Turkiye Klinikleri Journal of Pediatrics

.: ORIGINAL RESEARCH
Risk Factors to Pre-Clinical Atherosclerosis Evaluated by Carotid Intima-Media Thickness in Juvenile Idiopathic Arthritis: Descriptive Research
Juvenil İdiyopatik Artiritte Karotis İntima Media Kalınlığı ve Preklinik Ateroskleroz için Risk Faktörleri: Tanımlayıcı Araştırma
Mustafa ARMUTa, Ruhan DÜŞÜNSELb, Ayşenur PAÇ KISAARSLANb, Gonca KOÇc, Betül SÖZERİb, Ferhan ELMALId
aDepartment of Child Health and Diseases, Erciyes University Faculty of Medicine, Kayseri, Türkiye
bDivision of Pediatric Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Türkiye
cDivision of Pediatric Radiology, Erciyes University Faculty of Medicine, Kayseri, Türkiye
dDepartment of Biostatistics, Erciyes University Faculty of Medicine, Kayseri, Türkiye
Turkiye Klinikleri J Pediatr. 2023;32(1):26-35
doi: 10.5336/pediatr.2022-91466
Article Language: EN
Full Text
ABSTRACT
 Objective: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood. Cardiovascular morbidity and mortality are becoming important health problems for children with inflammatory rheumatic diseases. The aim of this study was to evaluate carotid intima-media thickness (CIMT) in children with JIA and to examine its association with JIA subtype, markers of inflammation, and early atherosclerosis. Material and Methods: We included 112 (50 boys and 62 girls) patients who have been followed by a diagnosis of JIA for at least 6 months and 54 healthy control subjects (32 girls and 22 males) who were matched with the patients age and gender. All children underwent a carotid artery. Inflammation markers were evaluated in the patient group. Cumulative drug doses, total disease duration (TDD), active disease duration (ADD) were calculated. All CIMT values were compared in patients, subgroups, and control groups, and their relationship with inflammation markers was investigated. Results: CIMT values in found that children with JIA were significantly higher than in healthy children. There was no difference between the disease subgroups in terms of CIMT. No relationship was found between CIMT measurements and atherosclerosis risk factors, drugs, erythrocyte sedimentation rate, white blood cell and C-reactive protein. A negative correlation was found between mean platelet volume (MPV) and right CIMT. A statistically significant positive correlation was detected between the right CIMT and TDD (r=0.221, p=0.022), and ADD (r=0.248, p=0.010). Conclusion: The study showed that the patients with JIA had more risks than healthy controls for cardiovascular disease (CVD) regardless of subgroup. We concluded early and aggressive therapies may be protective for CVD. Negative correlation was found between MPV and CIMT that is consistent with recently published literature, but there is need for further studies with a larger patient population.

