Abnormal phenotypes of 24-h blood pressure monitoring and their associations with inflammation and arterial stiffness in patients with rheumatoid arthritis

Abstract Objective. To evaluate the 24‑h profile of brachial and aortic blood pressure (BP) in patients with rheumatoid arthritis (RA) compared to the controls and to investigate the associations of the abnormalities.

Design and methods. The cross-sectional study included 85 patients with RA (males 22,4 %, aged 59,7 ± 14,3 years, hypertension (HTN) in 65 %, mean DAS‑28 (C‑reactive protein, CRP) 3,7 ± 1,1) and control group (40 patients matched by gender, age and risk factors). Office brachial BP was measured with a validated oscillometric device, 24-hour ambulatory blood pressure monitoring (ABPM) by BPLab Vasotens, arterial stiffness and aortic BP by applanation tonometry. Cardiovascular (CV) risk was calculated as mSCORE (EULAR recommended modified version). P < 0,05 was considered significant.

Results. The rate of BP control was 58 % in RA and 67 % in the control group (p = 0,48). Patients with RA and HTN compared to matched controls had higher levels of brachial and aortic office, mean daytime, nighttime and 24‑h systolic BP (SBP), patients with RA without HTN showed higher brachial night SBP (113 ± 10 vs 105 ± 9 mmHg, р = 0,02). All patients with RA had higher rate of masked HTN (28,2 % vs 7,5 %, p = 0,009), night SBP and DBP elevation (56,5 % vs 17,5 %, p < 0,001; 26,7 % vs 0 %, p = 0,02, in the group without HTN, respectively), isolated nocturnal HTN (30,6 % vs 5 %, p = 0,001) and non-dipping (83,5 % vs 62,5 %, p = 0,02). Univariate analysis revealed significant associations of night brachial SBP with age (r = 0,5), office SBP (r = 0,6) and diastolic BP (DBP) (r = 0,3), carotid-femoral (cf) pulse wave velocity (PWV) (r = 0,5) and mSCORE (r = 0,5); non-dipping pattern was associated with age (r = 0,22) and night brachial and aortic DBP (r = 0,36 and 0,35, respectively), р < 0,05 for trend. Multivariate analysis confirmed independent associations of night brachial SBP with cfPWV (β = 0,43, p = 0,009) and non-dipping with night brachial DBP (β = 0,57, p = 0,007). Non-dippers with elevated night SBP had the highest levels of cfPWV, CRP and mSCORE compared to dippers and non-dippers with normal night SBP.

Conclusions. High incidence of night SBP elevation does not depend on the history of HTN and is associated with cfPWV increase. Non-dipping state correlates with elevation of night brachial DBP. Combination of non-dipping state with night HTN is associated with arterial stiffness and higher CV risk. Inflammation might mediate these associations.

1. Cross M, Smith E, Hoy D, Carmona L, Wolfe F, Vos T et al. The global burden of rheumatoid arthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1316–1322. doi:10.1136/annrheumdis2013-204627

2. Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence of rheumatoid arthritis, based on the 1987 American College of Rheumatology criteria: a systematic review. Semin Arthritis Rheum. 2006;36(3):182–188. doi:10.1016/j.semarthrit.2006.08.006

3. van Halm VP, Peters MJL, Voskuyl AE, Boers M, Lems WF,Visser M et al. Rheumatoid arthritis versus diabetes as a risk factorfor cardiovascular disease: a cross-sectional study, the CARREInvestigation. Ann Rheum Dis. 2009;68(9):1395–1400. doi:10.1136/ard.2008.094151

4. Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis. 2012;71(9):1524–1529. doi:10.1136/annrheumdis2011–200726

5. Panoulas VF, Douglas KM, Milionis HJ, Stavropoulos-Kalinglou A, Nightingale P, Kita MD et al. Prevalence and associa-tions of hypertension and its control in patients with rheumatoid arthritis. Rheumatology (Oxford). 2007;46(9):1477–1482. doi:10.1093/rheumatology/kem169

6. Panoulas VF, Metsios GS, Pace AV, John H, Treharne GJ,Banks MJ et al. Hypertension in rheumatoid arthritis. Rheuma-tology (Oxford). 2008;47(9):1286–1298. doi:10.1093/rheumatology/ken159

7. Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ et al. Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med. 2018;378(16):1509–1520. doi:10.1056/NEJMoa1712231

8. ABC-H Investigators, Roush GC, Fagard RH, Salles GF,Pierdomenico SD, Reboldi G, Verdecchia P et al. Prognostic impact from clinic, daytime, and night-time systolic blood pressure in nine cohorts of 13,844 patients with hypertension. J Hypertens.2014;32(12):2332–2340; discussion 2340. doi:10.1097/HJH.0000000000000355

9. McEniery CM, Cockcroft JR, Roman MJ, Franklin SS,Wilkinson IB. Central blood pressure: current evidence and clinical importance. Eur Heart J. 2014;35(26):1719–1725. doi:10.1093/eurheartj/eht565

10. Whelton PK, Carey RM, Aronow WS, Casey DE Jr,Collins KJ, Dennison, Himmelfarb C et al. 2017 ACC/AHA/ AAPA/ ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269–1324. doi:10.1161/HYP.0000000000000066

11. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M,Burnier M et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: с hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36(10):1953–2041. doi:10.1097/HJH.0000000000001940

