by Dr. David Borenstein M.D. updated 7/2020

Is Premature Atherosclerosis Associated with Ankylosing Spondylitis (AS)?

Atherosclerosis (ASCVD) or hardening of the arteries is associated with angina, heart attacks and strokes. These cardiovascular diseases occur most frequently as individuals age into their 50’s and 60’s. Some individuals develop ASCVD at an earlier age. These individuals have premature (<55 years for males and <65 years for females) or extremely premature (<40 years of age) ASCVD. Complicating co-morbidities that predispose to ASCVD include diabetes, hypertension, obesity, and smoking to name a few. A question that remains is that of the predisposition of rheumatic disease patients to premature, and extremely premature ASCVD.

A study was completed through the Veteran’s Administration Health system investigating the association of rheumatic diseases with the development of ASCVD. Systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis were the illnesses studied. A total of 1,248,158 with ASCVD and 3,317,720 without ASCVD over 18 years of age in the VA system were the included study subjects. ASCVD was a history of angina, an ischemic stroke, or peripheral vascular disease. Cohorts of patients were separated by age – 40 or younger, men <55 and women <65 years of age. The number of SLE, RA, AS and PSA patients were determined in each group.

The premature ASCVD group included 135,703 individuals with and 1,153,535 of the same age without an event. In general, a higher proportion of Caucasians, African-Americans, and a lower proportion of women and Asians had premature ASCVD. A higher prevalence of diabetes, chronic kidney disease, and smoking was noted in the premature ASCVD group. As compared to young patients without ASCVD, SLE (70%), and RA (72%) individuals had a higher likelihood of having premature ASCVD. Patients with AS had no increase association with premature ASCVD while PSA had less than a 10% association, which is not significant.

The extremely premature ASCVD group included 7,716 individuals with and 441,836 of the same age without an event. In general, a higher proportion of African-Americans, and a lower proportion of Caucasians, women and Asians had extremely premature ASCVD. As compared to young patients without ASCVD, SLE (300%), and RA (240%) individuals had a higher likelihood of having extremely premature ASCVD. AS Patients had no significant increase in extremely premature ASCVD with less than 40% association, while PSA patients had no association.

Patients with illnesses that cause chronic inflammation that puts stress on the interior of blood vessels (endothelial damage) are at increased risk of damage. The inflammation may result in arterial stiffness and destabilization of the fatty deposits (plaques) in vessel walls. When these plaques are dislodged, heart attacks or strokes are possible.

Although AS and PSA are rheumatic disorders, they may not be inflammatory to blood vessels as RA or SLE. Also in this study, the number of PSA and as patients were fewer which may have decreased the opportunity to measure an increased risk in a larger population

Other factors like obesity, diabetes, and smoking add to the risk associated with rheumatic diseases. Limiting these other factors, as well as the control of the inflammation associated with SLE and RA would theoretically decrease the risk of stroke or heart attack in younger individuals.


  1. Mahtta D et al. Autoimmune rheumatic diseases and premature atherosclerotic cardiovascular disease: An analysis from the VITAL (Veterans wIth premaTure AtheroscLerosis) registry. Am J Med

David Borenstein, MD
Executive Editor