A pilot study on short term heart rate variability & its correlation with disease activity in Indian patients with rheumatoid arthritis.

Background & objectives: Cardiovascular complications may lead to mortality in patients with rheumatoid arthritis (RA). We assessed heart rate variability (HRV), an important autonomic function, to quantify the risk for cardiovascular complications in Indian patients with RA. Methods: The study was carried out in RA patients (n=45) diagnosed as per American College of Rheumatology criteria and healthy controls. HRV recording and analysis was done using Nevrokard software using time and frequency domain analyses. The overall autonomic tone, parasympathetic drive, sympathetic drive and sympatho-vagal ratio were quantified by using various parameters. It included standard deviation of all R-R intervals (SDNN), standard deviation of successive differences between adjoining normal cycles (SDSD), root-mean square of successive differences (RMSSD), and number of R-R intervals differing by >50 ms from adjacent intervals (NN50) in the time domain analysis. In frequency domain analysis, low frequency (LF) and high frequency (HF), LF/HF and total power were assessed. Results: Demographic profile was comparable between groups; however, systolic BP was higher in patients with RA. SDNN, SDSD, RMSSD, NN50, LF and HF power and total power (ms × ms) were significantly lower in patients with RA versus healthy controls (P<0.001). Disease activity score at 28 joints indicating severity of the disease was significantly and positively correlated with SDSD (r=0.375, R2=14.06; P=0.045) while LF and HF power (ms × ms) were significantly and inversely correlated with rheumatoid factor (r=-0.438 and -0.445; R2=19.1 and 19.8; P=0.017 and 0.016, respectively). Interpretation & conclusions: HRV was significantly altered in patients with RA and independently associated with disease activity. Hence autonomic function testing, using HRV, may be useful as part of cardiovascular risk assessment in these patients.

Usefulness of anti -CCP antibodies in rheumatic diseases in Indian patients.

BACKGROUND: The usefulness of anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) to identify rheumatic arthritis (RA) from other rheumatic diseases presenting with joint pain is not well studied. AIMS: We aimed to determine the sensitivity and specificity of anti-CCP antibodies in Indian RA patients with respect to non-RA rheumatic diseases and to study the relationship of anti-CCP antibodies and IgG, IgM and IgA rheumatoid factor in RA. SETTINGS AND DESIGN: Case-control cross-sectional study carried out in the rheumatology division of All India Institute of Medical Sciences. MATERIALS AND METHODS: Sixty-three patients with rheumatoid arthritis (RA) and 51 patients with non-RA rheumatic diseases having joint pain were included in the study. Sera were tested for anti-CCP antibodies (IgG) and IgA, IgM, IgG rheumatoid factor, using a commercially available enzyme-linked immunosorbent assay. STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS statistical software version 11.5. RESULTS: Fifty-four of 63 RA patients (85.71%) were positive for anti-CCP antibodies. In the non-RA group, anti-CCP antibody was positive in only 5 of 51 patients (9.8%). Our study found a sensitivity of 85% and a specificity of 90.19% with regard to the use of anti-CCP antibodies assay in patients with joint pain to correctly identify RA. Anti-CCP antibodies positive patients did not have more erosive disease. IgM-RF-positive patients had more erosion when compared to the IgM-RF-negative group. Thirty-two of 57 (56.1%) IgM-RF-positive patients had erosions, while no patient (0/6 patients) had erosions in the IgM-RF-negative group (P=0.01) CONCLUSION: Anti-CCP antibodies have high sensitivity and specificity for diagnosis of RA, in Indian patients. Anti-CCP antibodies positive patients did not have more erosive disease in our study.

Adult onset Still's disease as a cause of acute liver failure.

A 29-year old lady presented to the hospital with high-grade intermittent fever, arthritis and macular skin rash. Investigations revealed anaemia, polymorphonuclear leucocytosis and raised erythrocyte sedimentation rate. Other tests including those for antinuclear antibody and rheumatoid factor were normal. The serum ferritin level however was raised. On the basis of these parameters a diagnosis of Still's disease was made. Treatment comprising oral steroids and anti-inflammatory agents was instituted. The patient recovered and was discharged only to present ten days later following 3 episodes of generalised tonic clonic seizures. Investigations revealed a persistently high serum ferritin with abnormal liver function test results. Jaundice developed and the patient went into grade IV hepatic encephalopathy following which she died. Still's disease is an idiopathic disease, diagnosed purely on the basis of the typical clinical features of the illness which include persistent arthritis, high fever, anaemia and an erythematous rash. Treatment for Still's disease mainly includes steroids and non-steroidal anti-inflammatory agents. Second-line treatment includes that used for controlling the arthritis and comprises gold, hydroxychloroquine, penicillamine, azathioprine, methotrexate, and cyclophosphamide.

Autonomic status in systemic sclerosis in India.

Systemic sclerosis (SSc) is a systemic connective tissue disease characterized by vasomotor disturbances. Autonomic dysfunction has been implicated in the pathogenesis of various symptoms in patients with SSc. In this retrospective study, thirty patients with SSc as cases and thirty age matched healthy subjects were enrolled as controls. The patients as well as controls were subjected to a standard battery of autonomic tests including reactivity and activity (tone) tests. Resting autonomic variables like blood pressure (BP), heart rate (HR) and respiratory rate (RR) were also recorded. In our study, we found significantly higher HR and RR in the patient group (P = 0.0001 and 0.012 respectively). We also observed significantly lower parasympathetic tone and parasympathetic reactivity in SSc patients than the controls. This study shows the status of autonomic functions in SSc patients in India, with lower central parasympathetic drive to the heart. The present study may give some insight for better understanding of this multisystem disorder of unknown etiology.