Descending Aorta Calcinosis and Hypertension in Patients with Radiographic Axial Spondyloarthritis

Keywords: RANKL/RANK/OPG, dihydropyridine calcium channel blockers, vascular stiffness, blood pressure, ankylosing spondylitis


This article is the result of our own clinical observations and a literature search on the development of aortic calcification and hypertension syndrome in patients with axial spondyloarthritis, as well as the clinical significance of the combination of these pathologies and management thereof.

The aim. To increase the awareness of practicing doctors regarding the possible association of aortic calcification and hypertension in patients with axial spondyloarthritis, their diagnosis and possible development mechanisms.

Materials and methods. For this article we described two patients with axial spondyloarthritis, calcinosis of descending aorta and high blood pressure and conducted a case-based review of related literature.

Results. The article presents the results of studies, where authors tried to explain possible mechanisms of development of aortic calcification and hypertension in patients with axial spondyloarthritis. Despite the fact that the data of these studies are scattered and researchers have not yet reached a certain consensus, the available results allow us to believe that patients with axial spondyloarthritis are at increased risk for the development of aortic calcification and hypertension syndrome. Given the possible consequences of these lesions, this cohort of patients requires increased attention from clinicians of various profiles.

Conclusions. Aortic calcinosis can develop in patients with axial spondyloarthritis at its various stages, and also be one of the reasons for the development of high hypertension in such patients. We consider it expedient to conduct a routine examination of the aorta in patients with radiographic axial spondyloarthritis in case of detection of hypertension in them, because this group of patients has a pathophysiological basis for the calcification of vessels of the elastic type, which is given above. This will make it possible to correctly assess the patient’s cardiovascular risks, to draw up more correct plan for their long-term management by a cardiologist in cooperation with a rheumatologist and a cardiac surgeon, as well as to choose more effective therapy for blood pressure correction.


