Diastolic left ventricular dysfunction in ankylosing spondylitis—A systematic review and meta-analysis

doi:10.1016/j.semarthrit.2014.02.004

Seminars in Arthritis and Rheumatism

Volume 44, Issue 1, August 2014, Pages 14-19

https://doi.org/10.1016/j.semarthrit.2014.02.004 Get rights and content

Abstract

Objectives

Ankylosing spondylitis (AS) is associated with increased mortality largely due to cardiovascular disease. Diastolic left ventricular (LV) dysfunction serves as a precursor to chronic heart failure and may cause morbidity and mortality. A systematic literature search was conducted to determine the prevalence of diastolic LV dysfunction in patients with AS.

Methods

We identified all echocardiographic studies investigating diastolic LV function in patients with AS. The initial search yielded 166 studies of which 11 met the inclusion criteria.

Results

Compared to control subjects, AS patients had a worse E/A ratio [mean difference −0.13 m/s (95% CI: −0.19 to −0.07)], a prolonged deceleration time [mean difference 13.90 ms (95% CI: 6.03–21.78)], and a prolonged mean isovolumetric relaxation time [mean difference 8.06 ms (95% CI: 3.23–12.89)], all suggestive of diastolic LV dysfunction. The best way to establish diastolic LV dysfunction, however, is to combine E/A ratio, deceleration time, and isovolumetric relaxation time. The latter has been done in 3 studies, all reaffirming an increased prevalence rate of diastolic LV dysfunction in AS patients as compared with control subjects, i.e., 9% versus 0%, 30% versus 12%, and 45% versus 18%, respectively.

Conclusions

Our observations support the current evidence base for an increased risk of diastolic LV dysfunction in AS. However, larger studies are needed to investigate the exact magnitude of diastolic LV dysfunction and its clinical relevance in patients with AS.

Introduction

In ankylosing spondylitis (AS), cardiovascular disease increases mortality approximately 2-fold compared to the general population, and heart failure (HF) is an important contributor to the number of circulatory deaths [1], [2], [3], [4]. HF develops when structural or functional cardiac disorders impair the ability of the left ventricle to fill with or eject blood. A disturbed filling pattern, termed as diastolic left ventricular (LV) dysfunction, is caused by impaired relaxation of the left ventricle and may eventually lead to HF with preserved ejection fraction (HFpEF) [5]. Failing pump function of the heart is termed systolic LV dysfunction and may lead to HF with reduced ejection fraction (HFrEF) [5].

In RA, multiple studies have shown an increased prevalence of diastolic LV dysfunction but not systolic LV dysfunction [6]. Systemic inflammation appears to be an important risk factor for diastolic LV dysfunction and HFpEF, as systemic inflammation gradually damages the cardiomyocytes and causes increased collagen deposition in the heart [7]. Against this background, we hypothesize that AS patients are at an increased risk for diastolic LV dysfunction and its sequelae HFpEF. To address this item, we conducted a systematic review and meta-analysis to summarize all available studies investigating diastolic LV functioning in AS.

Section snippets

Search

A systematic literature search was conducted to identify all articles published from January 1990 to April 2013 that assessed diastolic LV function with echocardiography in AS. As technological advances in echocardiographic techniques may lead to discrepancies in the results, we only included studies published from 1990 onwards. We performed the search in Medline, EMBASE, and Cochrane library. The search details are shown in Figure 1. The complete search, including search terms, is described in

Description of selected studies

The original search yielded a total of 166 studies (Fig. 1). Of these, 61 studies were eligible for inclusion. A total of 34 either non-controlled studies or studies lacking echocardiographic parameters were excluded. A total of 16 studies were excluded because they were written in another language than English. The remaining 11 studies met the inclusion criteria and comprised a total of 600 AS patients and 415 control subjects.

Characteristics of patients included in the studies

Features of the included studies are presented in Table 2. Older

Discussion

This systematic review and meta-analysis examines prevalence of diastolic LV dysfunction in AS patients. We found that AS patients have increased features of diastolic LV dysfunction. AS patients had a lower E/A ratio, a prolonged mean DT, and a prolonged mean IVRT, all suggestive for diastolic LV dysfunction. The best way to establish diastolic LV dysfunction, however, is to combine the E/A ratio, DT, and IVRT as stated by the ASE and the EAE [10], [22]. The latter has been done in 3 studies,

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LV diastolic dysfunction in AS is gaining more evidence. A meta-analysis observed increased prevalence rate of LV diastolic dysfunction, since a worse E/A ratio, prolonged deceleration time and isovolumetric relaxation time were reported (9% vs. 0%, 30% vs. 12%, 45% vs. 18%, respectively) [227]. However, a cross-sectional study showed that diastolic dysfunction is infrequent and mild in AS (12%) [228].
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Diastolic left ventricular dysfunction in ankylosing spondylitis—A systematic review and meta-analysis

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Search

Description of selected studies

Characteristics of patients included in the studies

Discussion

Semin Arthritis Rheum

J Card Fail

J Am Coll Cardiol

J Am Soc Echocardiogr

Atherosclerosis

Int J Cardiol

Increased mortality in ankylosing spondylitis is related to disease activity

Ann Rheum Dis

Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis

J Rheumatol

Increased risk of cardiovascular and cerebrovascular diseases in individuals with ankylosing spondylitis: a population-based study

Arthritis Rheum

Diastolic dysfunction in rheumatoid arthritis: a meta-analysis and systematic review

Arthritis Care Res

Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria

Arthritis Rheum

Recommendations for the evaluation of left ventricular diastolic function by echocardiography

Eur J Echocardiogr

Assessment of left ventricular functions by tissue Doppler imaging in patients with ankylosing spondylitis

Rheumatol Rep

Subclinical cardiovascular target organ damage manifestations of ankylosing spondylitis in young adult patients

Mod Rheumatol

Patients with ankylosing spondylitis have evidence of left ventricular asynchrony

Echocardiography