Cardiovascular manifestations of ankylosing spondylitis

Summary In a retrospective study, 40 patients with ankylosing spondylitis were assessed for extraspinal manifestations. Cardiovascular complications were found in 17 patients (42.5%)∶5(12.5%) had aortic insufficiency, 3 (7.5%) had atrioventricular block and 5 (12.5%) had bundle branch block. Wolff-Parkinson-White syndrome was diagnosed in one case and short PR syndrome in another. Cardiovascular complications were more common in patients with longer disease duration. Ischemic heart disease was found in 17.5% of the cases and pulmonary fibrosis in 15%. Peripheral arthritis was found in 42.5% and its prevalence did not differ in patients with or without cardiac involvement.     

Pulmonary manifestations of ankylosing spondylitis.

Chest radiographs of 39 patients with ankylosing spondylitis were studied. Three showed apical pulmonary fibrosis, two with cavitary lesions. Other known causes of lung disease were excluded. Symptoms and roentgenographic evidence of spondylitis were present for many years prior to the onset of pulmonary symptoms, which variably included shortness of breath, cough, hemoptysis, pleuritic chest pain, fever, and chills. Apical pulmonary lesions of unknown cause were absent in 53 age, sex, and racematched osteoarthritis control patients. The findings suggest that apical pulmonary fibrosis may be an extra-skeletal manifestation of ankylosing spondylitis, the frequency of which approaches that of spondylitic heart disease.     

Prevalence and clinical manifestations of ankylosing spondylitis in young Greek males

Increased awareness and sensitivity of general physicians have increased the early diagnoses of seronegative arthritis in young patients, while new agents such as anti-TNF blockers have significantly changed the treatment of the disease. To investigate the prevalence, the clinical manifestations, and the ability for military service of young Greek males (18–30 years old) with ankylosing spondylitis (AS) in the pre-anti-TNF era. We retrospectively studied the AS cases recorded from 1989 to 1995 of the rheumatology department of the largest General Military Hospital in Greece; the diagnosis was based on the modified New York criteria for AS. A total of 285 AS cases were diagnosed among 357,184 young men. The overall prevalence of AS on December 1995 was estimated at 8.2 cases per 10,000 young men (95 % C.I. 7.2–9.2). All the patients had chronic back pain. Two hundred forty (84 %, 95 % C.I. 79–88 %) patients presented sacroiliitis of whom 163 (68 %, 95 % C.I. 62–73 %) were bilateral. Two hundred five patients (72 %, 95 % C.I. 66–77 %) had peripheral joint involvement. Thirty-one patients presented with anterior uveitis (11 %, 95 % C.I. 8–15 %). One patient had IgA nephropathy. None had gut involvement. HLA-B27 antigen was found in 257 patients (90 %, 95 % C.I. 86–93 %). Ninety-one patients (32 %, 95 % C.I. 27–38 %) had permanent discharge from the military service, while 128 (45 %, 95 % C.I. 39–51 %) were able for auxiliaries attendances. The prevalence of AS for the age group 18–30 years old in this young Greek men cohort was significantly lower than in other Caucasian European populations, and the clinical manifestations were considered as mild.     

Extra-articular manifestations and complications of ankylosing spondylitis

Extra-articular manifestations can be defined as all symptoms and signs etiopathogenically related, at least in part, to ankylosing spondylitis (AS) that arise in the various organs and tissues of the locomotor apparatus. Thus, ocular, intestinal and cardiac manifestations, which are common to all spondylarthritides through their association with HLA-B27, are grouped under this heading. Complications include clinical manifestations that result from persistent spondylitic activity and/or treatment. Table 1 provides a list and the main characteristics of these manifestations. Obviously, this classification is far from perfect since, among other factors, knowledge of the etiopathogenesis of AS is still fairly limited.     

