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Received Jul 26, 2017; Revised Oct 27, 2017; Accepted Nov 12, 2017
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1. Introduction
Rheumatoid arthritis (RA) is a chronic progressive disease associated with systemic inflammation that mainly affects synovial joints leading to tissues destruction, disability, and excess of mortality.
RA patients suffer a significantly reduced life expectancy (by 3 to 18 years) with respect to the general population with a standardized mortality ratio ranging from 1.2 to 2.7 [1]. This excess of mortality in RA patients has not changed over the past 20 years [2].
About one-third of premature deaths in RA are due to cardiovascular disease (CVD) [3], primarily coronary heart disease (CHD). Mortality risk for CHD in RA patients has been estimated to be >50% higher than the general population [4]. Moreover, unlike the general population, global CV mortality in RA has not appeared to have fallen over time [5] despite relevant improvements in early diagnosis and treatment.
This excess of CHD is not fully explained by the higher prevalence of traditional CV risk factors (smoking, dyslipidemia, hypertension, and diabetes) in RA patients with respect to the general population [6, 7]. Thus, it is conceivable that other nonconventional risk factors, likely related to systemic inflammatory RA burden, may be involved in chronic vascular atherosclerotic damage ultimately resulting in CHD and global cardiovascular disease. Therefore, there is an urgent need to develop novel CV risk scores encompassing novel risk factors to provide a more reliable estimate of CV risk in RA.
A significant impairment of both the compliance of the central arterial system, termed arterial stiffness, and the endothelial function was frequently reported in the RA population [8, 9].
Endothelial dysfunction (ED), the earliest pathological alteration of the arterial wall in atherosclerosis, is a measure of impaired nitric oxide (NO) synthesis and availability, hence a reduced vasodilatory and atheroprotective function. ED is associated with virtually all known CV risk factors [10] and independently predicts the risk of future CV events in the general population [11]. Therefore, measuring ED should be seen as a valuable tool for CV risk stratification, over and above established...