Hypertension in rheumatoid arthritis.

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.

Excess recurrent cardiac events in rheumatoid arthritis patients with acute coronary syndrome.

BACKGROUND: Cardiovascular mortality is increased in rheumatoid arthritis. Possible reasons include an increased incidence of ischaemic heart disease or worse outcome after acute coronary syndrome (ACS). OBJECTIVES: To assess the outcome of ACS in rheumatoid arthritis compared with case matched controls in the context of underlying cardiac risk factors, clinical presentation, and subsequent management. METHODS: 40 patients with rheumatoid arthritis and ACS identified from coronary care admission registers between 1990 and 2000 were case matched as closely as possible for age, sex, classical cardiovascular risk factors, type and severity of ACS, and admission date (+/-3 months) with 40 controls. A standardised proforma was used for detailed case note review. RESULTS: Age, sex, other cardiovascular risk factors, and type and severity of presenting ACS were not significantly different between cases and controls. Recurrent cardiac events were commoner in rheumatoid arthritis (23/40, 57.5%) than controls (12/40, 30%) (p = 0.013); there were 16/40 deaths in rheumatoid arthritis (40%) v 6/40 (15%) in controls (p = 0.012). Recurrent events occurred earlier in rheumatoid arthritis (log rank survival, p = 0.05). Presentation with chest pain occurred in all controls compared with 33/40 rheumatoid patients (82%) (p = 0.006); collapse occurred in one control (2.5%) v 7/40 rheumatoid patients (17.5%) (p = 0.025). Treatment during the ACS was not significantly different in the two groups. CONCLUSIONS: Recurrent ischaemic events and death occur more often after ACS in rheumatoid arthritis. Atypical presentation is commoner in rheumatoid arthritis. There is an urgent need to develop identification and intervention strategies for ACS specific to this high risk group.

Cardiovascular disease and psychological morbidity among rheumatoid arthritis patients.

OBJECTIVES: To examine whether patients with rheumatoid arthritis (RA) with co-morbid cardiovascular disease (CVD) have different psychological morbidity (and psychosocial risk factors for it) compared with RA patients without co-morbid CVD. METHODS: Patients with RA and co-morbid CVD (n = 44; hypertension alone for n = 27) were compared with RA patients without CVD (n = 110). Differences in psychological morbidity (depression and anxiety) and psychosocial risk factors for this (arthritis self-efficacy, acceptance, social support and optimism) were examined while controlling statistically for medical and demographic covariates. RESULTS: Groups did not differ on RA duration, RA activity, marital status or socioeconomic status, but RA patients with co-morbid CVD were older, less likely to be female and less likely to be in employment than those without CVD. RA patients with co-morbid CVD had significantly higher depression and were more likely to score above cut-offs for depression than RA patients without CVD. No differences existed in anxiety, although anxiety appeared to be more common than depression. Low optimism was identified as a possible psychosocial risk factor for depression. CONCLUSIONS: RA patients with co-morbid CVD have higher depression than RA patients without CVD; low optimism is a potentially modifiable risk factor that may mediate this difference. RA patients with co-morbid CVD may benefit from systematic screening for depression and targeted intervention if necessary.

Risk assessment for coronary heart disease in rheumatoid arthritis and osteoarthritis.

BACKGROUND: The risk of coronary heart disease (CHD) is increased in rheumatoid arthritis (RA). The reasons for this remain unknown, but traditional risk factors for CHD identified in the general population may be important contributors. OBJECTIVE: To assess comparatively the prevalence of traditional CHD risk factors and the absolute 10-year CHD risk in patients with RA or osteoarthritis (OA) without known cardiovascular co-morbidity. METHODS: Consecutive Caucasian hospital outpatients with RA (n = 150) or OA (n = 100) aged 40-75 years were assessed for known cardiovascular co-morbidity, age, sex, smoking status, presence of diabetes mellitus (DM), height, weight, systolic blood pressure (BP), total cholesterol (TC) and HDL cholesterol. Absolute 10-year CHD risk for each individual was calculated using the Joint British Societies CHD risk calculator. RESULTS: Prevalence and distribution of known cardiovascular co-morbid conditions were similar in RA (56/150, 37%) and OA (34/100, 34%). The resulting subgroups of patients without known co-morbidity (RA: n = 94; OA: n = 66) were not significantly different for age, sex, DM, smoking, systolic BP or TC: HDL cholesterol ratio. There was no significant difference in the absolute 10-year CHD risk between RA and OA (15.6+/-11.0 versus 14.8+/-9.3, p = 0.63). However, a significant proportion of patients without known cardiovascular disease in both the RA and OA subgroups had a 10-year CHD risk above the 15% or 30% risk levels, indicating the need for possible or definite intervention respectively. Over 80% of RA patients had at least 1 CHD risk factor that could be modified. CONCLUSION: Absolute 10-year CHD risk was not different between RA and OA patients in this study. Substantial numbers of RA and OA patients have potentially modifiable CHD risk factors present. We suggest that CHD risk should be assessed and modifiable risk factors addressed in the routine rheumatology clinic setting.