Keywords: Mean platelet volume; carotid intima-media thickness; juvenile idiopathic arthritis; atherosclerosis
ÖZET
 Amaç: Juvenil idiyopatik artrit [juvenile idiopathic arthritis (JIA)] çocukluk çağının en sık görülen kronik romatizmal hastalığıdır. Kardiyovasküler morbidite ve mortalite inflamatuar romatizmal hastalıkları olan çocuklar için önemli sağlık sorunları hâline gelmektedir. Bu çalışmanın amacı, JIA'lı çocuklarda karotis intima-media kalınlığını (KİMK) değerlendirmek ve JIA alt tipi, inflamasyon belirteçleri ve erken ateroskleroz ile ilişkisini incelemektir. Gereç ve Yöntemler: Çalışmaya en az 6 aydır JIA tanısı ile takip edilen 112 (62 kız, 50 erkek) hasta ile yaş ve cinsiyet açısından hasta gruplarına benzer 54 (32 kız, 22 erkek) çocuk sağlıklı kontrol grubu olarak alındı. Tüm çocuklara, karotis arter ultrasonografi yapıldı, inflamasyon belirteçlerine bakıldı. İlaç kümülatif dozları, aktif hastalık süreleri [active disease duration (ADD)], toplam hastalık süreleri [total disease duration (TDD)] hesaplandı. Tüm KİMK değerleri hastalar, alt gruplar ve kontrol grubunda karşılaştırıldı ve inflamasyon belirteçleri ile ilişkisi araştırıldı. Bulgular: JIA'lı çocuklarda KİMK değerleri sağlıklı çocuklardan anlamlı yüksek saptandı. JIA alt grupları arasında KİMK değerleri açısından fark saptanmadı. Ateroskleroz risk faktörleri, ilaçlar, eritrosit sedimantasyon hızı, beyaz küre sayısı ve C-reaktif protein ile KİMK değerleri arasında ilişki saptanmadı. Ortalama trombosit hacmi (OTH) ile sağ KİMK arasında negatif korelasyon bulundu. Sağ KİMK ile TDD (r=0,221, p=0,022) ve ADD (r=0,248, p=0,010) arasında istatistiksel olarak anlamlı pozitif korelasyon saptandı. Sonuç: Çalışmamızda, alt gruptan bağımsız olarak JIA'lı hastaların kardiyovasküler hastalık (KVH) açısından sağlıklı kontrollere göre daha fazla risk taşıdığını gösterdik. Erken ve agresif tedavilerin KVH için koruyucu olabileceği sonucuna vardık. OTH ve KİMK arasında yakın zamanda yayımlanmış literatürle uyumlu negatif korelasyon bulundu ancak daha geniş hasta popülasyonu ile daha ileri çalışmalara ihtiyaç vardır.

