الفهرس 
Juvenile Idiopathic ArthritisOnly 14 pages are availabe for public view
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Abstract
There is an increased risk of subclinical cardiovascular disorders within patients with juvenile idiopathic arthritis (JIA), despite absence of any suggestive manifestations. This risk was highly suggested through significant changes in E-selectin levels, flow mediated diameter changes, carotid and aortic intima media thickness and echocardiographic changes between patients and healthy control. Oligoarticular JIA patients were at great risk in spite of lack of the systemic manifestations that are commonly present in systemic JIA. Biological therapeutic agents were associated with better estimates of aortic intima media thickness.
Recommendations
1. Cardiovascular risk and atherogenesis should be screened on regular basis for patients with juvenile idiopathic arthritis (JIA) and should be continued into adult life.
2. Achieving good control for JIA patients should be a priority, not only to minimize the physical disabilities, but also to protect against the cardiovascular risks, particularly in patients with frequent relapses.
3. Doppler ultrasonography is a simple, non-invasive technique that could be used to detect subclinical atherosclerosis in JIA through measuring the basal and stimulated flow mediated diameter, carotid and aortic intima media thickness.
4. Regular follow-up for early detection of atherosclerosis in JIA should not be restricted to the patients with systemic manifestations.
5. Further research is needed to define tools for primary or early secondary prevention of atherogenesis in JIA patients.
6. Use of anti-TNF antibodies should be encouraged for pediatric patients with risk factors for cardiovascular disorders, particularly those with minimally controlled illness.
7. Re-establishment of healthy lifestyle, including avoidance of overweight and physical inactivity, in addition to good control of the blood pressure and dietary habits is of great importance for protecting those patients from the future atherogenesis burden.
8. Soluble E-selectin level would be a valuable affordable tool to screen for subclinical cardiovascular illness among pediatric patients with JIA.
Summary
Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease in children before the age of 16 years (Ilisson et al., 2015). Increased cardiovascular risk and impaired indices of sub-clinical atherosclerosis were reported in adult populations with JIA (Vlahos et al., 2011). The autoimmune and inflammatory mechanisms of the disease eventually lead to endothelial dysfunction and atherosclerosis (Evensen et al., 2016). About 50% of JIA patients still have an active disease when they reach adulthood (Ilisson et al., 2015).
In this cross-section with nested follow up study, we have investigated the presence of CVD and early atherogenesis in patients with JIA. The relation between these abnormalities and the disease activity, other systemic manifestations and the different modalities of treatment were studied. The study was conducted on 57 children and adolescents diagnosed as JIA, aged 6 to 16 years old, and 30 matched healthy controls, during the period from September 2021 to September 2022. Patients were enrolled consecutively during activity and remission status of the disease was determined at time of enrollment according to Juvenile Arthritis Disease Activity Score (JADAS)-10, including 26/57 (45.6%) males and 31/57 (54.4%) females. Family history of rheumatological diseases was present among 7% (4/57) of the patients, 5 of them had systemic JIA (SJIA), and the other 2 had polyarticular JIA. None of the patients had family history of cardiovascular disease. As regards anthropometric measurements, 8.7% (5/57) of the patients were short stature, 12.3% (8/87) were obese with BMI ≥95th percentile and 4/57 (7%) had BMI ≤ 5th percentile. SJIA represented 56.1% (32/57) of the patients, 22.8% (13/57) of them had oligoarticular JIA and 21.1% (12/57) had polyarticular JIA. JIA activity was elicited in 32/57 (56.1%) and remission status was estimated among the other 25/57 (43.9%) of patients at time of enrollment.
Patients were subjected to history, physical examination, anthropometric measurements, blood pressure assessment, laboratory investigation including full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lipid profile, Troponin I, and soluble E-selectin, and radiological assessment including duplex evaluation of flow mediated diameter (FMD), ultrasonographic assessment of aortic and carotid intima-media thickness (IMT), and echocardiography.
Serum levels of E-selectin showed higher estimates among JIA patients at time of enrollment than in the healthy control group, also were more elevated in patients with JIA activity than in those in remission. E-selectin levels higher than 342.2 ng/ml could discriminate JIA activity from healthy controls with a sensitivity of 96.9 % and specificity of 93.3 %. E-selectin level >275.1 ng/ml could discriminate JIA remission from healthy controls with a sensitivity of 96.0 % and specificity of 90.0%. No significant difference among the 3 types of JIA. E-selectin serum levels during activity were not correlated to the blood pressure or the FMD. However, they were positively correlated with certain parameters in the echocardiography, specifically right ventricular systolic pressure (RVSP) and left main coronary artery (LMCA). Patients with JIA in remission did not show any correlations between serum levels of E-selectin and the other measured parameters. Serum levels of E-selectin had significantly decreased when active patients achieved remission.
FMD basal value and percentage of change showed no difference between JIA patients and control, and between active and inactive JIA. However, basal and stimulated FMD declined significantly in active SJIA compared to oligoarticular JIA. FMD was not correlated with any of the echocardiographic parameters.
As regards echocardiographic findings, valvular affection was markedly detected among patients with JIA compared to healthy control. Additionally, there was significant decrease in the diameter of the left main coronary artery (LMCA) in the patients than in the healthy control. There were statistically significant higher estimates of aortic IMT in JIA patients in remission than in those in activity and healthy control. Significant changes were observed in the patients with active JIA after they went through remission including decrease in the mitral E/A, right myocardial performance index (MPI) and AIMT. Some echocardiographic parameters were significantly worse in patients with oligoarticular JIA than in the other 2 forms such as fractional shortening (FS), mitral E/A and left MPI that are associated with increased risk of diastolic dysfunction. No differences were found among the 3 types of JIA as regards the echocardiographic findings at time of follow up.