Accelerated atherosclerosis in autoimmune rheumatic diseases

J Clin Exp Invest www.clinexpinvest.org Vol 1, No 3, December 2010 Yazışma Adresi /Correspondence: Dr. Manole Cojocaru, Str. Thomas Masaryk No. 5 Sector 2 Postal Code 020983 Bucharest, Romania Email: manole_cojocaru@yahoo.com Received / Geliş Tarihi: 15.09.2010, Accepted / Kabul Tarihi: 11.11.2010 Copyright © Klinik ve Deneysel Araştırmalar Derg si 2010, Her hakkı saklıdır / All rights reserved Klinik ve Deneysel Araştırmalar Dergisi / Cilt/Vol 1, No 3, 232-234 Journal of Clinical and Experimental Investigations


INTRODUCTION
The mechanisms for the assumed accelerated atherosclerosis in autoimmune rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis include the classical risk factors, but may also be due to chronic inflammatory processes and immune dysregulation. 1,2This phenomenon can be attributed to the traditional risk factors for atherosclerosis and use of specific drugs, such as corticosteroids, but also may be the result of other autoimmune and inflammatory mechanisms that are aggravated in autoimmune rheumatic diseases. 3,4everal autoantibodies are associated with athero-sclerosis and its manifestations in humans.The antibody levels were higher in those patient groups than in control subjects. 5,6

Accelerated atherosclerosis in rheumatoid arthritis
Several types of cardiac involvement can occur in rheumatoid arthritis (RA).8][9] RA treatment and lifestyle of RA patients may favor physical inactivity, hypertension, diabetes mellitus, and obesity, but there is no clear evidence that these factors are implicated in accelerated atherosclerosis in RA. [10][11][12] Despite the fact that different factors could alter endothelium homeostasis, prevalent data support the view that abnormal endothelial function in RA is essentially linked to inflammation. 13,14

Accelerated atherosclerosis in SLE
Although atherosclerosis develops early in the course of the disease, older age at diagnosis seems to be the major determinant of atherosclerosis in SLE. 15 Among the nontraditional risk factors, cumulative dosage and/or longer duration of corticosteroid therapy and longer duration of disease seem to be the major predictors of atherosclerosis in SLE studies. 16The evaluation of risk factors for clinical atherosclerosis is difficult in SLE, since there are few observed cardiovascular events because of low prevalence of the disease. 17Whether premature atherosclerosis is a general feature of autoimmune diseases such as SLE or only affects a subgroup of patients whereas others do not have an increased risk remains to be demonstrated. 18

Accelerated atherosclerosis in antiphospholipid syndrome
The pathogenesis of accelerated atherosclerosis in APS may be a result of an interaction between traditional and nontraditional risk factors. 19Thrombophilia may be associated with premature atherosclerosis, and accelerated atherosclerosis was suggested as an additional clinical feature of APS. 20his pathological process may be mediated by the direct proinflammatory and procoagulant activity that anti-phospholipid antibodies (aPLs) exert on endothelial cells or indirectly, via the inflammatory immune mechanisms that have been implicated in autoantibody-mediated thrombosis. 21Further studies are needed to determine whether atherosclerotic plaques in autoimmune disease have special features or whether systemic factors such as aPLs trigger atherothrombosis more easly than in normal atherosclerosis. 22

Accelerated atherosclerosis in systemic sclerosis
Systemic sclerosis affects the microcirculation and injures the endothelium, leading eventually to vessel occlusion and tissue anoxia. 23In addition, systemic sclerosis significantly accelerates the sufferance of the vessel wall of the macrocirculation, increasing the risk of vascular occlusive diseases.Extend of enhanced atherosclerosis in systemic sclerosis is not yet clear, because fewer studies compared with those of RA, SLE, and APS. 24

Primary systemic vasculitis and accelerated atherosclerosis
Many similarities exist between atherosclerosis and primary systemic vasculitis with respect to the initial localization, the role of multiple causal factors and pathogenetic mechanisms, and some clinical manifestations and possible future treatment strategies. 25Vessel intima is the site at which inflammation develops in atherosclerosis and in most types of primary systemic vasculitis. 26Vasculitis may trigger or favor not only inflammatory but also immune reactions associated with atherogenesis, for example, increasing the expression of autoantigens on activated endothelial cells. 27,28herosclerosis in Sjögren's syndrome Cardiac involvement is very rare among patients having Sjögren's syndrome. 3Currently there is no available data suggesting that this common autoimmune condition is associated with enhanced atherosclerosis.The data suggest that further studies are indicated to determine the risk of atherosclerosis among patients with Sjögren's syndrome. 5,6

Conclusions
Enhanced and premature atherosclerosis is a feature of some autoimmune rheumatic diseases and a possible feature of others because of inflammation and more specific immune mechanisms.The risk of cardiovascular disease is very high in SLE and also increased in RA and most likely to a varying degree in other autoimmune disease.However, it is not clearly established that the increased risk is present in most if not all patients, or only affects a smaller subgroup of patients.