  1. Poddubnyy D, Sieper J, Akar S, Muñoz-Fernández S, Haibel H, Hojnik M, et al. Characteristics of patients with axial spondyloarthritis by geographic regions: PROOF multicountry observational study baseline results. Rheumatology (Oxford). 2022;61(8):3299-3308.
  2. Boel A, van Lunteren M, López-Medina C, Sieper J, van der Heijde D, van Gaalen FA. Geographical prevalence of family history in patients with axial spondyloarthritis and its association with HLA-B27 in the ASAS-PerSpA study. RMD Open. 2022;8(1):e002174.
  3. Michelena X, López-Medina C, Marzo-Ortega H. Non-radiographic versus radiographic axSpA: what’s in a name? Rheumatology (Oxford). 2020;59 Suppl 4:iv18–iv24.
  4. Diekhoff T, Lambert R, Hermann KG. MRI in axial spondyloarthritis: understanding an ‘ASAS-positive MRI’ and the ASAS classification criteria. SkeletalRadiol. 2022;51(9):1721-1730.
  5. Walsh JA, Magrey M. Clinical Manifestations and Diagnosis of Axial Spondyloarthritis. J Clin Rheumatol. 2021;27(8):e547-e560.
  6. Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing Axial Spondyloarthritis: A Guide for Primary Care. Mayo Clin Proc. 2020;95(11):2499-2508.
  7. Toussirot E. The Risk of Cardiovascular Diseases in Axial Spondyloarthritis. Current Insights. Front Med (Lausanne). 2021;8:782150.
  8. Hintenberger R, Affenzeller B, Vladychuk V, Pieringer H. Cardiovascular risk in axial spondyloarthritis–a systematic review. Clin Rheumatol. 2023;42(10):2621-2633.
  9. Larsen AI. Aortic calcification; from innocent bystander to independent predictor; the delicate balance in biology; da aaaCapo: Editorial accompanying ‘Abdominal aortic calcification – from ancient friend to modern foe’. Eur J Prev Cardiol. 2022;28(17):e20-e24.
  10. Madhur MS, Elijovich F, Alexander MR, Pitzer A, Ishimwe J, Van Beusecum JP, et al. Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic? Circ Res. 2021;128(7):908-933.
  11. Barna OM, Kirzhner GD, Smarovoz YaI. [Arterial hypertension in patient with ankylosing spondyloarthritis]. Actual problems of higher medical education and science: Proceedings of the All-Ukrainian scientific and practical conference with international participation; 2021 Apr 8; Kharkiv, Ukraine. Kharkiv; 2021. p. 22-23. Ukrainian.
  12. Ansell BM, Bywaters EG, Doniach I. The aortic lesion of ankylosing spondylitis. Br Heart J. 1958;20(4):507-515.
  13. Takagi H, Mori Y, Umeda Y, Fukumoto Y, Kato Y, Shimokawa K, et al. Abdominal aortic aneurysm with arteritis in ankylosing spondylitis. J Vasc Surg. 2003;38(3):613-616.
  14. Wang CM, Tsai SC, Lin JC, Wu YJ, Wu J, Chen JY. Association of Genetic Variants of RANK, RANKL, and OPG with Ankylosing Spondylitis Clinical Features in Taiwanese. Mediators Inflamm. 2019;2019:8029863.
  15. Loddenkemper K, Burmester GR. What is the Rank of RANKL in Spondylarthritis? Arthritis Rheum. 2008;58(3):641-644.
  16. Rochette L, Meloux A, Rigal E, Zeller M, Cottin Y, Vergely C. The Role of Osteoprotegerin and Its Ligands in Vascular Function. Int J Mol Sci. 2019;20(3):705.
  17. Udagawa N, Koide M, Nakamura M, Nakamichi Y, Yamashita T, Uehara S, et al. Osteoclast differentiation by RANKL and OPG signaling pathways. J Bone Miner Metab. 2021;39(1):19-26.
  18. Saidenberg Kermanac’h N, Bessis N, Cohen-Solal M, De Vernejoul MC, Boissier MC. Osteoprotegerin and inflammation. Eur Cytokine Netw. 2002;13(2):144-153.
  19. Vandooren B, Cantaert T, Noordenbos T, Tak PP, Baeten D. The Abundant Synovial Expression of the RANK/RANKL/ Osteoprotegerin System in Peripheral Spondylarthritis Is Partially Disconnected From Inflammation. Arthritis Rheum. 2008;58(3):718-729.
  20. Crotti TN, Smith MD, Weedon H, Ahern MJ, Findlay DM, et al. Receptor activator NF-kappaB ligand (RANKL) expression in synovial tissue from patients with rheumatoid arthritis, spondyloarthropathy, osteoarthritis, and from normal patients: semiquantitative and quantitative analysis. Ann Rheum Dis. 2002;61(12):1047-1054.
