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  • Review Article
  • Published:

Validated methods for assessment of subclinical atherosclerosis in rheumatology

Abstract

Rheumatoid arthritis, as well as other types of arthritides and connective tissue diseases, is associated with accelerated atherosclerosis, and increased cardiovascular morbidity and mortality. The early signs of cardiovascular disease therefore need to be recognized in patients with these conditions so that effective cardiovascular protection can be introduced. This Review provides an overview of validated techniques that are currently available to determine subclinical atherosclerosis in patients with rheumatic conditions. Techniques for early assessment of endothelial dysfunction include brachial artery flow-mediated vasodilation and laser Doppler flowmetry. Coronary circulation can be assessed by measuring coronary flow reserve using CT, MRI or PET based techniques. The standard indicators of arterial stiffness are pulse-wave velocity and the augmentation index. Carotid atherosclerosis is determined by the common carotid intima–media thickness (ccIMT) measurement or by the assessment of plaques and plaque areas. The combination of ccIMT with plaque assessment is likely to increase the predictive value of this approach. The potential use of a multimarker approach to increase the diagnostic and prognostic value of these clinical assessments is also discussed.

Key Points

  • Simple reliable tests for assessing subclinical cardiovascular disease in patients with rheumatic diseases (who are at high risk of developing cardiovascular disease) are needed

  • Flow-mediated dilation of the brachial artery has frequently been used to assess endothelial function in patients with rheumatic diseases, but a standardized cut-off value is still required

  • In rheumatic diseases, common carotid intima–media thickness has become the most commonly used indicator of subclinical atherosclerosis

  • A multimarker approach that includes several assessments of subclinical cardiovascular disease is needed for effective risk determination for individuals and at a population level

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Figure 1: Examples of CFR values obtained in a normal subject (left panels: CFR = 3.5) and in a patient with rheumatoid arthritis (right panels: CFR = 1.7).
Figure 2: Assessment of arterial stiffness.
Figure 3: Estimation of distance during PWV assessment.
Figure 4: Ultrasound image of the distal common carotid artery and the carotid bulb.

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Peter Libby, Julie E. Buring, … Eldrin F. Lewis

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Acknowledgements

This work was supported by research grants ETT 315/2009 (Z. Szekanecz) and 350/2006 (P. Soltész) from the Medical Research Council of Hungary; by the TÁMOP 4.2.1/B-09/1/KONV-2010-0007 project cofinanced by the European Union and the European Social Fund (Z. Szekanecz); and by a Bolyai Research Grant (P. Soltész).

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G. Kerekes, M. A. Gonzalez-Gay, M. Turiel, E. Végh and Z. Szekanecz researched data for the article. G. Kerekes, M. T. Nurmohamed, M. A. Gonzalez-Gay, I. Mcnnes and Z. Szekanecz wrote the article. All of the authors substantially contributed to the discussion of content and reviewed and/or edited the article before submission.

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Correspondence to Zoltán Szekanecz.

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Kerekes, G., Soltész, P., Nurmohamed, M. et al. Validated methods for assessment of subclinical atherosclerosis in rheumatology. Nat Rev Rheumatol 8, 224–234 (2012). https://doi.org/10.1038/nrrheum.2012.16

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