Document 8466

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croBepHbrrv(Ho BecbMayMepeHHbtM)Hapacra- cHrxaercfl no Mepe yBenilqeHnn Jl.J|.nrenbHocril npileMa l-KC (c 1,7 B reqeHile nepeutx 45
HileM qacrorbr ernx ocroxHeHrfr.
TaK, no .4aHHbrMo.qHoro perpocneKTvtBHo- trueil, Ao 1 ,1 nocre 90 nHefr) [33]. Sonee ror-o,
ilMelorcc AaHHbteo roM, qro npil PA paeemrre
r-o hccreAoBaHnF y naLlileHToB,noflyqaBunx
pe3NcTeHTHOCrTlK l4HcyfirHy Koppeflilpyer c
rrr6ynpoQeH N allervncanvu]/'noByto Kl{crory,
tracrora ceprneqHo-cocypl4crbtxocnoxneHult
aKTilBHocrbroBocna neHtt+ 1341,a npormBoBoccyulecTBeHHoBbrue, qeM B rpynne, nonyqaB- nafl ilTerbHaF Tepanrfl , BKJlloqaFmoKoKopTLlqyBCTnpilBOA14T
K BOCCTaHOBTeHnlo
Kmcnory KOl4.4HylO,
uefi ToflbKo aqerilncanhllnnoByto
( O P = ' l, 7 3 ) , e r o B p e M nK a K n p n e M g m < n o Q e H a r a BilrenbHocrl4 K rzrHcynnHy
[35].
EasucHac repanrn (EflBT)
v trpyrwx H nBn (e coreraHm c aqerilaca nvLIATar KaK cilcreMHoe BocnafleHile npil PA
roeofi rncnoroil) ne accot-ll/l4poBanocbc yBenilqeH ileM cepger{Ho-cocygvtcroro phcKa 1271. yBenilqrBaer tracToTy cepAeqHo-cocyAl/cTblx
ocroxHeHril, e$QeKTrBHoe re..teHhe Moxel
AHanrs pe3ynbraroe S-nerHero AeoftHoro cnenoro nfl aqe6o-rourponil pyeMoFo t4ccflerqoBa- HaBepHoe, cHt4Strb pl4cK cep.qellHo-cocyAl4crblx sa6oneea nuhi. I.:eirtcrBnrerbHo, HeKoroHrzrn
Physician's Health Study (e rccnegoBaHile
pbre ilccneAoBaHhF noATBepxAaor ery FilnoBoLurl14
2207 1 egopoeutfr MyxttrHa, npoQnnarTnqecKvl n pil HLrMaBu-tr il aqervncanwL\vtno Byto re3y.
npneM
rrlcnory) noKa3afl, qro glnreluHutfi
"3onorsrv craHAaproM) B netleHiln PA e HacHnBn (>60.qHef ) accoqrmpyercn c yBenilLte- Tonulee BpeMe FBflnercn MerorpeKcar. BnuqHrlo MerorpeKcara Ha cepAeLlHo-cocyAl4cryto
MiloKapAa(OP=2,86), a
HneM prcKa rrrHQapKra
154
cMeprHocrb nph PA 6urno nocBFUJeHoHecKor bKo h HTepecHbrx r/ccneAoaauuil.
l-pynnofi yLleHblx Ns CUIA 6utno npoBeAeHo 18-nerHee Ha6npAeune 1240 naLlreHroB
c PA, 588 hs Hrlx npilHnuanv MerorpeKcar. B
eroil rpynne cepAeqHo-cocygilcraq cMeprHocrb yMeHblxlrflacb ua 70 o/o.flpuet't Apyrilx
6agucuurx npenaparoB He Bnvnr Ha ypoBeHb
cepAeq Ho-cocygr4croil cvreprHocrll y naumeHroB c PA. Aaropbr TrccnegoBaHtAflnpegrtarator
Bsqrb ypoBeHb cepgeqHo-cocyAl4crofi cMeprHOCT].4
npr npileMe MeTOTpeKCaTa3a eTafloH
noKa3arenqnpil npileAn9 CpaBHeHhflAaHHOTO
Me Apyrilx npenaparoe[36].
