volumetric flow in the LAD but only flow velocity; thus an unchanging vessel diameter is assumed in the assessment of coronary flow response to a vasodilator stimulus. Dipyridamole mildly dilates epicardial coronary vessels. However, the standardized pharmacologic protocol of dipyridamole to measure hyperemic coronary flow and thus the CFR is still controversial [29], and 0.56 mg/kg dose has generally been used in most previous studies [30]. Thus, we used

References (30)

  • Y. Asanuma et al.

    Premature coronary-artery atherosclerosis in systemic lupus erythematosus

    N Engl J Med

    (2003)
  • C.P. Chung et al.

    Increased coronary-artery atherosclerosis in rheumatoid arthritis: relationship to disease duration and cardiovascular risk factors

    Arthritis Rheum

    (2005)
  • H. Divecha et al.

    Cardiovascular risk parameters in men with ankylosing spondylitis in comparison with non-inflammatory control subjects: relevance of systemic inflammation

    Clin Sci (Lond)

    (2005)
  • D. Erdogan et al.

    Coronary flow reserve in dipper and non-dipper hypertensive patients

    Blood Pressure

    (2005)
  • M.B. Britten et al.

    Microvascular dysfunction in angiographically normal or mildly diseased coronary arteries predicts adverse cardiovascular long-term outcome

    Coronary Artery Dis

    (2004)

    • Cited by (0)

    View full text
    Copyright © 2006 Elsevier Ireland Ltd. All rights reserved.