12. Chazova IE, Zhernakova YuV [on behalf of the experts]. Clinical guidelines. Diagnosis and treatment of arterial hypertension. Systemic Hypertension. 2019;16(1):6–31. In Russian. doi:10.26442/2075082X.2019.1.190179

13. Boggia J, Li Y, Thijs L, Hansen TW, Kikuya M, Björklund-Bodegård K et al. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet. 2007;370 (9594):1219–1229. doi:10.1016/S0140-6736(07)61538-4

14. Cicek Y, Durakoglugil ME, Kocaman SA, Cetin M, Erdogan T,Dogan S et al. Non-dipping pattern in untreated hypertensive patients is related to increased pulse wave velocity independent of raised nocturnal blood pressure. Blood Press. 2013;22(1):34–38. doi:10.3109/08037051.2012.701409

15. Cuspidi C, Sala C, Tadic M, Gherbesi E, Grassi G, Mancia G. Nondipping pattern and carotid atherosclerosis: a systematic review and meta-analysis. J Hypertens. 2016;34(3):382–385. doi:10.1097/HJH.0000000000000812

16. Fan H Q, Li Y, Thijs L, Hansen TW, Boggia J, Kikuya M et al.Prognostic value of isolated nocturnal hypertension on ambulatory measurement in 8711 individuals from 10 populations. J Hypertens. 2010;28(10):2036–2045. doi:10.1097/HJH.0b013e32833b49fe

17. Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K,Michimata M et al. Prognostic significance of the nocturnal decline in blood pressure in individuals with and without high 24 h blood pressure: the Ohasama study. J Hypertens. 2002;20 (11):2183–2189.

18. Tsioufis C, Syrseloudis D, Dimitriadis K, Thomopoulos C,Tsiachris D, Pavlidis P et al. Disturbed circadian blood pressure rhythm and C reactive protein in essential hypertension. J Hum Hypertens. 2008;22(7):501–508. doi:10.1038/jhh.2008.20

19. Hamamoto K, Yamada S, Yasumoto M, Yoda M, Yoda K, Tsuda A et al. Association of nocturnal hypertension with disease activity in rheumatoid arthritis. Am J Hypertens. 2016;29(3):340–347. doi:10.1093/ajh/hpv119

20. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62 (9):2569–2581. doi:10.1002/art.27584

21. Association of rheumatologists of Russia, Federal Clinical Guidelines“Rheumatoid arthritis”. URL: http://rheumatolog.ru/experts/klinicheskie-rekomendacii In Russian .

22. [Electronic resource] URL: https://www.das-score.nl/das28/DAScalculators/dasculators.html

23. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31 (9):1731–1768. doi:10.1097/HJH.0b013e328363e964

24. Troitskaya EA, Velmakin SV,Villevalde SV, Kobalava ZD. Characteristics and clinical associations of arterial stiffness and subclinical atherosclerosis in patients with rheumatoid arthritis. Kardiologiia. 2018;58(7S):46–54. doi:10.18087/cardio.2494 In Russian.

25. Agca R, Heslinga SC, Rollefstad S, Heslinga M, McInnes IB, Peters MJ et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76(1):17–28. doi:10.1136/annrheumdis-2016–209775

26. Protogerou AD, Panagiotakos DB, Zampeli E, Argyris AA, Arida K, Konstantonis GD et al. Arterial hypertension assessed “out-of-office” in a contemporary cohort of rheumatoid arthritis patients free of cardiovascular disease is characterized by high prevalence, low awareness, poor control and increased vascular damage-associated “white coat” phenomenon. Arthritis Res Ther. 2013;15(5): R142. doi:10.1186/ar4324

27. Nikitina NM, Romanova TA, Rebrov AP. Masked hypertension: the relevance of the problem for patients with rheumatoid arthritis? Arterial’naya Gipertenziya = Arterial Hypertension. 2016;22(4):364–369. doi:10.18705/1607-419X-2016-22-4-364-369In Russian.

28. Gkaliagkousi E, Anyfanti P, Chatzimichailidou S, Triantafyllou A, Lazaridis A, Aslanidis S et al. Association of nocturnalblood pressure patterns with inflammation and central and peripheral estimates of vascular health in rheumatoid arthritis. J Hum Hypertens. 2018;32(4):259–267. doi:10.1038/s41371-018-0047-0

29. Rihacek I, Nemec P, Rihacek M, Kianicka B, Berukstis A,Caprnda M et al. Ambulatory blood pressure monitoring and hypertension related cardiovascular risk in patients with rheumatoid arthritis. Int J Clin Rheumatol. 2017;12(6):142–150.

30. Belt NK, Kronholm E, Kauppi MJ. Sleep problems in fibromyalgia and rheumatoid arthritis compared with the general population. Clin Exp Rheumatol. 2009;27(1):35–41.

31. Taylor-Gjevre RM, Gjevre JA, Nair B, Skomro R, Lim HJ.Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis. Musculoskeletal Care. 2011;9:152–159. doi:10.1002/msc.208

32. Ulus Y, Akyol Y, Tander B, Durmus D, Bilgici A, Kuru O.Sleep quality in fibromyalgia and rheumatoid arthritis: associations with pain, fatigue, depression, and disease activity. Clin Exp Rheumatol. 2011;29(6Suppl69):S92–S96.

33. Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Fitzgerald JD,Ranganath VK et al. Sleep loss exacerbates fatigue, depression, and pain in rheumatoid arthritis. Sleep. 2012;35(4):537–543. doi:10.5665/sleep.1742