Assessing the cardiovascular toll of chronic inflammatory arthropathies: a case-control study on coronary artery disease severity

Abstract Introduction Chronic inflammatory rheumatic diseases (CIRD) cause persistent systemic inflammation, which contribute to atherosclerosis through endothelial injury, dysfunction, and altered lipid metabolism, creating a pro-atherogenic state despite low LDL ("lipid paradox"). Early, aggressive disease-modifying anti-rheumatic drugs (DMARDs) therapy may help reduce systemic complications, including coronary heart disease. Objective This study aimed to evaluate the severity of coronary artery disease and the extent of myocardium at risk in patients with CIRD compared to individuals without CIRD. Methods A retrospective study was conducted on patients with CIRD (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) who underwent coronary angiography at a tertiary care center between 2018 and 2022. For each CIRD patient, two matched controls were selected based on sex, age (±2 years), diabetic status, and clinical indication for coronary angiography. Indications for coronary angiography in both groups included chronic coronary syndrome, acute coronary syndrome, atypical chest pain, left ventricular disfunction evaluation, ECG abnormality and pre TAVR assessment. For statistical analysis, non-parametric tests were used for quantitative variables while categorical variables were analyzed using χ² tests and odds ratios (ORs). Results A total of 69 patients with CIRD were included (median age: 66.6 years, IQR: 58.3–75.2), of whom 43 (62.3%) were women and 15 (21.7%) had type II diabetes mellitus. The cohort included 18 patients (26.1%) with ankylosing spondylitis or spondyloarthritis, 13 (18.8%) with psoriatic arthritis, and 38 (55.1%) with rheumatoid arthritis. At the time of coronary angiography, the median LDL cholesterol was 103 mg/dL (IQR: 76.5–126.5) and the atherogenic index (Total Cholesterol/HDL) was 3.70 (IQR: 3.08–4.44). Inflammatory markers at CIRD diagnosis showed a median erythrocyte sedimentation rate (ESR) of 23.5 mm/h (IQR: 11–42) and C-reactive protein (CRP) of 0.5 mg/L (IQR: 0.13–1.51). Regarding treatment, 16 patients (23.1%) were on biologic DMARDs, 36 (52.1%) on conventional synthetic DMARDs (methotrexate), and 28 (40.5%) on oral corticosteroids. Compared to controls, CIRD patients had a higher number of coronary artery segments with significant stenosis (≥50%) (2 1 - 3 vs 1 0-2, p = 0.006) and greater myocardium at risk due to severe coronary stenoses (BCIS-1 Jeopardy Score: 4 2 – 6 vs 2 0 - 4, p 0.001). Revascularization was more frequent in CIRD patients (53/69 vs. 83/138 in controls; OR: 2.20, 95% CI: 1.14–4.22, p = 0.017). No significant differences in coronary disease severity were observed between CIRD subtypes or among patients treated with biologic DMARDs, synthetic DMARDs, or corticosteroids, though the small sample size limits this analysis. Conclusion Patients with CIRD exhibit more severe coronary artery disease and greater myocardium at risk compared to non-CIRD individuals.