Audiovestibular manifestations in patients with ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown origin affecting up to 1% of the population. Little is known about audiovestibular impairment in patients with AS, especially the presence of cochleovestibular dysfunction in these patients. To investigate audiovestibular manifestations in AS, we studied a series of 50 consecutive patients who fulfilled the modified New York diagnostic criteria for AS and 44 matched controls. Individuals with history of cardiovascular disease, cerebrovascular complications, peripheral artery disease, renal insufficiency, syphilis, Meniere and other vestibular syndromes, infections involving the inner ear, barotrauma, or in treatment with ototoxic drugs were excluded. Most patients with AS were men (80%). The mean age at the time of study was 52.5 years, and mean age at the onset of symptoms was 34.4 years. Twenty-nine (58%) patients showed abnormal hearing loss in the audiogram compared to only 8 (18%) controls (p < 0.001). Values of audiometric tests (pure-tone average and speech reception threshold) yielded significant differences between patients and controls (p < 0.001). It is noteworthy that the audiogram shape disclosed a predominant pattern of high-frequency sensorineural hearing loss in AS patients (50%) compared to controls (18%) (p = 0.002). Also, AS patients exhibited abnormal vestibular tests more commonly than controls. AS patients had an increased frequency of head-shaking nystagmus (20%) compared to controls (0%) (p < 0.001). Moreover, patients (26%) showed a significantly increased frequency of abnormal caloric test compared to controls (0%) (p < 0.001). Finally, a significantly increased frequency of abnormal clinical test of sensory integration and balance with a predominant vestibular loss pattern was observed in patients (36%) compared to controls (5%) (p < 0.001). In conclusion, the current study demonstrates strong evidence for inner ear compromise in patients with AS.     

Respiratory manifestations of ankylosing spondylitis (50 cases)

Fifty patients with ankylosing spondylitis underwent radiography of the chest. In addition, 2 of them had bronchography, 3 had computerized tomography (CT) of the chest, 9 had respiratory function tests and 8 head ventilation/perfusion study by the Xenon method. Seven thoracic images were questionably specific of spondylitis, showing plural symphysis, strips of atelectasis, pleural thickening, apical pulmonary sclerosis and opacities of the diaphragmatic hilum. CT proved valuable in 1 case to confirm pulmonary fibrosis and in 2 cases to reveal that pleural thickening was continuous with an opacity ensheathing the vertebral body. In 7 out of 9 cases the functional restrictive deficit was accompanied by normal or supranormal functional residual capacity and increased residual volume. In all patients explored by the Xenon method, there was apical-caudal inversion of the ventilation/perfusion ratio. These findings suggest 3 pathogenic hypotheses: mere sequelae of hypoventilation, specific lung tissue fibrosis, extension by continuity of the vertebra-ensheathing process to the subpleural spaces.     

Atypical clinical presentation of ankylosing spondylitis

OBJECTIVES: To describe a subgroup of patients with ankylosing spondylitis (AS), whose disease evolved without the characteristic inflammatory back pain or significant disability. METHODS: Three patients who were diagnosed in their late 5th decade of life as having AS are described. Information about asymptomatic cases of AS or patients who were unaware of their disease was gathered from case reports and from studies involving HLA-B27-positive individuals. Another source of information derived from studies that investigated conditions known to be a complication of AS, such as heart block or aortic regurgitation. RESULTS: The data collected from the literature suggest that 1.5% to 10% of the patients with AS are asymptomatic or have very mild disease. These patients are diagnosed late in the course of the disease. CONCLUSIONS: Because of the mild nature of the symptoms, the real prevalence of atypical AS is unknown. The information gathered from the literature allows to delineate 4 subgroups of patients with AS: (1) Classic AS with characteristic clinical and radiographic manifestations; (2) Asymptomatic AS with characteristic radiographic findings; (3) Asymptomatic AS with extra-articular features as the presenting manifestations; (4) Symptomatic AS without radiographic supporting evidence. Patients with asymptomatic or mild symptoms deserve more attention, because a better understanding of the factors that affect the expression of pain in different individuals may generate better pain control therapies.     

Full‐blown cardiac manifestations in ankylosing spondylitis

Ankylosing spondylitis often involves a heart, such as aortic or mitral regurgitation, conduction disorder, or cardiomyopathy. We present a 34‐year‐old male patient with ankylosing spondylitis who has severe aortic regurgitation, mild mitral stenosis, and a conduction disturbance of the left bundle branch block, identified using multimodal images.     

