The Characterisation and Risk Factors of Ischaemic Heart Disease in Patients With Coeliac Disease

L. Emilsson; R. Carlsson; M. Holmqvist; S. James; J. F. Ludvigsson

Disclosures

Aliment Pharmacol Ther. 2013;37(9):905-914. 

In This Article

Results

Some 3.7% (1075/28 833) of all CD patients and 2.9% (4142/143 729) of all reference individuals were registered in the Swedish Patient Register or the Cause of Death Register and also had a record in SWEDEHEART (P < 0.001, Figure 1). Some 430 (2.1%) of the CD patients and 1988 (1.8%) of the reference individuals were recorded in SWEDEHEART with a myocardial infarction (P < 0.001). In total 57 CD patients and 327 reference individuals were registered to have suffered ischaemic death without being entered in SWEDEHEART.

Patients With a First Episode of Myocardial Infarction Registered in SWEDEHEART

Age, Gender and Prior Medication Gender and age distributions were similar in CD patients and reference individuals with myocardial infarction ( Table 1 ). The use of Ca-blockers prior to first MI was less common in CD patients than in reference individuals ( Table 2 ).

Hypertension, Diabetes, Smoking and BMI Coeliac disease patients were less likely to be active smokers (OR = 0.74; 95% CI = 0.56–0.98) and more likely never smokers compared with ever smokers (OR = 1.38; 95% CI = 1.10–1.72) (Figure 2). BMI was significantly lower in CD patients than in reference individuals (24.6 vs. 26.1, P < 0.001) (Figure 2). Coeliac disease patients were less likely to suffer from HT (OR = 0.80; 95% CI = 0.64–1.00) (Figure 2), but this negative association failed to attain statistical significance (P = 0.054). The prevalence of any diabetes was similar in CD patients and reference individuals (OR = 1.08; 95% CI = 0.82–1.43) however, insulin-dependent diabetes was significantly more common in CD patients (OR = 1.50; 95% CI = 1.03–2.17) whereas diabetes with oral treatment was less common (OR = 0.64; 95% CI = 0.41–1.01).

Figure 2.

Odds ratios for a number of cardiovascular risk factors in patients with coeliac disease and ischaemic heart disease. Patients with coeliac disease and myocardial infarction (*) or coeliac disease and angiography (§) that is due to ischaemic heart disease. For example, the odds ratio of 0.80 for hypertension in patients with coeliac disease and myocardial infarction means that these coeliac patients were at a lower risk of having hypertension at time of infarction compared with reference individuals with myocardial infarction.

Laboratory Values The unadjusted median levels of haemoglobin and cholesterol were lower in CD patients, but CRP and creatinine levels were not ( Table 3 ). However, the mean level of CRP was higher in CD patients than in reference individuals (30 vs. 26). CD patients had 5.35 units lower haemoglobin (g/L) (95% CI = 1.34–9.37) (unianova - normal scale). Using a logarithmic scale because of the skewed distribution of laboratory values, the unianova, adjusted for gender, age and calendar year, revealed that CD patients overall had a 7% statistically significantly lower total cholesterol level at first myocardial infarction. We found no statistically significant differences for CRP or creatinine between CD patients and reference individuals.

Clinical Presentation and Presenting Symptoms Patients with CD tended to present at hospital with dyspnoea (OR = 1.30; 95% CI = 0.74–2.31) more commonly than reference individuals, whereas chest pain (OR = 0.76; 95% CI = 0.56–1.04) and cardiac arrest (OR = 0.34; 95% CI = 0.04–2.62) were less common. Cardiogenic shock on arrival to the hospital occurred more often in CD patients ( Table 2 ). Biochemical indication of infarction (See Appendix for included biochemical markers) was present in 92.2% of the CD patients and in 91.5% of the reference individuals ( Table 2 ).

Heart Function Left ventricular function, as defined by left ventricular ejection fraction (LVEF), was significantly better in CD patients (P = 0.049) ( Table 2 ).

Patients With Information on Angiography

For patients undergoing angiography, we observed a negative association between CD and daily smoking (OR = 0.69; 95% CI = 0.52–0.92) and HT (OR = 0.76; 95% CI = 0.62–0.93) (Figure 2). Prevalence of self-reported any diabetes on admission was similar, however (16.5% in CD patients vs. 17.5% in reference individuals, corresponding to an OR of 0.94; 95% CI = 0.72–1.22, Supplementary Table S4). Having a prior myocardial infarction or CABG and cardiogenic shock on arrival to the hospital were more common in CD patients (Supplementary Table S4). Indication for angiography did not differ between CD patients and reference individuals. Unstable angina pectoris, however, was slightly more common in CD patients, whereas ST elevation myocardial infarction was more common in reference individuals (Supplementary Table S4). Any stenosis (OR = 0.80; 95% CI = 0.66–0.97) and three-vessel disease [significantly so for three-vessel disease not affecting the left main stem ('LMS'), OR = 0.73; 95% CI = 0.57–0.94] were less common in CD patients. Complementary, not statistically significant results on coronary angiography are available in Supplementary Table S7.

Sensitivity Analysis

The sensitivity analyses were restricted to angiography because of IHD. We found a negative association between CD and HT (OR = 0.65; 95% CI = 0.49–0.86) and daily smoking (OR = 0.60; 95% CI = 0.42–0.87). CD patients had more often undergone angiography because of unstable angina pectoris and nonspecific chest pain but less often because of ST elevation myocardial infarction. Angiographic findings that were due to IHD were similar to those seen in any angiography (stenosis: OR = 0.60; three-vessel disease: OR = 0.62) (Supplementary Table S6).

Post hoc Analyses

In a subset of patients undergoing angiography <10 days prior to or <30 days after SWEDEHEART admission we evaluated the following biochemical markers: infarction, heart function, LVEF and angiographic findings. This evaluation revealed no significant differences in angiographic findings (Supplementary Table S8). Elevated biochemical markers were similar in both groups (Supplementary Table S8). Out of 430 coeliac patients with MI, 74 had a recorded second biopsy. Of these, 41 (55.4%) had persistent VA.

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