Krause D r coaer. npoBefiil perpocneKrttBHoe Ha6nloAeHme,BKrloLraB[uee256 nallneHroB c rfl)KerbrM PA. B nepiloA c 1980 no 1987
erofi rpynne 6urn Ha3HaqeH MerorpeKcar, B
cBn3tAc orcyrcrBneM eQQe<ra or npoBoAt4vofi paHee repanrr ApyrilMr 5l-lBl-1.flaqneHrbl 6unv pa3AeneHu na4 rpynnbt no orBery
Ha repanno MerorpeKcaroM, roroputfr oqeHilBancn qepe3 Fo.qnocne HaLrarane.{eF{ilq:1-c
r p y n n a y f i y q l x e H h e6 o n e e q e M H a 5 0 o / o , 2 - n ynyqueHile Ha 20-5Oo/o,3-n - Her yflytlrueHilF,
4 - n - n e q e H i l e n p e K p a u l e H o .f l o c n e 7 . 5 - 1 5 . 3
ner (e cpeAHeM 10 rer) npileMa npenapara
oueHilBanN cepAeqHo-cocyAl/cryro cMeprHocrb B rpynnax. Y naqreHToB c rnxenutu PA,
KOTOpbre
He orBerilnt Ha fieqeHre MeroTpeKcaroM (3-n rpynna), 6urno orMetleHo yBenrLteHile cMeprHocrl4 6onee qeM B 4 pasa no cpaBH e H i l o c o 6 u l n v H a c e a e H r e v r .A y n a l l r e H r o B c
PA, roropbre orBeril ntAHa neLreHhe(naqreHrut
1-oh u 2-oh rpynn)- yeenrqeHile cMeprHocrn
3HaqilTefibHoHLrxe (craH4april3oBaHHoe orHoueHhe neraflbHocrm(SMR) a 1-ofi rpynne
6 u r r o 1 , 4 7 , e o 2 - o h 1. 8 5 , e 3 - e f r - 4 . 1 1 , e 4 - o i a
- 5.56)[37].
OgHaro, cornacHo AaHHbrxLandewe RB, van
den Borne BE il coaer., MerorpeKcar yBenvqtABaer ypoBeHb roMoril4crevHa (Hesaercnvstil
Qarrop cepAeqHo-cocyAr/croro pLlcra ), roropuril cBH3aHc yBenilqeHHbrMpncKoM cMeprHocru y 6onuHurx c cyuecrByroull4M paHee
arepocKnepo3oM. [1o gaHHstMBCe rex xe aBTopoB Qonreean Kilcnora AononHilTenbHonpLl
neqeHilh MeroTpeKcaroM Moxer yMeHbuarb
ypoBeHb roMoql4cr enHa, xorfl l43onr poeaHuutfr
A R S M E D I C AN S s( 1 5 )
eQQe<r Qonueeofr Kilcrorbr Ha cepgeqHo-cocyAl/cryro narofi orillo He il3BecreH [38].
,l,ocrarovHo r.r14poKonpnMeHcorcn ceroAHn
rpynnbr npenaparoB, o6regrHnou-lrlxcq o6ulhM TepMLlHoM - "6uonorilqecKile>) areHTbl
nnu 6uonoFhqecKile voAnQrKaropbt l/MMyHHoro orBera ("bioloeics,). lAx ornw\tATerbHac
oco6eHHocrb - cefleKTNBHoeBnilFHne Ha Hav6onee Ba)KHbre3BeHbn LrMMyHonaroFeHe3a
BocnanilTerbHbrx 6oaegHefi, npn MrHilMafibHofi rurepQepeHuvtvt c HopManbHbrMrlMexavTMMyHHOTO
HL43MaMil
OTBera.
lzlveorcn .qaHHbteo roM, ttro y naureHToB
c rnxenbrrvr PA na QoHe neqeHilF ttnflnu<cnva6ov na6nroAaercn AocroBepHoe ynyqueHre eHAorenvr(AsaencutvtoiA Ba3oAt4flarawv
(vraprep paHHero arepocKrepoea), Koppenilpyroulee co cHLr)KeHreM BocnaflnrenuHoil
aKrnBHocrm 6onegHr [39]. cDHO-anuQa paccMarphBaercn He rorbKo KaK BaxHbtfr tvegnaTop BocnaneHne npm PA, Ho 14 cocy4ncroro
BocnaneHVA npv PA r arepocKfieport4qecKoM
nopaxeHLlr4cocyAoB 140,411.
Crarunur
lz1MelorccAaHHbre,qro HapffAy c rtAnonvnv4eMntrecKnMcrarilHbr o6naAaor n nport4BoBocnanilrenbHurv eQQeKroM.
HeAaeFrorpynnofi yqeHbrxKanda H, Hamasaki K, Kubo K, et al. 6urno h3yqeHaeQQerrmaHocrb cl4MBacrarnla (10 vrr/geHb B TeqeHue12
HeA.) y nar1heHroac PA (n=12) 142]. Ha QoHe
fletreHilq Ha6rogarocb AocroBepHoe yMeHblueHile qilcra 6onesHeFrHbrxcycraBoB, yny.]rxeHre o6ulero cocronHilq (no ereyanuHofi
aHano FoBofr urrane ), cn rxeH Lre KoHqeHTparIAtA
C-pearrr,rBHoro 6enrca (CPE), COe n rilrpoB
peBMaroilAHoro Qarropa. Orser no KpilrepilKonflernr peBMaroaoroB
cM Aveprrancrofr
(ACR) 2Oo/ooruaqeH 7 ns B (BB%) naqueHroe
Lfepe34 HeA.y 5 us 6 (83%) Ltepe3B HeA. vry 45
(80%) qepe3 12 nep,.B roxe BpeMff BntAAHtA Ha
il3yqaeMbre ilMMyHonorilqecKile noKa3arenh
(orHoueurrreTh 1/Th2) BbrrBfieHoHe 6stno.