The assessment of ankylosing spondylitis in clinical practice

Ankylosing Spondylitis (AS) is a chronic inflammatory arthritis that predominantly affects the axial skeleton in adolescent patients causing spinal pain and stiffness. There is a marked delay, on average 8 years, between onset of disease symptoms and clinical diagnosis. The distinction between the symptoms of mechanical and inflammatory back pain remains one of the main contributing factors for the delay in diagnosis. Several classification criteria exist to aid the diagnosis of AS, but their accuracy is poor. The Ankylosing Spondylitis Assessment Study group (ASAS) has defined a core set of domains for clinical outcome measurement in AS in order to assess the disease process in individual patients and to identify those with rapidly progressive disease. New therapies, such as the tumor necrosis factor (TNF) inhibitors, have transformed the treatment paradigm in AS, especially for those patients with aggressive disease. Thus, the definition of both patient selection criteria for these agents and the development of clinical methods to assess response to therapy have become a priority. This Review focuses on measuring the degree of disease activity, function and damage in patients with AS in an ambulatory care setting, and the assessment of suitability of various outcome measures for monitoring response to treatment with TNF inhibitors.     

Extra-articular manifestations of ankylosing spondylitis: prevalence, characteristics and therapeutic implications

Ankylosing spondylitis (AS) is the most frequent and most severe subtype of spondyloarthritis and can be an outcome of any of the other spondyloarthritis subtypes. It primarily affects the axial joints, most notably the sacroiliac joints. Other sites of involvement include the spine, peripheral joints, and entheses (capsules, ligaments, and tendons). Inflammatory enthesopathy progressing to ossification and ankylosis is the pathologic basis for the disease. Extra-articular manifestations vary widely in terms of both frequency and severity. The most common extra-articular manifestations are represented by uveitis, bowel disease, heart, lung, skin, bone and kidney involvement. This review focuses on prevalence and clinical characteristics of the most common extra-articular manifestations in AS, and discuss the diagnosis and therapeutic difficulties that rheumatologists faces when dealing with such manifestations. The advantages of treatment with non-steroidal anti-inflammatory drugs (NSAIDs), especially if continuous use is envisaged, should be weighted against possible gastrointestinal and cardiovascular disadvantages. In the presence of history of gastrointestinal complaints or a high cardiovascular risk, NSAIDs should be used with caution. TNF inhibition has demonstrated effectiveness in the treatment of AS symptoms and all currently available anti-TNF agents appear to have similar efficacy. However, the efficacy of anti-TNF agents varies in the presence of extra-articular manifestations. Etanercept appears to have very little effect on inflammatory bowel disease and limited efficacy on the course of uveitis probably inferior to the monoclonal antibodies infliximab and adalimumab.     

Differences in cardiovascular manifestations between ankylosing spondylitis patients with and without kyphosis

The objective of this study is to evaluate the differences in cardiovascular manifestations between ankylosing spondylitis (AS) patients with and without kyphosis. A retrospective review of consecutive AS patients treated at our hospital between June 2013 and June 2015 was performed. There were 122 patients who met all of the inclusion and exclusion criteria. Among these patients, there were 57 (ASK group) patients with global kyphosis (GK)?>?40° and 65 (AS group) patients with GK?<?40°. General information, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), electrocardiography, and echocardiography were record. ESR and CRP levels in the ASK group were significantly higher than the AS group (P?<?0.05). Fifteen patients in ASK group but 3 patients in AS group suffered from a left ventricular high voltage (P?<?0.05). Heart rate in ASK group was 83.91?±?13.68 beats/min, and it was 73.88?±?13.04 beats/min in AS group (P?<?0.05). The E/A ratio was 1.13?±?0.38 in ASK group and 1.32?±?0.49 in AS group (P?<?0.05). The mitral E-wave deceleration time and isovolumetric relaxation time were, respectively, 236.25?±?34.26 ms and 101.86?±?17.57 ms in ASK group, which were shorter in AS group (P?<?0.05). This study showed that AS patients with kyphosis had a statistically increased incidence of cardiovascular complications including a more rapid heart rate, left ventricular high voltage, and left ventricular diastolic dysfunction.     

Radiological manifestations in 200 patients with ankylosing spondylitis: correlation with clinical features and HLA B27.

The radiological manifestations of 200 patients with ankylosing spondylitis were appraised, and correlated with the patient's sex, anterior uveitis, and HLA B27. Radiological findings in female patients were no different from male patients. Only syndesmophyte formation in the spine was found significantly more frequently in patients with uveitis and HLA B27. Osteoporosis of the spine correlated strongly with a later age of onset, longer duration of the disease, older age at the time of study, Romanus lesions, syndesmophytes, spinal fusion, osteitis pubis, and widespread radiological destructive peripheral joint disease. Syndesmophytes were most frequently present at the dorso-lumbar junction. Spondylodiscitis was present in 8 patients and was most commonly present in the thoracic spine.