The assessment and modification of cardiovascular risk in inflammatory arthritis

摘要: Background Rheumatoid arthritis (RA) is a chronic inflammatory disorder that primarily affects synovial joints and the commonest form of polyarthritis. RA potentially confers significant morbidity, loss function reduced quality life. It multisystem with extra-articular manifestations affecting skin, cardiovascular, respiratory haematological systems. There an associated premature mortality which mainly attributable to cardiovascular disease (CVD). Much has been published on increased CVD risk confers, includes incidence myocardial infarction, congestive cardiac failure hypertension. Active higher burden both traditional (CV) factors (cigarette smoking, dyslipidaemia hypertension) novel (endothelial dysfunction, arterial stiffness insulin sensitivity) than would be expected in general population. Furthermore, inflammation may atherogenic. Certain drug therapies contribute CV risk, such as steroids anti-inflammatories. Whereas other therapies, anti-tumour necrosis factor agents, modulate risk. have many recent controversies regarding anti-inflammatories, non-selective non-steroidal anti-inflammatory drugs (NSAID) cyclooxygenase2 (COX2) inhibitors. These include gastrointestinal system side-effects, renal dysfunction The most publicised these issues was withdrawal rofecoxib 2004 by its manufacturers after clinical trial data emerged showed 3.5% infarction or ischaemic stroke patients no pre-existing who were receiving therapy. This lead scrupulous review medical journals relative risks NSAID COX2 inhibitor groups whole; well sub-analysis comparison individual preparations. In 2006 American Heart Association recommended order minimise any patient prescribed should lowest dose administered for shortest possible time. Furthermore, it clear from literature not just underlying processes medication can impact Dietary modification large bearing health outcomes. Large epidemiological studies Greece countries southern Europe confirmed adherence Mediterranean-type diet longevity CVD. A typically rich olive oil, fruit, vegetables, legumes fish, low intake red-meat. type often complemented modest amount alcohol, usually red wine, taken alongside meals. contrasts starkly typical west Scotland – ‘famed’ high saturated fat sugar relatively consumption fruit vegetables. Of late, much interest generated potential relationship between social deprivation effect general, particularly: diet, particular relevance Glasgow some deprived areas Scotland. While assessment calculators focussed markers blood pressure cholesterol, newer validated scores score deprivation, are CVD, family history Aims In this thesis my aims explore interventions various aspects RA, predominately assess further whether certain could modified. First all, I investigated feasibility well-controlled (that say, mild activity scores). rationale study removal therapy plus required active intervention provide equivalent symptom control achieved continuing NSAID. Other continued. assessed score, pain functional assessments. Secondary outcomes included control, symptoms function. Subsequently, within population reviewed. set up if existing resources used replicate real-life setting, east end south side Glasgow. Feasibility acceptability participants explored. Additionally, dietary activity, parameters assessed. Finally, given evidence linking poor outcomes, analysis undertaken using cohort recruited diet. Results calculations according conventional new algorithms compared. Results Thirty 44-joint ≤2.8 12-week study. All completed period without requiring re-introduction anti-inflammatories all continued their previously Eleven steroid injection at either 6 visit only 1 escalation modifying There deterioration components assessment. improvement recorded maximal median reduction 7 millimetres mercury (p=0.037). Seventy-five arm attended weekly cookery classes over week period. Fifty-five received basic printed information only. routine baseline, 3 months. Significant benefits seen group regards features activity: duration early morning months (p=0.041), global (p=0.002) (p= 0.011 0.049 respectively). Then demonstrated benefit systolic pressure. increase vegetable legume food frequency questionnaire. The substantial baseline demographic collected allowed comprehensive influence female living area undertaken. Three different used: Joint British Societies Coronary Risk Prediction, Framingham newer, Scottish, ASSIGN incorporates deprivation. more likely classify >20% 10-year (23% total cohort) JBSCRP. By ASSIGN, additional 16 individuals identified having JBSCRP alone. Conclusions The limited open-label design small participant numbers (n=30). However, tolerated did result need intervention, nor control. noted follow-up. To knowledge first supportive guide limitation use stable inform work area. 6-week prove instrumental increasing healthy foods cost. received, reviewing feedback, resulted beneficial effects future cost-effective easy implement being popular patients. Using identification greater number score. addition confers. Increased allow targeting target