Pathology
Males With Rheumatoid Arthritis Often Evidence Carotid Atheromas on Panoramic Imaging: A Risk Indicator of Future Cardiovascular Events

https://doi.org/10.1016/j.joms.2018.01.006Get rights and content

Purpose

Males with rheumatoid arthritis (RA) are at an exceedingly high risk of adverse intraoperative ischemic events, given the role of systemic inflammation in the atherogenic process. We hypothesized that their panoramic images would demonstrate calcified carotid artery atheromas (CCAPs) significantly more often than those from a general population of similarly aged men.

Patients and Methods

We implemented a retrospective observational study. The sample was composed of male patients older than 55 years of age who had undergone panoramic imaging studies. The predictor variable was the diagnosis of RA confirmed by a positive rheumatoid factor (RF) titer, and the outcome variable was the prevalence rate of CCAPs. The other major study variable was the level of RF among the patients evidencing CCAPs. The prevalence of CCAPs among the patients with RA was then compared with that of a historical general population of similarly aged men. Descriptive and bivariate statistics were computed, and the P value was set at .05.

Results

Of the 100 men (mean age 69.89 ± 8.927 years) with RA, 29 (29%; mean age 72.10 ± 7.68 years) had atheromas (CCAP+). Of these 29 men, 25 (86%; mean age 71.88 ± 7.43 years) had a RF titer of ≥41 IU/mL, twice that of normal. A statistically significant (P < .05) association was found between a diagnosis of RA and the presence of an atheroma on the panoramic image compared with the 3% rate found in the historical cohort.

Conclusions

The results of the present study suggest that CCAP, a risk indicator of future adverse cardiovascular events, is frequently seen on panoramic images of male patients with RA and that these individuals routinely manifest high titer levels of RF, a biologic marker of inflammation. Oral and maxillofacial surgeons planning surgery for male patients with RA must be uniquely vigilant for the presence of these lesions.

Section snippets

Study Design and Patient Sample

To address these research questions, we designed and implemented a retrospective observational study. The study was conducted in accordance with the Declaration of Helsinki guidelines. The institutional review board of the Veterans Affairs Greater Los Angeles Healthcare System approved the study protocol, and the need for informed consent from each subject was waived, given the retrospective nature of the project, its use of de-identified patient data, anonymous coding of information with the

Results

A total of 100 male patients (mean age 69.89 ± 8.92 years) with a diagnosis of RA and a confirmatory positive RF titer value (RF >20 IU/mL) were enrolled in our study. Of these, 29 (mean age 72.10 ± 7.68 years) evidenced an atheroma (CCAP+) on their panoramic radiographic image (Fig 1). The images of 4 additional subjects were deemed positive by only 1 of the 2 clinicians and thus were not calculated as positive for CCAP+. This rate was significantly greater (P = .00001) than the 3% evidenced

Discussion

The results of our study demonstrated a very high prevalence rate of calcified atheromas on the panoramic images of patients with RA and its association with very high titers of biologic markers of inflammation. The 29% CCAP+ prevalence rate is almost 10 times greater than that demonstrated among a similarly aged male cohort studied in 1994 in the same oral-maxillary surgery clinic.19 The implication of these findings are striking given that CCAPs seen on panoramic images, a previously

Oral and Maxillofacial Surgery Considerations

The presence of CCAPs on the panoramic images of patients with RA is indicative of immune-mediated major extra-articular comorbidities that can negatively affect the outcomes of ambulatory and in-hospital anesthetic and maxillofacial surgical procedures. The presence of such lesions is indicative of a high risk of MI and stroke, even among individuals not stressed by the surgical environment.20 The persistent systemic inflammation responsible for the development of the atherosclerotic disease

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  • The present report is the result of the work supported with resources from, and the use of facilities at, the Veterans Affairs Greater Los Angeles Healthcare System. Its contents do not represent the views of the US Department of Veterans Affairs or the US Government.

    Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.

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