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Routine cardiac screening in spondyloarthritis shown unneeded

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Data confirm a no-screen approach

Some patients with ankylosing spondylitis develop aortic insufficiency and need aortic valve replacements. Historically, clinicians worried about this risk and this led to a debate when an American College of Rheumatology panel recently developed ankylosing spondylitis treatment recommendations. This committee, on which I participated, decided to strongly recommend against routine screening with ECG or echocardiography. When we made that decision, we did not have these new data; we based our recommendation largely on our concerns about the cost efficacy of routine screening of asymptomatic patients.

Dr. David T.Y. Yu

The new findings reported by Dr. Reejhsinghani show for certain that we do not need routine structural screening on these patients. It’s certainly appropriate to assess a patient with ECG and echo if they have persistent hypertension, dyspnea, or other cardiac symptoms. I would also do further testing in an ankylosing spondylitis patient with a heart murmur, and it is also appropriate to keep in mind a possible increased risk in spondyloarthritis patients for ischemic cardiovascular diseases.

The data reported by Dr. Reejhsinghani are convincing, especially because of the matching she did to control for age and presence of hypertension.

David T.Y. Yu, MD, is a rheumatologist at the University of California, Los Angeles. He made these comments in an interview. He had no disclosures.




DENVER – The largest controlled assessment of structural cardiac disease in patients with axial spondyloarthritis (SpA) failed to show any excess above a matched healthy sample, a finding that boosts recent guidelines that recommended against routine cardiac assessments in these patients.

“These findings provide the first evidence to support current recommendations against routine echocardiographic screening in asymptomatic patients with axial spondyloarthritis,” Risheen Reejhsinghani, MD, said at the annual meeting of the Spondyloarthritis Research and Treatment Network.

Dr. Risheen Reejhsinghani Mitchel L. Zoler/Frontline Medical News

Dr. Risheen Reejhsinghani

“If a patient has symptoms of cardiac disease – uncontrolled hypertension, dyspnea, or chest pain – then you would do the appropriate testing as you would for anyone,” said Dr. Reejhsinghani, a cardiologist at the University of California, San Francisco.

Past reports from small and often uncontrolled groups of patients with ankylosing spondylitis (AS) had suggested a possible link between the disease and structural heart disease. The 2015 treatment recommendations for AS and axial SpA from the American College of Rheumatology and other organizations included a “strong” recommendation against screening for cardiac conduction defects or for valvular heart disease (Arthritis Rheum. 2016 Feb;68[2]:282-98).

The prospective study by Dr. Reejhsinghani and her associates enrolled 154 patients diagnosed with axial SpA and 51 age-matched controls recruited from Health eHeart participants, a community-based heart disease study run from San Francisco. Additional matching by hypertension status refined the population to 133 patients with axial SpA matched with 51 healthy controls. The researchers also did another prespecified analysis that compared the 51 controls with 94 age- and hypertension-matched patients who fulfilled the 1984 modified New York criteria for a specific diagnosis of AS. Overall, nearly two-thirds of the people in the study were men, they averaged about 43 years old, and the average duration from AS diagnosis was 18 years.

The researchers performed systematic cardiac examination by transthoracic echo in all 205 participants that examined them for aortic root size, aortic regurgitation, diastolic dysfunction, and size of the aortic annulus, sinotubular junction, and ascending aorta. These examinations identified an unusually large aortic root diameter in about 5% of the cases and 2% of the controls. Aortic insufficiency (regurgitation) occurred in about 40% of the cases and 50% of the controls. An analysis of the cases and controls that was matched for age and hypertension showed a diastolic dysfunction prevalence of 17% in the cases and 27% in the controls. None of the between-group differences were statistically significant. The results were similar for the entire age-matched group studied, the age- and hypertension-matched subgroup, and the AS subgroup.

Future studies need to examine the possible impact that various treatments, including biologics, have on the prevalence of cardiac disorders, Dr. Reejhsinghani said.

On Twitter @mitchelzoler

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