Van Doornum S il coaBr. e ceoeil pa6ore
ycraHoBilrm, qro aropBacrarilH woxer 6esonacHo Llcnoflb3oBarbcn y nallreHToB c PA m
oH e$QeKruBHo yMeHbruaer xoflecrepnl nnnonporeilHoB H.!43KoilnnorHocrl4 Lt xecrKocrb
aprepilanuHoil creHKLt, Koropan FBrflercn
tcc
I/ CN/EPTHOCTb
CEPAELIHO-COCYNVICTAA
3A5OI EBAEMOCTb
SOIIbHbIXPEBMATO/N.H
bIMAPTPI/TOMO53OPIIIITEPATYPbI
MapKepoM cepAeL{Ho-cocyArcrofi naroflorilh
nepTh3a KflilHL{qecKilx cep.4eqHo-cocyAr/cTbrx
HeKoropbtx
no
aBToCrarilHbr,
AaHHbrM
[43].
Qarropoe pr4cKacpegil xeHulLrH o6enx rpynn.
poB, nMerb uMMyHoMoAynilpyloqre e$Qer<rur, Kar oragarocb, rpynnbr 6anu conocraBrMbl
a neqeHile aTopBacTaTilHoMMoxeT Aaxe npilno KoflNqecTByKypFut4x, tAHAeKcyMaccbr rena
(l/MT), peryfiqpHoMy flcnoflb3oBaHilo acnilBecTn K HeKOTOpOMyCHilXeHNo aKTLTBHOCTI4
pvHa, caxapHoMy gua6ety, aprepilanuHoil rrPA 1441. O4Haro 4ansHeilu-rve vccnegoBaHhc
npL43BaHbr
nepreH3Lrvr,ypoBHlo Qrzsmvecroil arrheHocrtA,
AOnOflHl4TbtAfitAOnpoBeprHyrb err
pe3ynbrarbr r onpeAeflqrb, AonxHbt nv crarvHacneAcreeHFrofin peApacnoro)KeH Hocrn [6] .
Hbr LrcnoflbsoBarbcnnpr PA c AeofiHurv eQero guaqnr, vro yBeflilqeHHsrfiypoeeHb cepyMeHbul4Tb
il
nporpeccvrpoBaHue
areAeqHo-cocyguctoia sa6oneeaeMocrr y nallilQerrov
pocKneposa tAaKrvBnocru PA.
eHToBc PA He o6uqcHqercn roflbKo yBenilueB nacronulee BpeMc, noIr4epxaHile eQ$erHileM KraccrqecKilx cepAeqHo-cocyAl4crbrx
TilBHOTOV AnnTenbHOr-O
HaA CyCTaB- Qarropoe phcKa.
KOHTpOAF
9BN'ICTCF
HbIM A CTCTEMHbIM
BOCNATCHilCM
Hecvorpn Ha ro, Lrro rpa4iluLroHHbreOaryMeHbuJLrrb
pilcKa He Moryr o6uncurrb yBeflrqeHhe
Bo3MoxHocrbro
Topbr
AononHilTensHofr
cepAeqHo-cocygl4cryro cMeprHocrb npil PA. cepgeqHo-cocygncrofi
ea6oneeaeMocrl4 tA
Tarofr noAXoA onpaBAaH, nocKolrbKy ecrb AocMeprHocrv nptAPA, aaxHo noHilMarb, rJToBec
croBepHbreAaHHbre,qro paHHRq,arpeccilBHaF v ervx Qarropoe ro)Ke 3HaqrrereH. lloerovy
t p\nnrenuHacSflBT 6esonacHanpv PA moqeHu BaxHo, BbrcBnffTbv Tpatrv\l4oHHbrecepAeqHoeQQerrreHa Aflq noAaBfleHhn cycraBHoil gecocyAr/crure Qarropbr pl4cKa c uenbto krx KopcTpyKr_I]414
t cepAeqHo-cocyAl/cTbrx ocno)K- peKLll4l/.
uennit [45]. OgHaKo, l4ccneAoBaHilF BntAeHtAfl
Hanpnvrep, KypeHile,He ronbKo Qarrop prcorAeflbHbrx 6agNcHurx npenaparoB cro)KHbr, Ka cepAeqHo-cocyglrcrbrx sa6oneeaHuil, Ho
n3-3a Heo6xogrrrMocrvr6onuuroro KonhqecrBa il Moxer npeApacnonararb K pa3Bnrilo PA r,r
yBefinqilBarb ero rqxecrb 146,471.
