Ankylosing spondylitis (AS) is increasingly reported to be at higher risk for cardiovascular morbidity, particularly represented as aortitis and aortic root dilation. However, the determinants of aortic root size in this population have not been fully investigated. To address the clinical and demographic factors underlying increased aortic root diameter (ARD) in patients with AS. The study enrolled 31 patients with AS. Echocardiography (ECG) was performed to measure the ARD. Demographic data, disease characteristics, cardiac functional status, disease duration, and medication history were collected. Data were analysed to identify independent predictors of ARD. This study enrolled 31 patients with ankylosing spondylitis, predominantly male (n=25, 80.6%), aged 37.3±11.2 years. The ECG findings demonstrated a high frequency of subclinical cardiac involvement, mild aortic valve regurgitation (29.0%), aortic root dilation (22.6%), and, less frequently, including diastolic impairment (16.1%), mild left ventricular systolic dysfunction (9.7%), and cardiac chamber abnormalities (9.7%). The most frequent associated dysfunction was aortic regurgitation, affecting five patients (71%). Diastolic dysfunction was noted in three patients (43%). ARD demonstrated a moderate positive correlation with patient age (r=+0.46, p=0.01) and a modest positive correlation with disease duration (r=+0.39, p=0.03). Aortic root dilation is present in AS patients and is unconventionally linked to male gender, disease chronicity, and inflammation. These outcomes imply that chronic control of inflammation and regular ECG monitoring, particularly in male patients with chronic disease, may be indicated to detect early aortic pathology.
Introduction
Ankylosing spondylitis (AS) has been described as a chronic inflammatory arthritis primarily affecting the sacroiliac joints and spine (Baronio et al., 2020; Ebrahimiadib et al., 2021; Bate et al., 2023; Nagdalian et al., 2024). However, the clinical findings of this ailment also involve the non-axial skeleton, as demonstrated by a range of extra-articular manifestations, including cardiovascular manifestations that carry a notable prognostic importance (Moutsopoulos & Zampeli, 2021; Assadiasl & Soleimanifar, 2022; Mehrzad et al., 2022; Del Vescovo et al., 2023; Venerito et al., 2023). The most important characteristic is a contribution to the proximal aorta, where inflammation can lead to root dilation and valvular deficits (Willerson & Buja, 2020; Sen et al., 2021; Huyen et al., 2023; Sakhnenkova et al., 2023). This process is subclinical and can silently proceed for years, only manifesting as a late-onset murmur of aortic regurgitation or as an acute aortic syndrome (Klingberg et al., 2015; Bozkurt et al., 2016; Chetrit et al., 2020; Shoghi & Kian, 2022; Petronis et al., 2023).
The clinical challenge is linked to detecting the aorta before extensive damage occurs (Chetrit et al., 2020; Ebrahimiadib et al., 2021). The etiology is multifaceted, involving continuous systemic inflammation, biomechanical pressure, and genetic deficits (Hwang et al., 2021; Efremov, 2023; Cantile et al., 2024). A model that measures the contribution of specific factors, such as disease type, past medical history, smoking status, and genetic markers, is lacking.
With advances in the management of AS, the control of musculoskeletal symptoms with new medications has proportionally increased the significance of extra-articular risks, including aortitis, a silent but overwhelming inflammation of the aortic root that can result in progressive dilation and, hence, aortic deficits. While ECG diagnosis is recommended, the criteria for which patients require screening remain obscure and constitute a rich area of research (Nguyen & Hoang, 2022; Efremov, 2023). This uncertainty pertained to the partial interpretation of the influences of aortic dilation in AS. The present study sought to underscore the risk factors influencing aortic root diameter via integrating data on disease severity, treatment exposure, and comorbidities (Trung et al., 2022; Ncube et al., 2023).
Materials and Methods
Study Design
A cross-sectional clinical study was conducted in a private clinic in Duhok City (Kurdistan region, Iraq). The study protocol was reviewed and approved by the College of Medicine (University of Duhok), and informed consent was obtained from individual participants.
Inclusion criteria included adult patients (≥18 years) diagnosed with AS according to the modified New York criteria. Patients were excluded from the final analysis for any of the following reasons:
Data Collection
Statistical Analysis
The data analyses were conducted using IBM SPSS Statistics (V28, USA). A two-tailed p-value of < 0.05 was considered statistically significant. Continuous variables expressed as mean ± SD, compared using a t-test. Categorical variables expressed as n (%), compared using chi-square/Fisher’s exact test. Pearson’s r is used for continuous predictors. Significance threshold considered at p < 0.05.
Results and Discussion
The present study enrolled 31 patients with ankylosing spondylitis, predominantly male (n=25, 80.6%), aged 37.3±11.2 years. The disease duration was 9.5±8.3years. The duration of biological therapy was 15.6±16.4 months (Table 1).
Table 1. Demographic and clinical characteristics of ankylosing spondylitis patients
|
demography |
Mean±SD (Range) |
|
Age, years |
37.3 ± 11.2 (17–56) |
|
Sex, M/F |
25/6 |
|
Disease duration, years |
9.5 ± 8.3 (0.25–35) |
|
Biological Agent Duration, months |
15.6 ± 16.4 |
The ECG findings demonstrated a high frequency of subclinical cardiac involvement, mild aortic valve regurgitation (29.0%), aortic root dilation (22.6%), and, less frequently, including diastolic impairment (16.1%), mild left ventricular systolic dysfunction (9.7%), and chamber abnormalities (9.7%) (Table 2).
