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To the Editors:

We read with interest the recently published article in Arthritis Care & Research by Peters et al (1), in which the risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) was significantly increased compared with the general population, with a risk magnitude comparable with that found in type 2 diabetes mellitus (DM), confirming previous data (2). In a population of outpatients with RA, we identified 44 cases without CVD risk factors (i.e., arterial hypertension, DM, coronary artery disease, familial hypercholesterolemia, use of any cardiovascular drugs or statins, previous vascular procedure, association of cardiomyopathy and/or genetic CVD, and aortic aneurysm) and valve disease, and we compared these cases with a sex- and age-matched control group (Vizzardi et al: unpublished observations). These patients underwent an echocardiographic examination in which left ventricular (LV) dimension and systolic function, LV mass, LV diastolic function, and the elastic proprieties of the aorta were evaluated.

These patients showed increased aortic diameters (P < 0.001), lower aortic strain (P < 0.001) and distensibility (P < 0.001), and a higher stiffness index (P < 0.001) compared with controls. In addition, an increased LV mass (P = 0.03) and impaired diastolic function (E/A p: 0.0002; deceleration time P = 0.004; E/E' P = 0.0068) were found. The occurrence of increased LV mass and aortic stiffening, even in the absence of hypertension, suggests that RA patients show a condition of preclinical atherosclerosis in the same manner as a patient with DM. Independent from the coexistence of CVD risk factors, LV remodelling and hypertrophy, as well as LV diastolic filling, were reported in DM patients (3–6) with a higher prevalence than previously suspected. Along with the impairment of the elastic aortic properties in DM patients, some data showed that the aortic stiffness index was significantly higher, while aortic distensibility and aortic strain were significantly lower than in control subjects (7–8).

Our data showed that echocardiographic features of RA patients without CVD risk factors were the same as those reported in DM, probably because systemic chronic inflammation could induce a persistent endothelial activation with consequent impairment of LV diastolic function and elastic aortic proprieties. Therefore, we should assert that heart disease is an important extra-articular manifestation of RA, and that RA could be considered a CVD risk factor per se, quantitatively and qualitatively similar to DM.

  • 1
    Peters MJ, van Halm VP, Voskuyl AE, Smulders YM, Boers M, Lems WF, et al. Does rheumatoid arthritis equal diabetes mellitus as an independent risk factor for cardiovascular disease? A prospective study. Arthritis Rheum 2009; 61: 15719.
  • 2
    Van Halm VP, Peters MJ, Voskuyl AE, Boers M, Lems WF, Visser M, et al. Rheumatoid arthritis versus diabetes as a risk factor for cardiovascular disease: a cross-sectional study, the CARRE Investigation. Ann Rheum Dis 2009; 68: 1395400.
  • 3
    Galderisi M. Diastolic dysfunction and diabetic cardiomyopathy: evaluation by Doppler echocardiography. J Am Coll Cardiol 2006; 48: 154851.
  • 4
    Boyer JK, Thanigaraj S, Schechtman KB, Perez JE. Prevalence of ventricular diastolic dysfunction in asymptomatic, normotensive patients with diabetes mellitus. Am J Cardiol 2004; 93: 8705.
  • 5
    Falcao-Pires I, Goncalves N, Moura C, Lamego I, Eloy C, Lopes JM, et al. Effects of diabetes mellitus, pressure-overload and their association on myocardial structure and function. Am J Hypert 2009; 22: 11908.
  • 6
    Zabalgoitia M, Ismaeil MF, Anderson L, Maklady FA. Prevalence of diastolic dysfunction in normotensive, asymptomatic patients with well-controlled type 2 diabetes mellitus. Am J Cardiol 2001; 87: 3203.
  • 7
    Seyfeli E, Duru M, Saglam H, Akgul F, Kuvandik G, Kaya H, et al. Association of left ventricular diastolic function abnormalities with aortic elastic properties in asymptomatic patients with type 2 diabetes mellitus: a tissue Doppler echocardiographic study. Int J Clin Pract 2008; 62: 135865.
  • 8
    Karamitsos TD, Karvounis HI, Didangelos TP, Papadopoulos CE, Kachrimanidou MK, Selvanayagam JB, et al. Aortic elastic properties are related to left ventricular diastolic function in patients with type 1 diabetes mellitus. Cardiology 2008; 109: 99104.

E. Vizzardi MD*, I. Cavazzana MD*, F. Franceschini MD*, A. Tincani MD*, L. Dei Cas MD*, * Spedali Civili, Brescia, Italy.