In addition to well-known extra-articular manifestations, ankylosing spondylitis (AS) has been reported to be associated with a number of cardiovascular diseases, including aortitis, aortic valve disease, conduction disturbances, cardiomyopathy, and ischemic heart disease.
Cardiac issues are found in an estimated two to 10 percent of people with AS. In the 1930s, a study found aortitis (inflammation of the aorta) in a group of patients with AS. Since then, a number of cardiovascular diseases have been linked to AS, many of which begin prior to the onset of clinical symptoms.
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Aortitis is the inflammation of the aorta, the large artery
that takes blood from the heart and distributes it to the rest of the body.
Aortitis can result in aortic insufficiency, or the inability of the aorta to
carry sufficient amounts of blood to the body, and hypertension (high blood
pressure). A number of people with AS have chronic inflammation at the base of
the heart, around the aortic valve, and at the origin of the aorta. Years of
chronic inflammation can lead to valve leakage, which sometimes requires
surgical intervention. Management of aortitis includes controlling the
inflammation with medications, treating complications, and preventing its
recurrence. Aortic valve disease – a condition in which the valve between the
heart’s main pumping chamber (left ventricle) and the aorta does not work
properly. There are two main types of aortic valve disease – aortic stenosis
(narrowing of the aortic valve opening) and aortic regurgitation, in which the
aortic valve does not close properly, causing blood to flow backward into the
left ventricle. This condition, which can cause shortness of breath, chest pain
(angina), and dizziness, is often treated with surgery to repair or replace the
Conduction disturbances are arrhythmias that cause the heart
to beat too fast (tachycardia) or too slow (bradycardia), and to pump blood
less efficiently. The disturbances are caused either by a disruption of the
heart’s normal electrical conduction system or by heart disease. People with
conduction disturbances often feel a palpitation or skipped heart beat and a
fluttering sensation the chest and neck, as well as fatigue, dizziness,
lightheadedness, shortness of breath, and chest pain. In extreme cases,
conduction disturbances can cause sudden cardiac arrest. Arrhythmias are
treated with medication, ablation (radiofrequency energy delivered at the site
of the electrical disturbance), defibrillation (an electronic shock to the
heart), or with an implantable cardioverter defibrillator (a pacemaker-like
device that delivers a shock to the heart to restore normal rhythm).
Cardiomyopathy is a disease that enlarges and weakens the
heart muscle, making it harder for the heart to pump blood to the rest of the
body. Left untreated, cardiomyopathy can lead to heart failure, blood clots,
valve problems, and cardiac arrest. The symptoms of cardiomyopathy include
shortness of breath with exertion or even at rest, swelling of the legs, ankles
and feet, abdominal bloating, fatigue, and an irregular heartbeat. Most often,
cardiomyopathy is treated by managing symptoms, preventing the condition from
worsening, and reducing the risk for complications. Medications like ACE
inhibitors (a type of blood pressure medication) can help improve the heart’s
pumping capabilities, and beta blockers can help improve heart function, as
well. Some patients receive a pacemaker to coordinate contractions between the
left and right ventricles or a ventricular assist device to keep blood
circulating through the heart.
Ischemic hearts disease is characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease. People with ischemic heart disease, also called atherosclerosis, often have angina, chest pressure, decreased tolerance for exercise, and difficulty breathing; many people mistake these symptoms for heartburn. Treatment includes anti-angina medications (nitroglycerin), medications to lower blood pressure and blood cholesterol, angioplasty with stent placement, and coronary bypass surgery.
Many people with AS also suffer from a condition called costochondritis, which can mimic the chest pain cause by an acute heart attack. Costochondritis is a benign inflammation of the cartilage connecting the ribs to the breastbone. The pain can often be excruciating, especially after exercise or coughing. The pain usually goes away on its own; however, in certain cases, it can last for several months or longer. Treatment focuses on pain relief, with prescription nonsteroidal anti-inflammatories like ibuprofen or naproxen or narcotics (Vicodin, Percocet) if the pain is severe. In addition, antidepressants (amitriptyline) and the epilepsy drug gabapentin (Neurontin) have proven successful in treating chronic pain. Stretching exercises, nerve stimulation, and injections of numbing medications can also help control the pain of costochondritis.