Increased levels of antibodies to cytokeratin 18 in patients with rheumatoid arthritis and ischaemic heart disease.

OBJECTIVE: To determine whether raised levels of antibodies to CK18 in patients with RA are associated with ischaemic heart disease (IHD). METHODS: IgA, IgG, and IgM antibodies to CK18 were measured by enzyme linked immunosorbent assay (ELISA) in patients with RA with (n = 34) or without (n = 28) IHD. The relationship between CK18 antibody levels and markers of inflammatory and/or cardiovascular disease was examined. RESULTS: Initial analysis showed that IgG antibody levels to CK18 were higher in patients with RA with IHD than in those without (50.1 v 34.5 AU, p = 0.047), although significance was lost after correction for multiple comparisons. Further analysis showed a significant difference (p = 0.015) between patients with IHD and a positive family history, and patients without IHD and a negative family history (53.7 v 29.0 AU, Kruskal-Wallis multiple comparison Z value test). There was also a significant trend of increasing 10 year cardiovascular risk with increasing CK18 IgG antibody levels (p = 0.01). No association was found between CK18 antibody levels and conventional markers of inflammation or cardiovascular disease, but an association was found between levels of CK18 IgG and IgG antibodies to cytomegalovirus (CMV) (Spearman's r(s) = 0.379, p(corr) = 0.04). No evidence for cross reactivity of CK18 antibodies with CMV antigens was found. CONCLUSION: Levels of IgG antibodies to CK18 are raised in patients with RA with IHD, particularly if they also have a positive family history. This may reflect damage to CK18 containing cells in the cardiac vasculature and/or in atherosclerotic plaques, and may be a useful additional marker for the identification of patients with, or likely to develop, IHD.

The role of endothelial cell dysfunction in the cardiovascular mortality of RA.

Rheumatoid patients present clinically with chronic inflammatory immune arthritis but die of the same cardiovascular (CVS) disease as the normal population. Recent studies emphasize the increased frequency and earlier development of CVS involvement in RA. The mechanisms of this accelerated atherosclerosis are the subject of active research. The hypothesis that rheumatoid vasculitis is a major factor has been pursued through studies in primary systemic vasculitis. These reveal diffuse endothelial dysfunction occurring across a spectrum of vasculitis and involving more than one vascular bed. This may relate to cytokines such as TNF alpha that are both prominent in rheumatoid inflammation and important in the upregulation of endothelium in innate immune responses. Endothelial injury or dysfunction is widely accepted as the initial factor in atheroma. Its occurrence in vasculitis leads us to propose a model for RA where this dysfunction is the essential first step on which other factors, ranging from adverse lipid profiles to specific T-cell subsets, may build accelerated atherogenesis related to the rheumatoid inflammation.

Hypertension is not a disease of the left arm: a difficult diagnosis of hypertension in Takayasu's arteritis.

Hypertension and its cause may be missed by failure to measure blood pressure in both arms. We report a case of Takayasu's arteritis where diagnostic confusion arose because there was a failure to detect a difference in blood pressure between the arms.

Unique aspects of nursing care for Amish children.

The purpose of this article is to increase nurses' understanding of the Amish culture so nurses can give culturally competent care to Amish children. The Amish live in large multigenerational families on farms where hard work is valued; worldly conveniences such as electricity, telephones, and automobiles are usually shunned. However, the Amish are willing to accept and participate in modern healthcare, if its value is clearly understood. Amish beliefs and traditions are described, and recommendations for the nursing care of Amish children which are consistent with the Amish faith are presented.

Boyer's model of scholarship applied to a career ladder for nontenured nursing faculty.

This article presents a career ladder for the reappointment and promotion of nontenured clinical faculty, based on Boyer's model of the scholarship of teaching, application, discovery, and integration and on his four principles and six standards. Titles, lengths of appointments, criteria, obligations, and professional development are defined for four levels of clinical faculty. Guide questions modeled on Boyer's dimensions of scholarship, principles, and standards that were used to guide the development of the career ladder are included.

The evolution of health programming on cable television.

Health-oriented television programming occurred only on a sporadic basis until 1982, when a health information project was embodied in the formation of the Cable Health Network (CHN), a 24-hour, advertiser-supported, satellite-delivered cable network. As the network began, however, it ran into difficulties. A series of events led to a metamorphosis, including a merger of CHN with ABC/Hearst's network Daytime into the Lifetime network. A gradual but substantial replacement of health programming with more general entertainment fare took place. The network has enjoyed greater financial success in recent times, but success has come considerably at the expense of the health component, even though health promotion remains an important part of the programming. The study supports the suggestion by some researchers that the impact of mass media health promotion should be studied in the context of lifestyle and audience usage, rather than strictly as a linear message-audience-effect model.