Anahtar Kelimeler: Ortalama trombosit hacmi; karotis intima-media kalınlığı; juvenil idiyopatik artrit; ateroskleroz
REFERENCES:
  1. Napoli C, D'Armiento FP, Mancini FP, Postiglione A, Witztum JL, Palumbo G, et al. Fatty streak formation occurs in human fetal aortas and is greatly enhanced by maternal hypercholesterolemia. Intimal accumulation of low density lipoprotein and its oxidation precede monocyte recruitment into early atherosclerotic lesions. J Clin Invest. 1997;100(11):2680-90. [Crossref]  [PubMed]  [PMC] 
  2. Saydah S, Bullard KM, Imperatore G, Geiss L, Gregg EW. Cardiometabolic risk factors among US adolescents and young adults and risk of early mortality. Pediatrics. 2013;131(3):e679-86. [Crossref]  [PubMed]  [PMC] 
  3. Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, et al; American Heart Association Expert Panel on Population and Prevention Science; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Nutrition, Physical Activity and Metabolism; American Heart Association Council on High Blood Pressure Research; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on the Kidney in Heart Disease; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2006;114(24):2710-38. [Crossref]  [PubMed] 
  4. Roifman I, Beck PL, Anderson TJ, Eisenberg MJ, Genest J. Chronic inflammatory diseases and cardiovascular risk: a systematic review. Can J Cardiol. 2011;27(2):174-82. [Crossref]  [PubMed] 
  5. Petty RE, Cassidy JT, Laxer RM, Lindsley CB. Chronicarthritis. In: Cassidy J, Petty R, Laxer R, Lindsley C, eds. Textbook of Pediatric Rheumatology. 6th ed. Philadelphia: Saunders; 2011. p.211-35. [Crossref] 
  6. Jednacz E, Rutkowska-Sak L. Atherosclerosis in juvenile idiopathic arthritis. Mediators Inflamm. 2012;2012:714732. [Crossref]  [PubMed]  [PMC] 
  7. McGill HC Jr, McMahan CA, Herderick EE, Malcom GT, Tracy RE, Strong JP. Origin of atherosclerosis in childhood and adolescence. Am J Clin Nutr. 2000;72(5 Suppl):1307S-15S. [Crossref]  [PubMed] 
  8. Urbina EM, Williams RV, Alpert BS, Collins RT, Daniels SR, Hayman L, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young. Noninvasive assessment of subclinical atherosclerosis in children and adolescents: recommendations for standard assessment for clinical research: a scientific statement from the American Heart Association. Hypertension. 2009;54(5):919-50. Erratum in: Hypertension. 2010;56(3):e36. [Crossref]  [PubMed] 
  9. Bohr AH, Fuhlbrigge RC, Pedersen FK, de Ferranti SD, Müller K. Premature subclinical atherosclerosis in children and young adults with juvenile idiopathic arthritis. A review considering preventive measures. Pediatr Rheumatol Online J. 2016;14(1):3. [Crossref]  [PubMed]  [PMC] 
  10. Fathi R, Marwick TH. Noninvasive tests of vascular function and structure: why and how to perform them. Am Heart J. 2001;141(5):694-703. [Crossref]  [PubMed] 
  11. Wallace CA, Ruperto N, Giannini E; Childhood Arthritis and Rheumatology Research Alliance; Pediatric Rheumatology International Trials Organization; Pediatric Rheumatology Collaborative Study Group. Preliminary criteria for clinical remission for select categories of juvenile idiopathic arthritis. J Rheumatol. 2004;31(11):2290-4. [PubMed] 
  12. Järvisalo MJ, Jartti L, Näntö-Salonen K, Irjala K, Rönnemaa T, Hartiala JJ, et al. Increased aortic intima-media thickness: a marker of preclinical atherosclerosis in high-risk children. Circulation. 2001;104(24):2943-7. [Crossref]  [PubMed] 
  13. Coll B, Feinstein SB. Carotid intima-media thickness measurements: techniques and clinical relevance. Curr Atheroscler Rep. 2008;10(5):444-50. [Crossref]  [PubMed] 
  14. Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med. 1999;340(2):115-26. [Crossref]  [PubMed] 
  15. Pietrewicz E, Urban M. Wczesne zmiany miazdzycowe u dzieci chorych na młodzieńcze idiopatyczne zapalenie stawów [Early atherosclerosis changes in children with juvenile idiopathic arthritis]. Pol Merkur Lekarski. 2007;22(129):211-4. Polish. [PubMed] 
  16. Głowińska-Olszewska B, Bossowski A, Dobreńko E, Hryniewicz A, Konstantynowicz J, Milewski R, et al. Subclinical cardiovascular system changes in obese patients with juvenile idiopathic arthritis. Mediators Inflamm. 2013;2013:436702. [Crossref]  [PubMed]  [PMC] 
  17. Breda L, Di Marzio D, Giannini C, Gaspari S, Nozzi M, Scarinci A, et al. Relationship between inflammatory markers, oxidant-antioxidant status and intima-media thickness in prepubertal children with juvenile idiopathic arthritis. Clin Res Cardiol. 2013;102(1):63-71. [Crossref]  [PubMed] 
  18. Ilisson J, Zagura M, Zilmer K, Salum E, Heilman K, Piir A, et al. Increased carotid artery intima-media thickness and myeloperoxidase level in children with newly diagnosed juvenile idiopathic arthritis. Arthritis Res Ther. 2015;17(1):180. [Crossref]  [PubMed]  [PMC] 