In 2011, Canadian researchers found that AS increases the risk of heart disease and stroke by as much as 25 percent to 60 percent. The increase was greatest for people with AS between the ages of 20 and 39. Compared to the non-AS population, the study found that AS patients had a 58 percent higher risk of valvular heart disease, a 37 percent higher risk of ischemic heart disease, and a 25 percent higher risk of stroke. The researchers say the link between AS and heart disease exists for a number of reasons, including the chronic inflammation associated with AS, the use of NSAIDs, and a tendency to exercise less than the general population due to pain.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used class of medications to treat the pain and stiffness associated with spondylitis. Sometimes, higher doses of NSAIDs are needed to maintain relief from spondylitis symptoms. This can pose a problem because long-term NSAID use can cause significant side effects, especially in the gastrointestinal tract. A different class of NSAIDs, known as Cox-2 inhibitors (or Coxibs), allegedly reduce the risk of gastrointestinal complications associated with traditional NSAID therapy.
But now, research is showing that prescription-strength NSAIDs also carry significant risks of cardiovascular events. In a study published in the British Medical Journal in 2011, researchers found that NSAIDs significantly increase the risk of cardiovascular events in people who take these medications on a regular basis. In fact, long-term users of prescription NSAIDs have a two-fold to four-fold increase in the risk of heart attack, stroke or cardiovascular death. The researchers looked at 31 studies with more than 116,000 patients who took prescription-strength NSAIDs and compared the NSAIDs with other NSAIDS or a placebo. They found that ibuprofen (Advil) carries the highest risk of stroke, etoricoxib (which is not sold in the U.S.) carries the highest risk of cardiovascular death, and rofecoxib (Vioxx, which was withdrawn from the market) has the highest risk of heart attack. They found that naproxen (Aleve) is the safest of the NSAIDs, but that it still carries some cardiovascular risk.
For years, doctors have exercised caution when prescribing NSAIDs for chronic pain relief because of their well-known risk for causing ulcers and serious bleeding in the stomach and GI tract. After a study found that Vioxx, a Cox-2 inhibitor, carried a significant increase in the risk of heart attack and stroke, doctors began to wonder if other pain-relieving medications had heart risks, as well. By the time Merck withdrew Vioxx from the market in September 2004, the drug had caused a reported 60,000 deaths worldwide. A study published in the Archives of Internal Medicine in 2010 found that people taking opioid drugs, which have long been used to treat pain, also have an elevated risk of heart attack compared to NSAIDs. Many clinicians, however, think that NSAID gels and patches may relieve pain without the adverse abdominal and heart effects that pills cause. Others say to simply use NSAIDs judiciously.
So what is a patient, who relies on NSAIDs for symptom relief, to do? The best advice is to talk to your doctor about the risks and benefits of NSAIDs and to disclose any pre-existing heart conditions or risks.
Studies show that nearly everyone—including people with spondylitis—can become more heart healthy by following a few key steps such as eating a healthful diet, exercising regularly, quitting smoking, and maintaining a healthy body weight. The National Institutes of Health says you should also know your blood pressure, cholesterol, and triglyceride levels, and keep them under control. Making healthy choices and managing any medical conditions, including spondylitis, can help keep your heart healthy.
Tumor necrosis factor-alpha (TNF-α) inhibitors are biologic medications that have shown great promise in treating spondylitis. A 2009 study in the journal Arthritis and Rheumatism discovered a side benefit of TNF-α inhibitors. Etanercept (Enbrel) improves the lipid profile (cholesterol and triglycerides) in AS patients and, therefore, may protect against atherosclerosis. Other studies have shown that TNF-α inhibitors can improve the aortic stiffness that people with spondylitis can suffer.
Spondylitis patients should be screened with a physical exam, and an echocardiogram (a diagnostic test that may show abnormalities such as valve dysfunction or damage to heart tissue) annually to rule out any issues affecting the heart. If problems aren’t detected, they can’t be treated.
When it comes to spondylitis and cardiovascular disease, the bottom-line is simple: Take care of yourself, pay attention to your symptoms and manage them accordingly, and speak with a healthcare professional if you have questions or concerns about your condition or your treatment, or your risk for cardiovascular disease.
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