Beyond inflammation. Coronary artery disease distribution in patients with chronic inflammatory rheumatic diseases. A case-control study.

Abstract Introduction Atherosclerosis remains the major pathological mechanism underlying most life-threatening cardiovascular (CV) events, particularly myocardial infarction and stroke. Chronic inflammatory rheumatic diseases (CIRD) increase CV risk by accelerated atherosclerosis, which appears to start as endothelial dysfunction caused by persistent inflammation. A higher incidence of coronary artery disease (CAD) has been observed in this population, but its distribution remains unknown. The strongest evidence is for rheumatoid arthritis, which increases the risk of CV disease by 50% beyond traditional risk factors. Ankylosing spondylitis and psoriatic arthritis may also elevate risk, but the evidence is weaker. It is widely recommended to assess and aggressively manage traditional CV risk factors in patients with CIRD. Purpose To compare coronary artery disease and its distribution in patients with and without CIRD. Methods A case-control study was performed. Patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis who underwent coronary angiography at a tertiary hospital between 2018 and 2022 were included as cases. For each case, at least two matched controls were selected based on sex, age at the angiography (±2 years), diabetic status and clinical indication for angiography. Results Sixty-nine patients with CIRD (62% rheumatoid arthritis, 21% ankylosing spondylitis and 17% psoriatic arthritis) and 138 patients without CIRD were included. The median age was 66.84±11.34 years, 64% were women and 22% had diabetes in both groups. In both groups, the main indication for angiography was acute coronary syndrome (30% STEMI, 22% non-STEMI and 13% unstable angina); other indications included atypical chest pain (12%), stable angina (7%), left ventricular dysfunction (6%), pre-TAVR study (6%) and scar on echocardiography or Q waves on ECG (4%). The left anterior descending artery was more affected in patients with CRID compared to controls (OR 2.22 (1.20-4.09) p=0.01). In contrast, there was no difference in the left main coronary artery, circumflex artery and right coronary artery. Regarding CAD segment distribution, the mid-distal left anterior descending artery (mdLAD) and the posterior descending artery (PDA) were significantly more affected in the CRID group than in the controls (OR 2.37 (1.31-4.28) p=0.004 for mdLAD and 3.73 (1.29-10.70) p=0.01 for PDA). Furthermore, there was no difference in coronary calcification, coronary ectasia or the presence of thrombus between both groups. Finally, revascularization (even percutaneous or surgical) was significantly more frequently performed in the CIRD group (OR 2.53 (1.28-4.98) p=0.0075). Conclusions Patients with CIRD have more anterior descending artery involvement than controls. They were also more likely to undergo revascularisation. These data highlight the need for monitoring and management of CV risk factors in these patients.Figure 1.Forest plot. Table 1.