  19. Vlahos AP, Theocharis P, Bechlioulis A, Naka KK, Vakalis K, Papamichael ND, et al. Changes in vascular function and structure in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2011;63(12):1736-44. [Crossref]  [PubMed] 
  20. Satija M, Yadav TP, Sachdev N, Chhabra A, Jahan A, Dewan V. Endothelial function, arterial wall mechanics and intima media thickness in juvenile idiopathic arthritis. Clin Exp Rheumatol. 2014;32(3):432-9. [PubMed] 
  21. Pertovaara M, Kähönen M, Juonala M, Laitinen T, Taittonen L, Lehtimäki T, et al. Autoimmunity and atherosclerosis: the presence of antinuclear antibodies is associated with decreased carotid elasticity in young women. The Cardiovascular Risk in Young Finns Study. Rheumatology (Oxford). 2009;48(12):1553-6. [Crossref]  [PubMed] 
  22. Skare TL, Verceze GC, Oliveira AA, Perreto S. Carotid intima-media thickness in spondyloarthritis patients. Sao Paulo Med J. 2013;131(2):100-5. [Crossref]  [PubMed] 
  23. Jednacz E, Rutkowska-Sak L. Assessment of the body composition and parameters of the cardiovascular risk in juvenile idiopathic arthritis. Biomed Res Int. 2015;2015:619023. [Crossref]  [PubMed]  [PMC] 
  24. Sozeri B, Atikan BY, Ozdemir K, Mir S. Assessment of vascular function in systemic onset juvenile idiopathic arthritis. Clin Rheumatol. 2016;35(7):1699-703. [Crossref]  [PubMed] 
  25. Doyon A, Kracht D, Bayazit AK, Deveci M, Duzova A, Krmar RT, et al; 4C Study Consortium. Carotid artery intima-media thickness and distensibility in children and adolescents: reference values and role of body dimensions. Hypertension. 2013;62(3):550-6. [Crossref]  [PubMed] 
  26. Willeit P, Thompson SG, Agewall S, Bergström G, Bickel H, Catapano AL, et al; PROG-IMT study group. Inflammatory markers and extent and progression of early atherosclerosis: Meta-analysis of individual-participant-data from 20 prospective studies of the PROG-IMT collaboration. Eur J Prev Cardiol. 2016;23(2):194-205. [Crossref]  [PubMed]  [PMC] 
  27. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO 3rd, Criqui M, et al; Centers for Disease Control and Prevention; American Heart Association. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003;107(3):499-511. [Crossref]  [PubMed] 
  28. Goodson NJ, Symmons DP, Scott DG, Bunn D, Lunt M, Silman AJ. Baseline levels of C-reactive protein and prediction of death from cardiovascular disease in patients with inflammatory polyarthritis: a ten-year followup study of a primary care-based inception cohort. Arthritis Rheum. 2005;52(8):2293-9. [Crossref]  [PubMed] 
  29. Thompson CB, Jakubowski JA. The pathophysiology and clinical relevance of platelet heterogeneity. Blood. 1988;72(1):1-8. [Crossref]  [PubMed] 
  30. Sansanayudh N, Numthavaj P, Muntham D, Yamwong S, McEvoy M, Attia J, et al. Prognostic effect of mean platelet volume in patients with coronary artery disease. A systematic review and meta-analysis. Thromb Haemost. 2015;114(6):1299-309. [Crossref]  [PubMed] 
  31. Makay B, Türkyilmaz Z, Unsal E. Mean platelet volume in children with familial Mediterranean fever. Clin Rheumatol. 2009;28(8):975-8. [Crossref]  [PubMed] 
  32. Özer S, Yılmaz R, Sönmezgöz E, Karaaslan E, Taşkın S, Bütün İ, et al. Simple markers for subclinical inflammation in patients with Familial Mediterranean Fever. Med Sci Monit. 2015;21:298-303. [Crossref]  [PubMed]  [PMC] 
  33. Gasparyan AY, Ayvazyan L, Mikhailidis DP, Kitas GD. Mean platelet volume: a link between thrombosis and inflammation? Curr Pharm Des. 2011;17(1):47-58. [Crossref]  [PubMed] 
  34. Schanberg LE, Sandborg C, Barnhart HX, Ardoin SP, Yow E, Evans GW, et al; Atherosclerosis Prevention in Pediatric Lupus Erythematosus Investigators. Premature atherosclerosis in pediatric systemic lupus erythematosus: risk factors for increased carotid intima-media thickness in the atherosclerosis prevention in pediatric lupus erythematosus cohort. Arthritis Rheum. 2009;60(5):1496-507. [Crossref]  [PubMed]  [PMC] 
  35. Berezhny VV, Marushko YY. Condition of artery wall and endothelium function in children with juvenile rheumatoid arthritis. [Link] 
  36. Del Giudice E, Dilillo A, Tromba L, La Torre G, Blasi S, Conti F, et al. Aortic, carotid intima-media thickness and flow- mediated dilation as markers of early atherosclerosis in a cohort of pediatric patients with rheumatic diseases. Clin Rheumatol. 2018;37(6):1675-82. [Crossref]  [PubMed] 

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-To send press releases or notifications through e-mail

-To generate a list for an event or competition

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-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

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