nallileHToB tAMtATenbHoro nepuoAa ilccneAoBaHVA,a rapKe roro Qarra, qro 6orulultHcreo
Y naureHToB c PA voxer Bcrpetrarbcfl vttnallileHroe c PA Hyxgaercn B 3aMeHe 6asucnpileMoM l-KC 4ra6er (qaule
Ayr-lr/poBaHHurfr
HOrO npenapaTa hnh KoppeKL\tAtA
ero rqo3br B Bcero ero orHocl4rcn K npileMy l-KC eHyrpu). B
napannenb- erofi rpynne nallreHroB ypoBeHb roulaKoeoil
xo4e neqeHre r Heo6xoE:AMocrtA
HOFOnpileMa Apyrilx neKapcrB.
FnoKo3brKpoBl/AonxeH il3MepflTbcfl exeroAHo
nnvv'aue B cflyqae 3HaqilTerbHoro yBeflilqeHrF
TPAI414414OH H bI E OAKTOPbI P]4CKA
Ao3br fKC. y nallreHroa c PA, y Koropbrx yxe
A<ryareH ceroAHe Bonpoc o ponr4 TpaAN- .qilarHocrTrpoBaHcaxapHbrx gua6e1 l-KC HyxHo
no Bo3MoxHocrr ug6eraru tAnv wcnonb3oBarb
4l4oHHbrxQarropon pilcKa B onpeAeneHril
pl4cKoB cep.qeqHo-cocyArlcrbrx ocnoxHeHmil y
ilx B MaKcrMa.nbHoBo3MoxHoil Husroil Ao3e.
AprepnanbHas rnnepreH3nq - FBrqercc nonallileHroe c PA.
KypeHne, caxapHurfi Eua6e\ aprepilanbHae
6oquurv eQQerrovr MHor-l4xfieKapcrBeHHbrx
rilnepreH3vq, fvnepnilnrAeMnF', oxvtpeHme Lr npenaparoB, ncnoflb3yeMbrxgrte neLreHnnPA,
rvnotrttr'aun+ - BaxHbre Qarropur pr4cKa l4EC,
BKfloqan HnBC, l-KC, reQnyHoMl4.q tA LI KnoKoropbre Moilr,r 6ur o6uqcnmru 6onee BbrcoKyro cnopilH. flpoQrru
aprepnanbHoro AaBneHre Aon)KeHonpe4enqrbcn y nallreHroe c PA
cepAeLrHo-cocy.qrcryo 3a6oneBaeMocrb y nauileHroB c PA. OAnaro 6orulunHcrBo LrccfleAo- nepeA HaqafloM np[eMa eTrx npenapaToB, a
B nocneAyoueM Heo6xo.qilM ero AilHaMmqeceaHniAno Ka3afio, rrro rparqmLlnoHHbre Qarropur
pilcKa o6urqHo He yBennqeHbry naqileHToB c
rnft roHrponu. HflBC, rar r3BecrHo, yMeHbuaor rNnoreH3ilBHbreeQ$e<rur MoqeroHHbrx
PA, e cpaBHeHhmc KoHrporuHoft rpynnofi. B
Nurses' Health Study 6uuo o6cregoaaHbtxeHcpeACrB, B- a.qpeHo6noraropoB vt tAHrtA6utoulvfHbr c PA u 6es aprpilTa (a raccregoBalrztr' poB aHrhoreH3h Hn peBpau{a}oulero QepveHra,
il npaKTnqecKil He Bnnr,tor Ha eQQerrrBHocrb
npvHnnv yqacrhe 6oree'114 rurcqq xeHulru)
OgHoil ta33aAaq mccfleAoBa+ttnqBflcflacb oKc- 6noraropo B Kar br.lreBbrxraHanoe [48] . f1o eroil
lcc)
npilLfhHe nallreHTaM c PA tA apTepvanbHoil rvnepTeH3ileil, KoropbtM Heo6xoAl4Mo AnilTeflbHOeret{eHile HnBC, o6bt,{Horpe6y0rcF 60flee
BbrcoKhe Ao3bt rilnoTeH3LlBHbtxnpenapaToB
nnv Bo3MoxHo BKfloqeHile B rmnoTeH3ilBHylo
cxeMy 6noraropa Kanbr-lfleBoroKaHana. OAHaKo, y naqreHToB c PA, HyxHo KoHTponhpoBarb
npreM H[|BC tA,no Bo3Mo)KHocrtAt cKarb anbrepHaruebr AnF 3aMeHbt,oco6eHHo ecnr apTepharfbHaq rilnepTeH3rlfl vnv ceptreqHae HeAocraroqHocrb nporpeccnpyor Aaxe Ha Qoue
aAeKBarHofirepan r v ervx cocrocH mlt.
