Increased Cardiovascular Risk in Ankylosing Spondylitis
Yes, patients with ankylosing spondylitis have a significantly increased risk of cardiovascular disease compared to the general population, with cardiovascular and cerebrovascular mortality elevated by approximately 36% overall. 1
Magnitude of the Risk
The cardiovascular disease risk in AS is substantially elevated and clinically significant:
Patients with AS demonstrate a 36% increased risk of cardiovascular and cerebrovascular death (adjusted HR 1.36,95% CI 1.13-1.65), with men showing even higher risk at 46% (HR 1.46,95% CI 1.13-1.87). 2
The standardized mortality ratios in AS range from 1.6 to 1.9, with circulatory disease being one of the main causes of death. 1
AS patients have approximately a two-fold higher prevalence of ischemic heart disease compared to controls. 3
Mechanisms Behind Increased Risk
The elevated cardiovascular risk stems from both traditional risk factors and disease-specific inflammatory processes:
Chronic systemic inflammation in AS directly contributes to accelerated atherosclerosis, independent of traditional cardiovascular risk factors. 1, 4
AS patients demonstrate increased subclinical atherosclerosis, with significantly greater carotid intima-media thickness (0.62 ± 0.09 mm vs 0.57 ± 0.09 mm in controls, p=0.02) even after adjusting for traditional cardiovascular risk factors. 5
Disease activity, number of flares, and duration of flares over time all contribute independently to cardiovascular risk. 1
AS patients have a higher prevalence of traditional cardiovascular risk factors than the general population, compounding their inflammatory risk. 3
Clinical Implications for Management
EULAR guidelines explicitly state that rheumatologists must be aware of and actively manage this increased cardiovascular risk:
Rheumatologists are responsible for ensuring cardiovascular disease risk management is performed in AS patients. 1
Cardiovascular risk assessment should be performed at least once every 5 years and reconsidered following major changes in antirheumatic therapy. 1
Disease activity should be controlled optimally to lower cardiovascular risk, as inflammation is a key modifiable risk factor. 1
AS-Specific Cardiac Manifestations
Beyond atherosclerotic disease, AS patients face additional cardiac complications:
Increased prevalence of cardiac abnormalities including aortic valve dysfunction and conduction disorders, though their precise contribution to overall cardiovascular risk requires further study. 1, 4
These AS-related cardiac manifestations appear to have an etiological link to the underlying inflammatory process. 4
Important Clinical Pitfalls
Common errors in managing cardiovascular risk in AS include:
Failing to recognize that cardiovascular risk management is a core responsibility of the rheumatologist, not just the primary care physician. 1
Underestimating the cardiovascular toxicity of NSAIDs and corticosteroids, which are commonly used in AS but carry cardiovascular risks that must be weighed against their anti-inflammatory benefits. 1
Not performing regular cardiovascular risk assessments every 5 years or after major treatment changes. 1
Inadequate control of disease activity, which independently drives cardiovascular risk through chronic inflammation. 1