Open Access Open Badges Research article

Ischemic arterial events and atherosclerosis in patients with systemic sclerosis: a population-based case-control study

Annica Nordin1*, Kerstin Jensen-Urstad2, Lena Björnådal1, Susanne Pettersson13, Anders Larsson4 and Elisabet Svenungsson1

Author affiliations

1 Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden

2 Department of Clinical Physiology, Södersjukhuset, Karolinska Institutet, SE-171 76 Stockholm, Sweden

3 Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, SE-171 76 Stockholm, Sweden

4 Department of Clinical Chemistry and Pharmacology, Akademiska Hospital, SE-751 85 Uppsala, Sweden

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Citation and License

Arthritis Research & Therapy 2013, 15:R87  doi:10.1186/ar4267

Published: 14 August 2013



While microvascular disease is well described in systemic sclerosis (SSc), it is still unclear whether the occurrence of ischemic macrovascular events and atherosclerosis is enhanced among patients with SSc.


In this study, 111 SSc patients (74% of prevalent cases in Stockholm County) and 105 age- and sex-comparable population controls were investigated. Previous ischemic arterial events were tabulated. As surrogate measures of atherosclerosis, plaque occurrence and intima-media thickness (IMT) were determined with carotid ultrasound and the ankle-brachial index (ABI) was calculated. Traditional cardiovascular risk factors were recorded and we also measured biomarkers indicating systemic inflammation and endothelial activation/dysfunction.


Mean age was 62 ± 12 years for patients and controls. Ischemic arterial events were more common, due to increased occurrence of ischemic heart disease (IHD) and ischemic peripheral vascular disease (IPVD), in the patient group (12% vs. 4%, P = 0.03 and 9% vs. 0%, P = 0.003 respectively). On a group level, there was no difference regarding the occurrence of ischemic cerebrovascular disease, the frequency of plaques, IMT or ABI between SSc patients and controls. Subgroup analyses revealed that patients with anticentromere antibodies (ACA+) had more plaques and more ischemic arterial events compared to other SSc patients (67% vs. 39% and 32% vs. 11%; P = 0.006 and P = 0.01, respectively) and compared to controls (67% vs. 41% and 32% vs. 7%, P = 0.02 and P = 0.0003, respectively). Biomarkers of inflammation/endothelial activation were generally increased among SSc patients.


Patients with SSc are at enhanced risk for IHD and IPVD. The ACA+ SSc subgroup was particularly affected with both ischemic arterial events and premature atherosclerosis. The microvascular vulnerability of ACA+ patients is previously well documented. We demonstrate that ACA+ SSc patients have an enhanced risk of macrovascular injury as well. This group should be followed closely and modifiable cardiovascular risk factors should be treated at an early stage.