Consideration of hypertensive retinopathy as an important end-organ damage in patients with hypertension.

Longstanding and therapy-resistant hypertension may cause cerebral, renal, cardiac and retinal end-organ damage (EOD). Retinal hypertensive abnormalities are correlated with an increased risk of cardiovascular (CV) disease in general but are not included in CV risk assessment tools. Research into prevalence and determinants of retinal organ damage, such as hypertensive retinopathy (HR), is scarce. We evaluated the prevalence of HR and the association with other signs of EOD in patients with hypertension. A retrospective observational study was performed in all hypertensive patients referred by a general practitioner to the hypertension clinic at the Diakonessenhuis, Utrecht and Zeist, the Netherlands between 2011 and 2013. A screening of risk factors, albuminuria, left-ventricular hypertrophy (LVH) and retinal fundoscopy was performed. In all, 44% (123/280) of patients referred to the clinic were diagnosed with HR, while 15 and 11% were diagnosed with LVH and microalbuminuria, respectively. Patients with isolated HR consisted of 31% of all patients. When HR was added as a form of EOD, the percentage of patients with a treatment indication increased from 3 to 14%. Patients who were already on treatment goal exhibited a high prevalence of HR (28%), warranting treatment intensification. HR is prevalent in a third of hypertensive patients referred to our clinic, and isolated HR accounts for the majority of (end-) organ damages. Fundoscopy in the evaluation of hypertension might improve the indication for therapy. Furthermore, diagnosing HR could be helpful in selecting patients with hypertension on treatment goal in need of more aggressive treatment.

Tumor necrosis factor blocking therapy and congestive heart failure in patients with inflammatory rheumatic disorders: a systematic review.

INTRODUCTION: Tumour necrosis factor (TNF) blocking therapy is an effective treatment for chronic inflammatory arthritis. As circulating TNF might induce or exacerbate the development of congestive heart failure (CHF), several trials have investigated the effect of TNF blocking therapy on CHF. However, due to inefficacy and even a risk of exacerbation of CHF, TNF blocking therapy has since then been contraindicated in patients with advanced CHF, New York Heart Association class III and IV. We review current knowledge on the pathophysiological mechanisms and safety of TNF blocking therapy in chronic inflammatory arthritis patients with regard to CHF. METHODS: A systematic search of the literature published up till December 2013 was conducted in MEDLINE, EMBASE and the Cochrane Library to identify all studies investigating the effect of TNF blocking therapy on the occurrence and risk of CHF in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). All articles reporting data on the prevalence or incidence of CHF during treatment with TNF blocking therapy in patients with in RA, AS or PsA were included. Also imaging studies and studies with biomarkers, investigating the effect of TNF blocking therapy on cardiac function were included. RESULTS: In total, 54 studies were included. Results from large prospective registries suggest that first, a potentially harmful effect of TNF blocking therapy on the incidence of CHF in older RA patients cannot be excluded and that no harmful effect was observed of TNF blocking therapy in other patients. Second, we found that TNF blocking therapy potentially improves several echocardiographic parameters of cardiac function in RA, AS and PsA, but due to small sample sizes, these results require validation in larger studies. Third, we found improvement in NT-proBNP levels after use of TNF blocking therapy in both RA and AS. CONCLUSION: Based on current literature, in patients with chronic inflammatory arthritis and concomitant symptomatic mild-tomoderate CHF (NYHA class I or II), treatment with TNF blocking therapy is not contraindicated. In chronic inflammatory arthritis patients with concomitant symptomatic moderate-to-severe CHF, NYHA class III-IV, treatment with TNF blocking therapy should be avoided if possible. Whenever, treatment with TNF-blocking therapy is considered in these patients consultation with a cardiologist is recommended before treatment is initiated.

Subclinical renal dysfunction is independently associated with cardiovascular events in rheumatoid arthritis: the CARRÉ Study.

BACKGROUND: Patients with rheumatoid arthritis (RA) have double the risk of cardiovascular (CV) disease, largely independently of traditional CV risk factors. Renal dysfunction is associated with CV morbidity and mortality in the general population, but data on this association in RA are lacking. OBJECTIVE: To investigate the association between renal function and CV events in RA. METHODS: The CARRÉ Study is an ongoing prospective cohort study of Dutch patients with RA, which records CV events. Glomerular filtration rate (GFR) was estimated with the abbreviated Modification of Diet in Renal Disease formula. Logistic regression determined the association between estimated GFR and the occurrence of CV events. RESULTS: 353 patients were followed for 3 years, and 23 (7%) had a CV event. Patients who had an event had a significantly lower baseline GFR than those who did not (59 vs 79 ml/min, p=0.001). This association remained significant after adjustment for traditional risk factors: in this analysis, a decrease in GFR of 5 ml/min was associated with a 30% (95% CI 7% to 59%) increase in the occurrence of CV events. During follow-up, an unfavourable change in GFR was noted in patients who later had a CV event compared with those who did not. CONCLUSION: These data confirm that, in RA, renal dysfunction is associated with a higher risk of CV disease independently of traditional CV risk factors.