Study of Cardiovascular Manifestations in Ankylosing Spondylitis

INTRODUCTION : Ankylosing spondylitis is a chronic inflammatory disorder primarily affecting the sacroiliac joints and vertebral column, often manifesting in young males than in females in the ratio of 3:1 in the second or third decade. Even though ankylosing spondylitis is principally a disease of axial and peripheral joints, extraarticular manifestations of the disease are also common, affecting Cardiac, ophthalmic, pulmonary, renal and neurological systems. Ankylosing spondylitis has a worldwide prevalence of 0.1 to 1.4%. The prevalence of rheumatoid arthritis among Indian population is found to be 0.85%. According to Yang et al, the prevalence of cardiac manifestations in ankylosing spondylitis patients were found to be 10% to 30% Bulkley and Roberts were one of the first to put forward pathophysiologic description of valvular heart diseases in ankylosing spondylitis, when they studied autopsy findings in eight patients with ankylosing spondylitis. They demonstrated aortic root dilatation, with a cellular inflammatory process with fibroplast overactivity along with tissue thickening involving the aortic cusps, aortic annulus, conduction system leading to aortic regurgitation and conduction abnormalities in patients with ankylosing spondylitis. AIMS AND OBJECTIVES: AIM: To find the prevalence of cardiovascular manifestations in patients suffering from Ankylosing Spondylitis. OBJECTIVES : • To observe the cardiovascular manifestations in patients with Ankylosing Spondylitis by chest X Ray, electrocardiography and echocardiogram compared with the controls. • To find out the relation between cardiac lesions with the age, sex of the patient, clinical parameters, Grading by X Ray and duration of Ankylosing Spondylitis. METHODOLOGY : The study is undertaken on the patients approaching the outpatient department as well as the Inpatients of the Coimbatore Medical College Hospital, Coimbatore during the period of study (i.e. July 2015 to July 2016). A total of fifty (50) subjects who had approached the Rheumatology Department in the Hospital, and having satisfied the ASAS criteria were selected for the study. These patients were compared with another fifty (50) age and sex matched control group, who had come to the OP department for non-specific complaints. The control group was selected on a random basis. SELECTION CRITERIA : (a) Inclusion Criteria : • Adult patients (both sex) between the age group of 18 to 60. • Patients satisfying Assessment of Ankylosing Spondylitis International Society (ASAS) criteria for Ankylosing Spondylitis. (b) Exclusion Criteria : • Pregnant women. • Minors (below the age of consent). • Persons suffering from congenital heart diseases. • Persons suffering from Psoriatic Arthritis. • Persons suffering from Rheumatic valvular heart diseases. • Persons not capable of giving consent (psychiatric patients). OBSERVATION AND RESULTS : The study is undertaken on the patients approaching the outpatient department of the Rheumatology department and in the inpatients of Coimbatore Medical College Hospital during the period of study (July 2015 to July 2016). A total of fifty patients who had satisfied the ASAS criteria were selected for the study. These patients were compared with another fifty control group who came to the OP Department for non – specific complaints. The control group was selected on a random basis. In the study group the mean age group of patients with AS was 38.1 years with a standard deviation of 3.1 years and that of the control group was 38.3 years with standard deviation of 3.9 years. The youngest patient was 32 years and oldest was 45 years among the study groups. DISCUSSION: Cardiac involvement is a well documented extraarticular manifestation among the patients suffering from ankylosing spondylitis. These abnormalities have been documented in several studies using echocardiography, electrocardiography. In this study cardiac conduction abnormalities and valvular abnormalities were seen in 11 patients with ankylosing spondylitis. Among them cardiac conduction abnormalities were seen in 5 (10%), aortic regurgitation in 4(8%), Isolated aortic root dilatation(2%), mitral regurgitation(2%). Cardiac conduction abnormalities seen were first degree heart block (4%), second degree heart block (2%), left anterior fascicular block(2%), left bundle branch block(2%). Aortic regurgitation was mild in 2%, moderate in 4%, severe in 2%. 4% of AR were associated with aortic root dilatation. CONCLUSION : Cardiovascular manifestations in ankylosing spondylitis were seen in 11 out of 50 cases. Maximum prevalence occurred in the age group of 41-45 years with a male to female ratio of 3.5:1.Mean age of the cases with cardiovascular abnormalities was found to be 41.45 years. • Duration of ankylosing spondylitis among the cases in the study group varied between 1 – 11 years. The maximum prevalence of Cardiovascular manifestations in AS occurred in patients with increased duration of the disease. Mean duration of the diease associated with cardiovascular manifestations was found to be 8.36 years. • No significant correlation was found in association with sex, increased number of positive clinical parameters to the occurrence of cardiovascular manifestations in ankylosing spondylitis. • Increase in C-Reactive protein, grading of sacroiliitis by X Ray, cardiac symptoms in AS, Chest X Ray also were not found to be significantly associated with the cardiovascular manifestations. • Three patients had cardiomegaly (6%) in the chest X Ray and those patients had cardiac symptoms like chest pain and breathlessness. • The electrocardiogram revealed significant cardiac conduction abnormalities (10%) and left ventricular hypertrophy(6%) among the cases. Conduction abnormalities were first degree AV block (4%), second degree AV block(2%), left anterior fascicular fascicular block (2%), left bundle branch block (2%) whereas only 2% of control subjects had conduction abnormalities in ECG, left anterior fascicular block. • The echocardiographic abnormalities were found in 12% of the cases which had significant association in patients with AS. Most common abnormality found among AS patients were aortic regurgitation (8%) [Mild – 2%, Moderate – 4%, severe – 2%]. One case had moderate mitral regurgitation (2%) and one another had aortic root dilatation(2%) with 4% aortic regurgitation associated with aortic root dilatation