Lipids, Inflammation, and Cardiovascular Risk in Rheumatoid Arthritis
Conditions: Rheumatoid Arthritis, Cardiovascular Disease
Sponsor: Brigham and Women's Hospital

STUDY PROTOCOL: Lipids, inflammation, and cardiovascular risk in rheumatoid arthritis 
NCT02714881 
Protocol ID: 2016P000219 
Last updated 5/11/2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Objective 
 
The objective of this study is to elucidate the relationship between inflammation and lipoprotein 
atherogenicity, and to determine the relative contribution of inflammation and lipids to 
cardiovascular (CV) risk in RA. Our central hypothesis is that inflammation and lipoprotein 
atherogenicity is tightly linked such that both factors are important to assess CV risk in RA. 
Further, we hypothesize that this relationship is obscured by a consideration of routine lipids 
alone.  
 
Study population and design 
The Lipids, Inflammation and CV Risk in RA (LiiRA, ClinicalTrials.gov: NCT02714881) study 
conducted from 2016 to 2021, prospectively enrolled RA patients, age>35, with active RA with a 
plan to initiate tumor necrosis factor inhibitor (TNFi) therapy as directed by their treating 
rheumatologist. Exclusion criteria include prior cardiovascular disease, statin use, prednisone 
dose or equivalent >10mg, or biologic DMARD use in the past 24 weeks. All subjects underwent 
PET myocardial perfusion imaging (MPI) at baseline, were initiated on a TNFi, and returned for 
study visits at 6, 12 and 24 weeks, where a repeat PET MPI was performed.  At each study visit, 
subjects had assessment of RA disease activity, current RA therapy, and screening for adverse 
events.  Blood draws were also performed for measurements of fasting lipids, inflammatory 
markers and subclinical markers of myocardial injury.  
 
A control group of healthy subjects with similar age and sex from our prior work using the same 
imaging protocol and quantitative analysis of myocardial perfusion PET images was also included 
to compare baseline imaging findings in the RA cohort. Inclusion criteria for this study were 
patients without a history or clinical evidence of CAD.  
 
Assessment of myocardial blood flow and flow reserve 
Myocardial blood flow was measured at rest and during maximal hyperemia using 15-20 mCi of 
13N-ammonia as the flow tracer and a whole-body PET/CT scanner (Discovery RX or MI 
LightSpeed 64, GE Healthcare, Wakesha, WI). Low dose CT scans were used for attenuation 
correction and for semi-quantitative visual assessment of coronary artery calcification. Coronary 
artery calcium (CAC) was categorized as absent, mild (1-99), moderate (100-299), and severe (≥ 
300). This semi-quantitative visual assessment correlates well with the Agatston score.  Maximal 
hyperemia was achieved using regadenoson as per standard care. Patients were asked to refrain 

from caffeinated products for 12 hours, theophylline-containing and arterial vasodilator 
medications the day of the study.  
 
A semiquantitative 17-segment visual assessment using a standard 5-point scoring system was 
used to evaluate for myocardial ischemia and scar. Absolute MBF was computed from the rest 
and stress myocardial perfusion PET images using commercially available software 
(Corridor4DM; Ann Arbor, Michigan) and a two-compartment tracer kinetic model.  All images 
were motion corrected and analyzed in a blinded fashion. Intrareader and inter-reader variability 
from our laboratory have previously been published.  MFR was calculated as the ratio of stress 
over rest myocardial blood flow. All reported MBF and MFR values indicate global measure. MFR 
was calculated as the ratio of stress over rest myocardial blood flow. Rest MBF was also 
normalized by the rest rate-pressure product, an index of cardiac work, by dividing rest flow by 
the resting rate pressure product and multiplied by 10,00022. Corrected MFR was defined as 
stress MBF divided by corrected rest MBF. All reported MBF and MFR values indicate global 
measure.CMD was defined as a MFR <2.5, reflecting mild coronary microvascular dysfunction, 
based on prior work. 
 
Effect of reducing inflammation on CMD, primary cohort 
A TNFi, specifically certolizumab was used as the intervention to reduce inflammation. TNFi’s are 
the most commonly used treatment after inadequate response to the first line therapy 
methotrexate for RA. Per our protocol, subjects were allowed to switch to other treatments if 
certolizumab was inadequate in controlling RA disease activity at the discretion of their treating 
rheumatologist with the overall goal to control inflammation.  
 
The study was designed to enroll 75 subjects with an expectation anticipating 25% loss to follow-
up with an anticipated of n=66 subjects completing the study.  The study ultimately recruited 74 
subjects with 66 subjects completing the study.  As this study was initiated prior and enrolled 
through the COVID-19 pandemic, subjects’ follow-up times extended beyond 24 weeks; this 
modification was approved by the Mass General Brigham Institutional Review Board. All patients 
were enrolled from rheumatology practices at Brigham and Women’s Hospital, Brigham and 
Women’s Faulkner Hospital, Massachusetts General Hospital, Boston, MA and Mount Auburn 
Hospital, Cambridge, MA. All PET MPI was performed at Brigham and Women’s Hospital. 
 
Study Outcomes and Measures 

The primary outcome was the change in global MFR after 24 weeks of treatment starting with 
TNFi therapy. MFR, the ratio of peak vasodilator stress to rest MBF, represents the maximal ability 
to augment coronary flow and myocardial perfusion. The secondary outcome was change in hs-
cTnT at baseline and 24 weeks.  Inflammatory marker and hs-cTnT measurement was also 
available for baseline, week 6, 12 and 24 weeks.   
 
 
Inflammatory biomarkers 
Blood biomarkers were measured and broadly categorized into clinically measured acute phase 
reactants and inflammatory pathways implicated in RA or CVD. The acute phase reactants 
included: erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP), 
measured using clinical assays. The remainder of the biomarkers were measured at Children’s 
Hospital as previously described. Inflammatory pathways implicated in RA or CVD comprised of 
IL-1a, IL-1b, IL-6, and sTNFR2. Inflammatory biomarkers without clinical cut-off values were 
categorized into tertiles. Changes in biomarkers were also categorized into tertiles. 
 
Clinical measurements 
RA Disease Activity was assessed using the validated disease activity score (DAS)28-CRP with 
3 components. DAS28-CRP3 incorporates the 28 tender and swollen joint count and hsCRP. We 
additionally calculated the clinical disease activity index (CDAI), which does not include hsCRP 
in the calculation.    
 
Statistical Analysis 
Means and standard deviations were used to describe most continuous variables, medians and 
IQRs were used to describe variables with non-normal distributions, and frequency and percent 
were used to describe categorical variables. Comparison p-values for outcome variables and 
other variables before and after TNFi therapy were computed using paired t-tests or the Wilcoxon 
signed rank test for non-normally distributed variables. Spearman’s correlation was used to test 
the correlation between the log of baseline inflammatory markers and the primary outcome, MFR, 
and secondary outcome, hs-cTnT. As well, Spearman’s correlation was used to test the 
relationship between change in inflammation and the primary and secondary outcomes. An 
exploratory subgroup analysis was also performed to test the correlation between change in 
inflammatory markers with change in hs-cTnT, among subjects with CMD (MFR<2.5) at baseline 
and 24 weeks.  As measurements were available for inflammatory markers and hs-cTnT at 

multiple time points, we additionally tested the association between the inflammatory markers 
with hs-cTnT over time.