Coeliac disease (CD) is an autoimmune condition with a high prevalence among general population and multisystemic involvement: a more complex scene than a merely gastrointestinal disease. Therefore, an early diagnosis and treatment with a gluten-free diet is mainly important to reduce mortality and comorbidities. Together with autoimmune diseases (as Hashimoto thyroiditis, insulin-dependent diabetes mellitus, autoimmune liver disease and connective tissue diseases), also an accelerated progression of atherosclerosis and a higher prevalence of heart disease have been reported in coeliacs. In the present paper we tried to collect from literature the emergent data on the probable relationship between coeliac and cardiovascular disease, focusing on pathophysiological bases of vascular injury. Data and opinions on the development of cardiovascular risk in patients with CD are conflicting. However, the major evidence supports the theory of an increased cardiovascular risk in CD, due to many mechanisms of myocardial injury, such as chronic malabsorption, abnormalities of intestinal permeability, and direct immune response against self-proteins. The conclusions that come from these data suggest the utility of a careful cardiovascular follow up in coeliac patients.

Inflammation characterizes all stages of atherothrombosis and provides a critical pathophysiological link between plaque formation and its acute rupture, leading to coronary occlusion and heart attack. In the last 20 years the possibility of quantifying the degree of inflammation of atherosclerotic plaques and, therefore, also of vascular inflammation aroused much interest. 18Fluoro-deoxy-glucose photon-emissions-tomography (18F-FDG-PET) is widely used in oncology for staging and searching metastases; in cardiology, the absorption of 18F-FDG into the arterial wall was observed for the first time incidentally in the aorta of patients undergoing PET imaging for cancer staging. PET/CT imaging with 18F-FDG and 18F-sodium fluoride (18F-NaF) has been shown to assess atherosclerotic disease in its molecular phase, when the process may still be reversible. This approach has several limitations in the clinical practice, due to lack of prospective data to justify their use routinely, but it’s desirable to develop further scientific evidence to confirm this technique to detect high-risk patients for cardiovascular events.

Aims According to new Guidelines, the use of an anti-PCSK9 monoclonal antibody in combination is recommended in secondary prevention in patients with very high risk who do not reach the target with the maximum tolerated dose of statin and ezetimibe, and in those patients with very high-risk familial hypercholesterolemia. The therapy is always combination, while the single treatment with anti-PCSK9 monoclonal antibody is indicated in patients with statin intolerance. The present study aims to determine the cardiovascular effects that are highlighted in the treatment of dyslipidaemia with the anti-PCSK9 monoclonal antibody, especially as regards the endothelial function (using the non-invasive methods of EndoPAT), the arterial stiffness (using the non-invasive methods of SphygmoCOR) and the effective improvement on the lipid profile (reduction total cholesterol, LDL and triglycerides). Methods The study is a single-centre prospective study enrolling 47 patients in primary and secondary prevention with non-target LDL cholesterol. Patients were evaluated and enrolled from April 2019 to June 2020 (recruitment period). The average follow-up was 12 weeks, from intaking one of anti-PCSK9, Alirocumab 75 or 150 mg and Evolocumab 140 mg. The scheduled evaluations of the enrolled population were before the beginning of the therapy and after a period of 12 weeks. Results After 12 weeks of treatment we demonstrated a statistically significant reduction in total cholesterol (P < 0.001) and LDL (P < 0.001). An important effect on the inflammatory profile was highlighted, resulting in a decrease in Hs-CRP at 12-weeks (P 0.057), associated with an improvement on endothelial function (P 0.003). Reduction of arterial stiffness was no significant (P 0.238). Conclusions Data confirm anti-PCSK9 monoclonal antibodies, associated with statins and/or ezetimibe to reach LDL target, improve significantly lipid profile and endothelial function. Furthermore anti-PCSK9 monoclonal antibodies are safe and practically free of side effects.