Thromboembolic and atherosclerotic cardiovascular events in inflammatory bowel disease: epidemiology, pathogenesis and clinical management

Abstract

Inflammatory bowel disease (IBD) is associated with an increased risk of cardiovascular disease (CVD). The increased risk of CVD concerns an increased risk of venous thromboembolism (VTE), atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF), at corresponding relative risks of 2.5, 1.2 and 2.0, respectively, as compared with the general population. Especially young patients under the age of 40 years run a relatively high risk of these complications when compared with the general population. Chronic systemic inflammation causes a hypercoagulable state leading to the prothrombotic tendency characteristic of VTE, and accelerates all stages involved during atherogenesis in ASCVD. Increased awareness of VTE risk is warranted in patients with extensive colonic disease in both ulcerative colitis and Crohn’s disease, as well as during hospitalization, especially when patients are scheduled for surgery. Similarly, critical periods for ASCVD events are the 3 months prior to and 3 months after an IBD-related hospital admission. The increased ASCVD risk is not fully explained by an increased prevalence of traditional risk factors and includes pro-atherogenc lipid profiles with high levels of small dense low-density lipoprotein cholesterol particles and dysfunctional high-density lipoprotein cholesterol. Risk factors associated with HF are location and extent of inflammation, female sex, and age exceeding 40 years. A dose-dependent increase of overall CVD risk has been reported for corticosteroids. Immunomodulating maintenance therapy might reduce CVD risk in IBD, not only by a direct reduction of chronic systemic inflammation but possibly also by a direct effect of IBD medication on platelet aggregation, endothelial function and lipid and glucose metabolism. More data are needed to define these effects accurately. Despite accumulating evidence on the increased CVD risk in IBD, congruent recommendations to develop preventive strategies are lacking. This literature review provides an overview of current knowledge and identifies gaps in evidence regarding CVD risk in IBD, by discussing epidemiology, pathogenesis, and clinical management.

Incidence and disease‐related risk factors for cerebrovascular accidents in patients with inflammatory bowel diseases: A systematic review and meta‐analysis

“…Chronic systemic inflammation is considered a key factor for endothelial dysfunction and increased arterial stiffness, which was closely associated with atherosclerosis 23 . Patients with chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, were reported to have an increased risk of arterial thromboembolic events 24 . IBD is a group of non‐specific inflammatory diseases of the intestine, characterized by chronic relapsing and remission inflammation 1,2 .…”

“…23 Patients with chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, were reported to have an increased risk of arterial thromboembolic events. 24 IBD is a group of non-specific inflammatory diseases of the intestine, characterized by chronic relapsing and remission inflammation. 1,2 A meta-analysis of 41 studies showed that patients with IBD exhibit significant endothelial dysfunction, increased arterial stiffness, and carotid intima-media thickness.…”

Ischemic Heart Disease in Patients with Inflammatory Bowel Disease: Risk Factors, Mechanisms and Prevention

“…The activation of the coagulation cascade and proinflammatory cytokines as a consequence of active intestinal inflammation may be a factor that contributes to the occurrence of acute arterial events [ 36 ]. Disease activity should be regarded as a modifiable risk factor for cardiovascular events, and aggressive control of inflammation might reduce the risk of thrombosis in patients with IBD.…”

Spotlight on Cardiovascular Risk Assessment in Patients with Inflammatory Bowel Disease

“…Moreover, important clinical risk factors predisposing IBD patients to VTE are not taken into account. Over the past decade, studies identified disease flare, frequent or prolonged hospitalization, surgery, and extensive colonic disease as such [5]. The European Crohn's and Colitis Organisation (ECCO) guideline recommends treating all admitted IBD patients with thromboprophylaxis to reduce VTE risk, irrespective of the indication for hospitalization.…”

“…An important gap in current knowledge is the additional risk-enhancing effect of IBD diagnosis and accompanying disease characteristics. The literature provides important clues regarding IBD-specific risk factors that might be useful for accurate CVD risk estimation [5]. CVD risk appears to be associated with disease flares (specifically the 3 months before and after hospitalization), disease location (higher risk for colonic involvement as compared to ileal/ileocecal disease in those with Crohn's disease), and the extent of inflammation (higher risk in individuals with pancolonic UC than those with distal colitis/proctitis).…”