Oxnpenme, oco6eHHo 6prouHoil TAn, qBflnercn QarropoM pt4cKa4.nc cepgeq Ho-cocy,qncrutx sa6oreea+tAil e o6ulell nonynellLlra.OgHaKo, npil PA cepgeqHo-cocyAVCraA cMeprHocrb
Bbrue npr hHAeKce Maccbt rena (l/MT) MeHbue 20 kg/m2. Kaxercns FBflqercn npLt3HaKoM
tqxenoro PA, il coorBercrBeHHo qeM Tflxenee PA, TeM Bbrlue sa6oneeaeMocrb t4 cMepTHocrb. flaqreHrur PA gonxHbt norsAepxmBarb
HopMarbHsrfr eec refla, 3a6orilTbcn o BocnoflHeHW 6enra tABIATaMwHoB
il eroMy Moxer noMor.f
b c6anaucvtpoBaHHoenvraHne. [49,50].
A[erearHan cocro+Ht to Ll rnxecrw QvtsuqecKaq aKTrBHocrb eule oAilH saxHurfr $arrop
cH ilxe Hil e cepgeq Ho - cocyr,t/ crbrx p klcKo e. O r 3hqecKile ynpaxHeHilq 6esonacHbt npra PA ra
Aaxe Moryr yMeHbuarb aKTTlBHocrs6onegHyr,
il noeroMy AoflxHbr BbtnoflHqrscq6oruHbtMll B
peMnccvtA. flpn nporpecct poBaHVtA3a6oneBaHVAdilshqecKile ynpaxHeHile raoKe AoJtxuut 6uttu, Ho npil oroM Qttsr.lvec<aqaKTLlBHocrb
Ha BocnaneHHbrecycraBbt AoaxHa 6urrs MVHTAvansuoil [51].
Ao6aerr K nrqe c pur6urv xrpoM, 6orarure
overofi -3 xilpHbrM14KncnoraMil, noATBeptrvnv
cBoro eQQerrneHocrb B KoMnreKCHoMreqeuurtt PA. OHr voryr cnoco6crBoBarb yMeHblueHilo rcnonb3oBaHne HnBC, a raKxe Moryr
yMeHbruarb ce p4eq Ho - cocyAl4crbt e pucru. [,nn
AOCTilXeHTq pe3ynbTaToB BaxHo nprHilMaTb
aAeKBarHbreEosbt (Aoea Ha 10-15 vn pur6uero
xnpa e cyxr) AaHHbtxnpenaparoe[52].
PAHHnT ErArHOS
14'|EL|EH]4E
.[,ononurrefl bHo K KoHTpono rpaAnLlnoHHbtx
Kaprqr4o
BacKynFp Hbrx Qarro po B pl4cKa,yMeHbluNTbcepAeqHo-cocyAt/cruril pmcr Moxer paHA R S M E D I C AN A s( 1 5 )
HAe &narHocrilKa PA u 6urcrpoe ageKBarHoe
fletreHile. Ecru vHeHne, qro nallileHTbr c PA
ypoeeHb KapgrloBacKyrMetor noBbrrxeHHurft
nnpHofi cMeprHocrl4, Bo3Mo)KHonoroMy, tlro
na4HeHT il Bpaq cocpeAoToqeHbt Ha aprpt/re [53]. Kporvreroro, cepAeqHo-cocy4t/crae
narofloriln y 6oluuurx PA Moxer nporeKarb
acrMnroMno[7]. Bpavrz AolxHbt 6ulrs HacropoxeHbr ra o6paularb BHLlMaHheHa MenKre fi
HerilnhqHbre nponB neuwil cep4eLtHo-cocyAl4croil 6one3Hr y naqneHToe c PA, noMHq o BbtcoKoM pl4cKe cocyAl4crbtx KaracrpoQ y eroil
rpynnbr.
SAKNloqEHNE
Cep.qevHo-cocyrqhcraff narofl ortAe - ocHoBHafl npnqfiHa ocIoxHeHHoro TeqeHhfl v neTaflbHocrn y naWeHToB c PA. SorulurHcreo
qro xpoHylilccneAoBarenefi npe4nonarael
LrecKoecilcreMHoe BocnaneHile cnoco6creyer
3HatfLlTenuHo 6on uu-re ft ce p6ett Ho-cocy gtttctoil
sa6oneeaeMocrr y nnL\c PA, qeM B o6uteil nonynqunv H qTo KoHTponb HaA BocnaneHileM
npr PA yMeHblxaer cMeprHocrb or cocy4l4cTbrx KaracrpoQ e eroil rpynne. KnaccrqecKre cepAeqHo-cocyAl4crbte Qarropur pytcKa
ilrpaoT ponb il MoryT, B HeKoTopbtxcrytlaFx,
6 u r r u n o r e H q n m p o B a H H bnt p e n a p a r a M n , v c nonb3yeMbrMil .qnq fleqeHhn PA. IlpoQvnaKrnKa cepgeqHo-cocyguctoil sa6oneeaeMocrt4 y
nauneHroe c PA rpe6yer rov6rHrpoBaHHoro
noAXoAa, BKn]oqa|ou-leroKoHTponb 3a ynpaBneeMbrMl4 TpaAil4roHHbrMl4 cepAetlHo-cocyAkrcrblMu QarropavtA pttcKa r eQQerrueuufr vr
AnmTenbHurfi<ourpoflb aKTrlBHocrl4PA, eurcoKyo cTeneHb HacTopoxeHHocTtAv KaK MoxHo
6onee nonHoe AilHaMrLtecKoeo6creAoeaHre
cepgeqHo-cocygncrofr
cilcreMbt y 4aHHoi
rpynnbr nauheHToB.
