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The utility of maximal oxygen uptake testing as cardiovascular disease risk marker in female patients with rheumatoid arthritis without associated lung disease



The aim of this study was to evaluate maximal oxygen uptake (VO2 max) as a marker of cardiovascular disease (CVD) in rheumatoid arthritis (RA) and its relation to the CVD risk factors in a cohort of female patients with RA without associated lung disease.

Patients and methods

A total of 132 female patients with RA were assessed for cardiopulmonary fitness with a VO2 max testing. Moreover, 100 healthy female individuals were recruited as control group. Exclusion of patients with pulmonary fibrosis/nodules by using high-resolution computed tomography was done. Traditional CVD risk factors and disease characteristics and their correlation with VO2 max level were assessed in all patients.


Based on VO2 max mean, patients were classified into three groups: unfit (<16.72 ml/kg/min), fairly fit (16.73–25.6 ml/kg/min), and with average fitness (>25.6 ml/kg/min). Patients had significantly worse VO2 max mean (21.28 ±6.96 ml/kg/min) compared with control (30.88±7.36 ml/kg/min). Patients with poor VO2 max level were more likely to be older, hypertensive, with family history of CVD, with high BMI, and with high mean of Framingham risk score. Significant differences were detected between the fitness subgroups in mean of carotid intima–media thickness and presence of carotid plaques. Long duration of RA, uncontrolled disease activity, high health assessment questionnaire, high C-reactive protein, and positive anticyclic citrullinated protein antibodies were correlated significantly with reduced VO2 max level.


VO2 max test can be used as a surrogate CVD marker inpatients with RA. VO2 max can be used as a noninvasive test to detect and quantify fitness defects in patients with RA at increased risk of CVD.


  1. Book C, Saxne T, Jacobsson LT. Prediction of mortality in rheumatoid arthritis based on disease activity markers. J Rheumatol 2005; 32:430–434

    PubMed  Google Scholar 

  2. Nicola PJ, Crowson CS, Maradit-Kremers H, et al. Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis. Arthritis Rheum 2006; 54:60–67

    Article  Google Scholar 

  3. Van den Oever IA, Alper M, et al. Management of cardiovascular risk in patients with rheumatoid arthritis: evidence and expert opinion. Ther Adv Musculoskelet Dis 2013; 5:166–181

    Article  Google Scholar 

  4. Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid arthritis. Respir Med 2012; 106:1591–1599

    Article  Google Scholar 

  5. Nannini C, Ryu JH, Matteson EL. Lung disease in rheumatoid arthritis. Curr Opin Rheumatol 2008; 20:340–346

    Article  Google Scholar 

  6. Doyle TJ, Hunninghake GM, Rosas IO. Subclinical interstitial lung disease: why you should care. Am J Resp Crit Care Med 2012; 185:1147–1153

    Article  Google Scholar 

  7. Tanaka N, Kim JS, Newell JD, et al. Rheumatoid arthritisrelated lung diseases: CT findings. Radiology 2004; 232:81–91

    Article  Google Scholar 

  8. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA 2007; 298:2507–2516

    Article  CAS  Google Scholar 

  9. Metsios GS, Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJ, et al. Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review. Rheumatology 2008; 47:239–248

    Article  CAS  Google Scholar 

  10. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010; 69:1580–1588

    Article  Google Scholar 

  11. Peters MJL, Symmons DPM, McCarey D, Dijkmans BAC, Nicola P, Kvien TK,et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis 2010; 69:325–331

    Article  CAS  Google Scholar 

  12. Prevoo ML, Van’t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38:44–48

    CAS  Google Scholar 

  13. Wallace TM, Levy JC, Mattews DR. Use and abuse of HOMA modelling. Diabetes Care 2004; 27:1487–1495

    Article  Google Scholar 

  14. Homma S, Hirose N, Ishida H, Ishii T, Araki G. Carotid plaque and intima-media thickness assessed by B-mode ultrasonography in subjects ranging from young adults to centenarians. Stroke 2001; 32:830–835

    Article  CAS  Google Scholar 

  15. Touboul PJ, Hennerici MG, Meairs S, Amarenco P, Bornstein N, Csiba L, et al. Mannheim carotid intima–media thickness consensus (2004–2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis 2007; 23:75–80

    Google Scholar 

  16. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen van Zanten JJ, et al. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis 2013; 72:1819–1825

    Article  CAS  Google Scholar 

  17. ACSM. Guidelines for exercise testing and prescription. 7th ed. Philadelphia, PA: Lippincott Wiliams & Wilkins; 2005

    Google Scholar 

  18. Minor MA, Johnson JC. Reliability and validity of a submaximal treadmill test to estimate aerobic capacity in women with rheumatic disease. J Rheumatol 1996; 23:1517–1523

    CAS  PubMed  Google Scholar 

  19. Tierney M, Fraser A, Kennedy N. Physical activity inrheumatoid arthritis: a systematic review. J Phys Act Health 2012; 9:1036–1048

    Article  Google Scholar 

  20. Caspersen C, Merritt R, Heath G, Yeager K. Physical activity patterns of adults aged 60 and older. Med Sci Sports Exerc 1990; 22:79–84

    Article  Google Scholar 

  21. Eurenius E, Biguet G, Stenstrom CH. Attitudes toward physical activity among people with rheumatoid arthritis. Physiother Theory Pract 2003; 19:53–62

    Article  Google Scholar 

  22. Stevens J, Cai J, Evenson KR, Thomas R. Fitness and fatness as predictors of mortality from all causes and from cardiovascular disease in men and women in the lipid research clinics study. Am J Epidemiol 2002; 156:832–841

    Article  Google Scholar 

  23. Wei M, Kampert JB, Barlow CE, et al. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA 1999; 282:1547–1553

    Article  CAS  Google Scholar 

  24. Dunn AL, Marcus BH, Kampert JB, et al. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999; 281:327–334

    Article  CAS  Google Scholar 

  25. Ytterberg AJ, Joshua V, Reynisdottir G, et al. Shared immunological targets in the lungs and joints of patients with rheumatoid arthritis: identification and validation. Ann Rheum Dis 2014; 74:1772–1777

    Article  Google Scholar 

  26. Doyle TJ, Lee JS, Dellaripa PF, et al. A roadmap to promote clinical and translational research in rheumatoid arthritis-associated interstitial lung disease. Chest 2014; 145:454–463

    Article  Google Scholar 

  27. Kelly CA, Saravanan V, Nisar M, et al. Rheumatoid arthritis-related interstitial lung disease: associations, prognostic factors and physiological and radiological characteristics - a large multicentre UK study. Rheumatology (Oxford) 2014; 53:1676–1682

    Article  CAS  Google Scholar 

  28. Gonzalez-Gay MA, Gonzalez-Juanatey C, Vazquez-Rodriguez TR, Miranda-Filloy JA, Llorca J. Insulin resistance in rheumatoid arthritis: the impact of the anti-TNFa therapy. Ann N Y Acad Sci 2010; 1193:153–159

    Article  CAS  Google Scholar 

  29. Tam LS, Tomlinson B, Chu TT, Li TK, Li EK. Impact of TNF inhibition on insulin resistance and lipids levels in patients with rheumatoid arthritis. Clin Rheumatol 2007; 26:1495–1498

    Article  Google Scholar 

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Correspondence to Samah H. El-Medany.

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El-Medany, S.H., El-Magd, G.H.A. The utility of maximal oxygen uptake testing as cardiovascular disease risk marker in female patients with rheumatoid arthritis without associated lung disease. Egypt Rheumatol Rehabil 45, 74–80 (2018).

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