Image of heart and flare in back to show axial spondyloarthritis
Credit: Tatiana Ayazo

Having inflammatory types of rheumatic disease means that your risk of having a heart attack, stroke, or other serious cardiovascular issue is far higher than average. That’s certainly not great news, but take heart: You have the power to lower your risk and protect your ticker and blood vessels — and it starts with patient education.

In honor of American Heart Month this February, we’re taking a closer look at how axSpA, gout, and lupus affect your heart — and what you can do to keep your heart healthy. You can also check out A Patient’s Guide to Understanding Rheumatoid Arthritis and Heart Disease for more information on this topic.

If you have axial spondyloarthritis (axSpA), you likely know that lowering inflammation is key to controlling your condition. What you might not realize is that doing so might also reduce your risk of heart attack, stroke, and other serious cardiovascular problems.

Although axSpA primarily impacts the lower back and the joints that connect the spine to the pelvis (sacroiliac joints), it may also cause damage elsewhere in the body, including your heart and blood vessels.

Bear in mind that heart disease is the number-one killer of both men and women in the U.S., so almost everyone is at risk for it to some extent. Exactly how much having axSpA further elevates that risk is unclear.

One 2020 study, published in the Journal of Rheumatology, compared the likelihood that axSpA patients would have a serious cardiac event within the next 10 years (as calculated by their ASCVD risk score) and did not find any significant difference between axSpA patients and the general population.

That said, many other studies have suggested that having axSpA is indeed a major risk factor for heart disease. A 2020 study published in Rheumatology determined that people with axSpA had an 80 percent higher odds of developing heart failure than control subjects. Patients with axSpa were also found to have the following, each of which increases the risk of a serious cardiovascular event:

  • Hypertension (22%)
  • High cholesterol (17%)
  • A body mass index (BMI) in the obese category (14%)

The increased risk of heart disease seems to affect people with both radiographic axSpA (also called ankylosing spondylitis) and non-radiographic axSpA. (Both conditions cause similar symptoms and disease burden, but the difference is that  people with non-radiographic axSpA don’t show visible damage to their joints on X-rays.)

A large study from Spain found that a similar percent of people with non-radiographic axSpA and radiographic axSpA were in the “very high risk” category for cardiovascular disease.

Why Axial Spondyloarthritis Might Harm Your Heart

While not everyone with axSpA faces an equal risk of cardiovascular disease, most rheumatologists believe that having any type of inflammatory arthritis likely increases the risk to a certain extent.

“The literature has strongly showed that inflammatory types of rheumatic disease — such as lupus, rheumatoid arthritis, ankylosing spondylitis or axial spondyloarthritis, psoriatic arthritis, and gout — increase the risk of cardiovascular disease,” says rheumatologist Theodore R. Fields, MD, Professor of Clinical Medicine at Weill-Cornell Medical College.

Here’s why — and what you can do to stay healthy.

Inflammation

When it comes to connecting the dots between rheumatic disease and cardiovascular disease, inflammation tops the list. That’s because the same underlying inflammation that causes axSpA has the potential to also cause inflammation in your blood vessels. Atherosclerosis, a buildup of fatty plaque on artery walls, “seems to form more easily in the setting of inflammation,” says Dr. Fields.

Inflammation also makes any plaque you already have in your arteries more apt to break off, form a clot, and travel toward your brain (where it can cause a stroke) or your heart (where it can cause a heart attack).

Of course, not everyone with axSpA has the same level of inflammation in their body. As part of assessing your disease activity, your doctor may periodically run blood tests that measure C-reactive protein (CRP), interleukin-6 (IL-6), and homocysteine. These are inflammatory markers that, when elevated, provide clues about how well-controlled your axSpA is.

If your disease activity is high, your doctor may suggest adjusting your medication regimen to lower it. That move, in turn, is likely to also reduce your risk of cardiovascular disease, though not every medication used to treat axSpA will have the same benefit on your heart health. (More on this below.)

“What is likely, though not completely understood, is that good care of your autoimmune disease may help, so keep those appointments and make sure things are tuned up,” says Joshua F. Baker, MD, Associate Professor of Rheumatology and Epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center.

In addition to ordering blood tests that check for inflammation, your rheumatologist should be keeping close tabs on your overall heart health or refer you to a cardiologist for this purpose. Researchers writing in Expert Opinion on Biological Therapy advise that such monitoring includes:

Overlapping Risk Factors

Research has found that people with axSpA often have a number of comorbid conditions like high blood pressure, high cholesterol, obesity, and diabetes. Meanwhile, international international research has found that an average of 29 percent of people with axSpA are smokers.

Combining any of the above factors with the underlying inflammation from axSpA likely magnifies the danger. On a more positive note, traditional risk factors (aside from a family history of heart disease) are often controllable. That means if you’re a smoker who quits or you’re overweight and lose 20 pounds, you’ll improve your heart health.

At the same time, making healthy changes that benefit your heart might benefit the trajectory of your inflammatory arthritis. Last year, research published in Therapeutic Advances in Musculoskeletal Disease found that axSpA patients who had at least one traditional heart disease risk factor were more apt to have high axSpA disease activity. Those who did not have any tended to have lower axSpA disease activity.

“The first thing to do to protect yourself [from cardiovascular disease] is to take up healthy lifestyle behaviors like healthy eating — the Mediterranean diet is one option — regular exercise, quitting smoking, and limiting alcohol use,” says Dr. Baker.

Of course, making lifestyle changes isn’t always easy, adds Dr. Fields. “It is a challenge to get to ideal weight, and it may be harder to a patient with arthritis or disease-related fatigue to exercise,” he says. “Changing your diet to improve cholesterol or triglycerides can be hard. Getting into an aerobic exercise program when you have arthritis and fatigue can likewise be difficult.  But, for people with inflammatory arthritis, the effort to address modifiable risk factors is well-worth the challenge.”