  21. Kim HR, Lee SH, Kim HY. Elevated serum levels of soluble receptor activator of nuclear factors-kappaB ligand (sRANKL) and reduced bone mineral density in patients with ankylosing spondylitis (AS). Rheumatology (Oxford). 2006;45(10):1197-1200.
  22. Guder C, Gravius S, Burger C, Wirtz DC, Schildberg FA. Osteoimmunology: A Current Update of the Interplay Between Bone and the Immune System. Front Immunol. 2020;11:58.
  23. Fassio A, Atzeni F, Rossini M, D’Amico V, Cantatore F, Chimenti MS, et al., On Behalf Of The Study Group OnOsteoporosis And Skeletal Metabolic Diseases Of The Italian Society Of Rheumatology. Osteoimmunology of Spondyloarthritis. Int J Mol Sci. 2023;24(19):14924.
  24. Jones DH, Kong YY, Penninger JM. Role of RANKL and RANK in bone loss and arthritis. Ann Rheum Dis. 2002;61 Suppl 2:ii32-ii39.
  25. Chen CH, Chen HA, Liao HT, Liu CH, Tsai CY, Chou CT. Soluble receptor activator of nuclear factor-kappaBligand (RANKL) and osteoprotegerin in ankylosing spondylitis: OPG is associated with poor physical mobilityand reflects systemic inflammation. Clin Rheumatol. 2010;29(10):1155-1161.
  26. Cawley KM, Bustamante-Gomez NC, Guha AG, MacLeod RS, Xiong J, Gubrij I, et al. Local Production of Osteoprotegerin by Osteoblasts Suppresses Bone Resorption. Cell Rep. 2020;32(10):108052.
  27. Carrillo-López N, Martínez-Arias L, Fernández-Villabrille S, Ruiz-Torres MP, Dusso A, Cannata-Andía JB, et al.; European Renal Osteodystrophy (EUROD) Workgroup. Role of the RANK/RANKL/OPG and Wnt/β-Catenin Systems in CKD Bone and Cardiovascular Disorders. Calcif Tissue Int. 2021;108(4):439-451.
  28. Roldan CA, Chavez J, Wiest PW, Qualls CR, Crawford MH. Aortic root disease and valve disease associated with ankylosing spondylitis. J Am Coll Cardiol. 1998;32(5):1397-1404.
  29. García-Gómez MC, Vilahur G. Osteoporosis and vascular calcification: A shared scenario. Clin Investig Arterioscler. 2020;32(1):33-42. English, Spanish.
  30. Chen Y, Zhao X, Wu H. Arterial Stiffness: A Focus on Vascular Calcification and Its Link to Bone Mineralization. Arterioscler Thromb Vasc Biol. 2020;40(5):1078-1093.
  31. Ndip A, Williams A, Jude EB, Serracino-Inglott F, Richardson S, Smyth JV, et al. The RANKL/RANK/OPG Signaling Pathway Mediates Medial Arterial Calcification in Diabetic Charcot Neuroarthropathy. Diabetes. 2011;60(8):2187-2196.
  32. Jaminon A, Reesink K, Kroon A, Schurgers L. The Role of Vascular Smooth Muscle Cells in Arterial Remodeling: Focus on Calcification-Related Processes. Int J Mol Sci. 2019;20(22):5694.
  33. Eder L, Sadek M, McDonald-Blumer H, Gladman DD. Aortitis and Spondyloarthritis--An Unusual Presentation: Case Report and Review of the Literature. Semin Arthritis Rheum. 2010;39(6):510-514.
  34. Grewal GS, Leipsic J, Klinkhoff AV. Abdominal aortitis in HLA-B27+ spondyloarthritis: Case report with 5-year follow-up and literature review. Semin Arthritis Rheum. 2014;44(3):305-308.
  35. Lassalle C, Lonchampt MF, Puechal X, Dernis E. [Thoraco-abdominal aortitis in ankylosing spondylitis: A case reportand review of literature]. J Mal Vasc. 2011;36(3):200-208. French.
  36. Balčiūnaitė A, Budrikis A, Rumbinaitė E, Sabaliauskienė J, Patamsytė V, Lesauskaitė V.Ankylosing Spondyloarthritis Resulting Severe Aortic Insufficiency and Aortitis: Exacerbation of Ankylosing Spondyloarthritis and Stenosis of the Main Left Coronary Artery after Mechanical AorticValve Implantation with Cardiopulmonary Bypass. Case Rep Rheumatol. 2020;2020:9538527.
  37. Mehdipour Dalivand M, Abdolazimi R, Manafi-Farid R, Jamshidi A, Kassaee K, Foolad S,et al.A case of ankylosing spondylitis presenting with fever of unknown origin diagnosed as aortitis: A case report. Clin Case Rep. 2023;11(11):e8207.
  38. Angeli F, Verdecchia P, Masnaghetti S, Vaudo G, Reboldi G. Treatment strategies for isolated systolic hypertension in elderly patients. Expert Opin Pharmacother. 2020;21(14):1713-1723.
How to Cite
Aksonova, O. G., Kirzhner, G. D., & Smarovoz, Y. I. (2024). Descending Aorta Calcinosis and Hypertension in Patients with Radiographic Axial Spondyloarthritis. Ukrainian Journal of Cardiovascular Surgery, 32(2), 141-150.