,Il4TEPATYPA:
1.
2.
MasypoeB.lzl.PeervarongHurilaprpt4r(<nnHilKa, ArarHOCTl,'lKa,
IeLleHue). B.lz1.
MaSypoe, A.M.llwna. Cn6.: MeA Macc Me4ra,
2000.
PincusI FerraccioliG, SokkaT et al. Evidence from cl i ni caltri al sand l ong-ter mobservationalstudiesthat disease-modifying
anti-rheumatic drugs slow radiographic
AN 3A5ON EBAEMOCTb I/ C MEPTHOCTb
CEPNE! HO- COCYAIACT
: O53OPI/TE P A TV P bI
A P TP I/TOM
s OIl b H b l xP EB M AT O/nH bl M
analyses.BMJ 2000;321: 199-204.
progressionin rheumatoidarthritis:updating a 1983 review.Rheumatology(Oxford) 14. S oderl i nMK , N i emi nenB H akal aM . Funct ionalstatus predictsmortalityin a commu2002;41: 1346-56.
nity based rheumatoidarthritispopulation.
3 . Wolfe F, MitchellDM, SibleyJT, et al. The
J R h e u m a t o1l 9 9 8 ;2 5 : 1 8 9 5 - 1 8 9 9 .
mortality of rheumatoidarthritis.Arthritis
1 5 . W a l l b e r g - J o n s s oSn, J o h a n s s o nH , O h m Rheum1994; 37: 481-494.
an ML, et al . E xtentof i nfl amma t ionpr ediAll-cause
HA.
4 . WatsonDJ, RhodesI Guess
cts cardiovasculardiseaseand overallmomortalityand vasculareventsamong patiertalityin seropositiverheumatoidarthritis.
nts with rheumatoidarthritis,osteoarthritis,
A retrospectivecohort study from disease
or no arthritisin the UK GeneralPractice
onset.J Rheumatol1999; 26: 2562-2571.
Research Database. J Rheumatol 2003;
l B , C l arkeSA, et al.
16.
C hehataJC , H assel A
30: 1196-1202.
Mortalityin rheumatoidarthritis:relationsh5 . Wolfe E FreundlichB, StrausWL. Increase
ip to singleand compositemeasuresof disdisand cerebrovascular
in cardiovascular
easeactivity.Rheumatology(Oxford)2OO1;
ease prevalencein rheumatoidarthritis.J
40:447-452.
R h e u m a to2l 0 0 3 ;3 0 : 36-40.
Turesson
C, O'Fallon WM, Crowson CS,
17.
EB,
et
al.
Rimm
EW,
Karlson
DH,
6 . Solomon
et al. Occurrenceof extraarticulardisease
Cardiovascularmorbidity and mortalityin
manifestationsis associated with excess
women diagnosedwith rheumatoidarthrimortalityin a communitybased cohort of
ti s . C i rc u l a ti o 2
n 0 0 3 ; 107: 1303-1307.
patientswith rheumatoidarthritis.J RheuN
i
col
a
C
S
,
H
,
C
row
son
7 . Ma ra d i t-Kre me rs
matol2OO2;29:62-67.
P J , e t a l . l n c re a s edunrecogni zedcoron a ry h e a rt d i s e a s eand sudden deaths i n 18. Merk. Merck announcesvoluntarywithdrawal of Vioxx.Sept 30, 2004.
rh e u m a to i da rth ri ti s:a popul ati on-based
B resal i erR , S andl erR S , Quan H, et al. f or
19.
2005;
52:
Rheum
cohort study. Arthritis
the AdenomatousPolypPreventionon Vio4 0 2 -4 1 1 .
xx (APPROVEe)Trial Investigators.CardioB . Ross R. Atherosclerosis- an inflammatovascular events associated with rofecoxib
ry diseaseN
. E n g lJ M e d 1 9 9 9 ;3 4 0 : 1 ' 1 5 in a colorectaladenomachemoprevention
126.
proteitri
al .N ew E nglJ Med 2005;352
l.