Medication Side Effects

Non-steroidal anti-inflammatory drugs (NSAIDs) — which include over-the-counter options like naproxen (Aleve) as well as prescription ones like celecoxib (Celebrex) and diclofenac (Voltaren oral tablets) — are often the first line of treatment for axSpA. These drugs relieve pain and inflammation, but they don’t treat the underlying immune system overactivity. Also problematic: They’ve been linked to an increased risk of major cardiovascular events, at least among members of the general population.

While it might seem like telling someone with axSpA to avoid NSAIDs is the way to go, it’s not that clear-cut. Some studies have actually found that axSpA patients who avoid or limit NSAIDs are more likely than those who regularly use these drugs to die from cardiovascular disease. It’s possible that, in people who start with abnormally high levels of inflammation, taking NSAIDs is actually protective because these medications lower inflammation.

Biologic drugs, especially tumor necrosis factor inhibitors (TNFis), are another story. “Biologic medications may reduce systemic inflammation and help with cardiac risk,” says Dr. Fields. Studies have suggested that TNFis might help by slowing down the accumulation of arterial plaque as well as stabilizing it (so it’s less likely to break off and form a clot).  Drugs in this class include etanercept (Enbrel) and adalimumab (Humira).

Not as much is known about how IL-17 biologics, like secukinumab (Cosentyx) and ixekizumab (Taltz), influence cardiovascular risk, though at least one study found that these drugs might be harmful to the walls of the arteries and damage heart cells. However, other studies have found no increased risk of major cardiovascular events for inflammatory arthritis patients (including those with axSpA).

Only one Janus kinase (JAK) inhibitor, tofacitinib (Xeljanz) is currently FDA-approved for use in axSpA, but upadactinib (Rinvoq) might soon follow. These oral drugs work well for some people with inflammatory arthritis, but the entire class also carries a boxed warning that it has been associated with “an increased risk of serious heart-related events such as heart attack or stroke, cancer, blood clots, and death.” Read more about what inflammatory arthritis patients need to know about JAK inhibitors and FDA safety warnings.

Of course, when choosing a treatment for your axSpA, cardiovascular disease risk is only one part of the equation, and finding an option that keeps your axSpA disease activity low is also crucial. But when you talk to your rheumatologist about the pros and cons of various options, it’s also wise to keep your personal level of cardiovascular risk in mind.

In a 2021 mini review article, published in Frontiers in Medicine, French rheumatologist Eric Toussirot, MD, PhD, concludes that an elevated risk of cardiovascular disease “is a reality for patients with axSpA and must be adequately evaluated.”

While treatment of axSpA — especially with a TNFi — may help keep your heart healthy, he explains that more research is needed in this area. “Overall, [cardiovascular] risk detection and management is an important aspect for patients with axSpA that deserves specific attention from physicians.”

The bottom line: There’s no better time than now to take your heart health into your own hands. Talk to your health care provider about your personal risk factors, medications, and lifestyle changes you can make to reduce your risk of heart disease.

Atzeni F, et al. Cardiovascular risk in ankylosing spondylitis and the effect of anti-TNF drugs: a narrative review. Expert Opinion on Biological Therapy. 2020. doi: https://doi.org/10.1080/14712598.2020.1704727.

Cision PR Newswire. AbbVie Submits Applications for Upadacitinib (RINVOQ®) in Non-Radiographic Axial Spondyloarthritis to U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA). https://www.prnewswire.com/news-releases/abbvie-submits-applications-for-upadacitinib-rinvoq-in-non-radiographic-axial-spondyloarthritis-to-us-food-and-drug-administration-fda-and-european-medicines-agency-ema-301455900.html

Genovese MC, et al. Safety of ixekizumab in adult patients with plaque psoriasis, psoriatic arthritis and axial spondyloarthritis: data from 21 clinical trials. Rheumatology. December 2020. doi: https://doi.org/10.1093/rheumatology/keaa189.

González Mazón I, et al. Subclinical atherosclerotic disease in ankylosing spondylitis and non-radiographic axial spondyloarthritis. A multicenter study on 806 patients. Seminars in Arthritis and Rheumatism. April 202. doi: https://doi.org/10.1016/j.semarthrit.2021.02.003.

Interview with Joshua F. Baker, MD, associate professor of rheumatology and epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center.

Interview with Theodore R. Fields, MD, rheumatologist and professor of clinical medicine at Weill-Cornell Medical College.

Liew JW, et al. Cardiovascular risk scores in axial spondyloarthritis versus the general population: a cross-sectional study. The Journal of Rheumatology. July 2021. doi: https://doi.org/10.3899/jrheum.200188.

Moltó A, et al. Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Annals of the Rheumatic Diseases. 2016. doi: https://ard.bmj.com/content/75/6/1016.

Robert M, et al. Effects of Interleukin 17 on the cardiovascular system. Autoimmunity Reviews. September 2017. doi: https://doi.org/10.1016/j.autrev.2017.07.009.

Toussirot E. The risk of cardiovascular diseases in axial spondyloarthritis. Current insights. Frontiers in Medicine. November 2021. doi: https://doi.org/10.3389/fmed.2021.782150.

van Sijl AM, et al. Tumour necrosis factor blocking agents and progression of subclinical atherosclerosis in patients with ankylosing spondylitis. Annals of the Rheumatic Diseases. 2015. https://ard.bmj.com/content/74/1/119.info.

Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. The Lancet. May 2013. doi: https://doi.org/10.1016/S0140-6736(13)60900-9.

Zhao SS, et al. Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis. Rheumatology. October 2020. doi: https://doi.org/10.1093/rheumatology/keaa246.