Acute-phase
Kushnewr
C.,
9 . Gabay
ns and other systemicresponsesto inflam- 20. SolomonSD, McMurrayJJV PfefferMA, et
448-454.
al., for the AdenomaPreventionwith Celem a ti o n .N E n g lJ M e d .1999;340:
coxib (APC)Study Group.New EnglJ Med
10. Ridker P.M. High-sensitiveC-reactive
2005;352
protein. Potentialadjunct for global risk
assessmentin the primary preventionof 21. H udson M, B aron M, R ahme E, Pilot L.
Anti-inflammatorydrugs with a decrease
cardiovasculardisease.Circulation'2001risk of recurrentacute myocardialinfarction
; 10 3 : 1B 13 - 18 1B .
in patientson aspirin.ACR66th AnnualScthe
biand
11. Libby P. Coronaryartery injury
i enti fi cMeeti ng,N ew Orl eans,20 02; 1663
inflammation,thology of atherosclerosis:
(abst).
rombosis,and stabilization.Am J Cardiol.
22. K o D ., W ang Y B ergerA K et al . Nonst er 2 0 0 0 ;8 6 : 3 J -9 J .\
oidal anti-inflammatorydrugs after acute
1 2 . R i d k e rP., H e n n e k e nsC ., B uri ngf.E .,R i fai
myocardial infarction. Am Heart J 2002;
protein
markers
of
other
and
N. C-reactive
143:475-481.
inflammationin the predictionof cardiova s c u l a rd i s e a s ei n women. N E ngl J Med. 23. GarciaRodriguezLA.The effect of NSAiDS
on the riskof coronaryheartdisease:fusion
2 0 0 0 ;3 4 2 : 8 3 6 -8 4 3 .
Low
of clinicalpharmacologyand pharmacoepiM,
et
al
.
1 3 . D a n e s hJ , Wh i n c u pB W al ker
2001;
demi l ogi cdata.C l i nE xp.R heum at ol.
gradeinflammationand coronaryheartdis. 5 ) :S 4 1 - S 4 5 .
1 9( s u p p l2
ease:prospectivestudyand updatedmeta158
2 4 . R a yW A , Ste i nC M , H a l lK ., et al . N on-stedensity lipoproteincholesterolas well as
ro i d a la n ti -i n fl a mma tory
drugs and ri sk of
clusteringof metabolicsyndromefeatures
serious coronary heart disease:an obsein rheumatoiodarthritis.ArthritsRes 2002;
rvationalcohort study. Lancet 2002; 359:
4:R5-R12.
11B - 12 3 .
35. H al grenR , B erneC . Gl ucosei ntol er ance
in
2 5 . Ba k S, A n d e rs e nM , T si ropoul os1.,et al .
patientswith chronic inflammatorydiseaRisk of stroke associatedwith nonstweroises is normalizedby glucocorticoids.Acta
d a l a n ti -i n fl a mma to ry
d rugs,S troke2003;
M e d S c a n d1 9 8 3 2; 1 3 :3 5 1 - 3 S 5 .
3 4 :3 7 9 -3 9 5
36. C hoi H K , H ernan MA , S eeger JD , et al.
26. LaytonD, HughesK, HarrisS, ShakirSAW.
Methotrexateand mortalityin patientswith
Comparisonof the incidencerates of thrrheumatoidarthritis:a prospectivestudy.
omboembolicevents reportedfor patients
L a n c e t2 0 0 2 ; 3 5 9 :11 7 3 - 1 1 7 7 .
p re s c ri b e dc e l e c o x i ba n d mel oxi cami n ge- 37. K rauseD , S chl eusserB , H erbornG, RauR.
n e ra lp ra c ti c ei n E n g l a ndusi ng prescri bti Responseto methotrexatetreatmentis aso n -Ev e n tsM o n i to ri n g(P E M)data.R heumsociatedwith reducedmortalityin patients
a t o l o g y2 0 0 3 ;4 2 : 1 - 1 1 .
with severe rheumatoidarthritis.Arthritis
27. MacDonaldTN, Wei L. Effect of ibuprofen
R h e u m2 0 0 0 ;4 3 : 1 4 - 2 1 .
on cardioprotective
effectof aspirin.Lancet 38. LandeweRB,van den Borne BE, Breedveld
2003; 361: 573-574.
FC, DijkmansBA. Methotrexateeffects in
2 8 . Ku rth 1 l G l y n nR J , W a l k erA M, et al . Inhi patientswith rheumatoidarthritiswith carb i ti o no f c l i n i c a lb e n e fi t sof aspi ri non fi rst
diovascularcomorbidity.Lancet2000;355:
myocardialinfarctionby nonsteroidalanti16 16 - 1 6 1 7
i n fl a m m a to ry
d ru g s .C i rcul ati on
2003; 108: 3 9 . H u r l i m a nD
n . ,F o s t e r A .N, o l l G .e, t a l .A n t i t u I191-i195.
mor necrosisfactoratreatmentimprovesen2 9 . V a n eJ B. Ba c kto a n a s p i ri na day.S ci ence
dothelialfunctionin patientswith rheumatoid
2002;296: 474-475.
arthri ti s.
C i rcul ati on
2O02;106:
2184-2 189.
30. BaigentC, PatronoC. Selectivecyclooxy- 40. StenvinkelP. Endothelialdysfunctionand
g e n a s e2 i n h i b i to rsa, s p i ri n,and cardi ovai nfl ammati on
i s therea l i nk?N epphol.Dial.
s c u l a rd i s e a s eA
, re a p p r ai salA.rthri ti sR heTranspl2001;
.
16: 1968-1971.
u m . ,2 0 0 3 : 4 8 : 1 2 - 2 0 .
4 1 . E l k i n dM . S . ,C h e n gJ . , B o d e n A l b a l8a. , e t
3 1 . S a tta rN , Mc C a re yD W C apel lH , Mcl nnes
al. Tumor necrosisfactor receptor levels
l A. E x p l a i n i n g
h o w * h i g h-grade,systemi c
are associatedwith carotidatherosclerosis.
i n fl a mma ti o na c c e l e ra t edvascul arri sk i n
S troke2002;33:31-38.
rh e u ma to i da rth ri ti sC
. i rc ul ati on
2003; 108: 42. K andaH , H amasakiK , K ubo K , et al . Ant i2957-2963.
inflammatoryeffect of simvastatinin patie3 2 . B o e rsM , N u rma h a me dM I D oel manC JA ,
nts with rheumatoidarthritis.J Rheumatol
e t a l . In fl u e n c eo f g l u c o corti coi ds
and di s2003
ease activityon total and high density lip- 43. JohnsonA G, N guyenTV D ay R O. D o nonoproteincholesterolin patientswith rheusteroidalanti-inflammatory
drugs affect blmatoid arthritis.Ann Rheum Dis 2003:62:
ood pressure?A meta-analysis.
Ann Intern
842-845.
M e d 1 9 9 4 ;1 2 1 : 2 B g - 3 0 0 .
3 3 . Gu rw i tzJ H , B o h nR L ,G l y nnR J,et al , Gl uc- 44. Yan DoornumS, McCollG, Wicks lP.Atorvocorticoidsand the risk for initiationof hyastatinreducesarterialstiffnessin patients
poglycemictherapy.Arch lnternMed 1994;
w i th rheumatoi darthri ti s.A nn R heu m Dis
154:97-101.
2004;63:1571-1575.
34. DesseinPH, StanwixAE, Joffe Bl. Cardio- 45. P i ncusI Gi bofskyA , W ei nbl attME . U r gent
vascularrisk in rheumatoidarthritisversus
care and tight controlof rheumatoidarthrosteoarthritis:acute phase responserelaitis as in diabetesand hypertension:better
te d d e c re a s ei n s u l i ns e nsi ti vi tyand hi ghtreatmentsbut a shortageof rheumatologiA R SV I F D I C N
A S 5( 1 5 )
159
CEPAEI HO- COCYAI/ CTAF,3AE ONEBAEMOCTb I/ C N/EPTHOCTb
SOIbHbIXPEBMATOI/AHbIM
APTPI/TOMO53OPIIITEPATYPbI
sts.ArthritisRheum2002;4G:85j -854.
46. PracticallmplementationTaskforcefor the
Preventionof Cardiovascular
Disease.Focus
document. Preventionof cardiovasculardisease:an evidence-basedclinicalaid 2004.
Med J Aust2004;181(6 Focus):F1-F14.
47. SaagKG,CerhanJR, KolluriS, et al. Cigarette smokingand rheumatoidarthritisseve ri ty .An n R heumD i s 1997;56: 463-469.
48. Van DoornumS, McCollG, Wicks lp. Accelerated atherosclerosis:an extraarticular
feature of rheumatoid arthritis? Arthritis
Rheum 2002: 46: 862-873.
49. EscalanteA, HaasRW,del RinconL paradoxicaleffect of body mass indexon survival
in rheumatoidarthritis:role of comorbidi-
160
ty and systemic inflammation.Arch Intern
Med 2005; 165: 1624-1629.
50. KremersHM, NicolaPJ,CrowsonCS, et al.
Prognosticimportanceof low body mass
index in relationto cardiovascularmortality in rheumatoidarthritis.ArthritisRheum
2004:50: 3450-3457.
51. de Jong Z, VlielandTP.Safety of exercise
in patientswith rheumatoidarthritis.Curr
O p i nR h e u m a t o2l 0 0 5 ;1 7 : 1 7 7 - 1 8 2 .
52. Stamp LK, James MJ, ClelandLG.Dietand
rheumatoidarthritis:a reviewof the literature. SeminArthritisRheum2005; 35:77-g4.
53. Maclean CH, LouieR, LeakeB, et al. euality of care for patientswith rheumatoidarthritis.JAMA 2000; 284:984-992.