Table 2. Echocardiographic Findings of Ankylosing Spondylitis Patients
|
Parameter |
Normal |
Abnormal (any grade) |
Abnormal (%) |
|
Aortic valve |
22 |
9 (mostly mild AR) |
29.0% |
|
Aortic root |
24 |
7 (mildly dilated/dilated) |
22.6% |
|
LV systolic function |
27 |
3 (mild dysfunction) |
9.7% |
|
Diastolic impairment |
25 |
5 (grade 1–mild) |
16.1% |
|
Cardiac chambers |
27 |
3 (mild dilation or LVH) |
9.7% |
|
Pericardial effusion |
30 |
0 |
0% |
Comparative study revealed that patients in the dilated aortic root group (n=7; 46.3±7.1 years) were older than those in the normal aortic root group (n=24; 34.8±8.4 years) (p = 0.008). The disease duration was significantly longer in the dilation group (13.1±5.4 years vs. 7.8±6.0 years, p=0.031). However, no significant differences were found between aortic root dilation and gender, duration of biologic therapy, or the extra-articular manifestations of peripheral arthritis and uveitis (p>0.05) (Table 3).
The most frequent associated abnormality was aortic regurgitation, affecting five patients (71%). Functional impairments were also common, with diastolic dysfunction noted in three patients (43%). Structurally, two patients (29%) presented with left ventricular hypertrophy (LVH), and in both cases, this was accompanied by mild systolic dysfunction, indicating a complex and severe cardiac phenotype (Table 3).
Table 3. Comparison between ankylosing spondylitis patients with and without aortic root dilation
|
Variables |
Normal Aortic Root (n = 24) |
Dilated Aortic Root (n = 7) |
p- value |
|
Age, years |
34.8±8.4 |
46.3 ± 7.1 |
0.008 |
|
Male gender |
18 (75 %) |
5 (71 %) |
0.81 |
|
Disease duration, years |
7.8 ± 6.0 |
13.1 ± 5.4 |
0.031 |
|
Biologic therapy duration, years |
2.4 ± 2.8 |
3.1 ± 2.9 |
0.52 |
|
Peripheral arthritis, yes |
7 (29 %) |
3 (43 %) |
0.48 |
|
Uveitis, yes |
5 (21 %) |
1 (14 %) |
0.68 |
The ECG findings in 7 cases with aortic root dilation have been shown that 4 patients presented with AR (2 mild AR and two trivial AR), and three with normal valvular results (Table 4).
Table 4. Echocardiographic abnormalities in patients with aortic root dilation (n = 7)
|
Age |
Gender |
Valvular Lesion |
LV Function |
Diastolic Grade |
Other Findings |
|
48 |
Male |
Trivial AR |
Normal EF |
None |
– |
|
55 |
Male |
Normal |
Normal EF |
None |
– |
|
38 |
Male |
Mild AR |
Normal EF |
Mild |
– |
|
56 |
Female |
Trivial AR |
Mild LV Dysfunction |
Mild |
LVH, Hypokinesia |
|
26 |
Female |
Normal |
Normal EF |
None |
– |
|
47 |
Male |
Mild AR |
Mild LV Dysfunction |
Mild |
LVH |
|
38 |
Male |
Mild AR |
Normal EF |
Mild |
– |
Aortic root diameter demonstrated a moderate positive correlation with patient age (r=+0.46, p=0.01) and a modest positive correlation with disease duration (r=+0.39, p=0.03), while the duration of biologic therapy, a history of peripheral arthritis, and a history of uveitis demonstrated no significant correlation with aortic root diameter (p>0.05) (Table 5).
Table 5. Correlation of clinical and demographic parameters with aortic root diameter
|
Variable |
Correlation with Aortic Root Diameter (r) |
p-value |
|
Age |
+0.46 |
0.01 |
|
Disease duration |
+0.39 |
0.03 |
|
Biologic therapy duration |
+0.12 |
0.55 |
|
Peripheral arthritis |
+0.18 |
0.33 |
|
Uveitis |
+0.09 |
0.64 |
The patients enrolled in the present study are characteristic of the phenotypic presentation of AS, as reflected by a higher male prevalence and early disease onset. The male-to-female ratio is 4:1 (80.6% male), which is consistent with published epidemiological data (Ncube et al., 2023; Tam et al., 2023; Anderson et al., 2024; Gentile et al., 2024; Kariri et al., 2024), that consistently report a higher rate and more severe disease in male patients (Bakland et al., 2011; van der Horst-Bruinsma et al., 2013; Rutten et al., 2022). The age of patients (37.3 years) and the disease duration (9.5 years) reflect the chronic nature of AS, which is evident in immediate adulthood, with a wider disease duration (0.25 to 35 years) (Ebrahimiadib et al., 2021; Hwang et al., 2021; Machate et al., 2022; Xie et al., 2023).
The duration of biological agent administration (15.6 months) indicates that a large number of patients have been subjected to long-term therapy (Lindström et al., 2019; Tański, Świątoniowska-Lonc, et al., 2021). These results are crucial, as they confirm that the study population is matched for investigating cardiac indices of AS in settings pertinent to rheumatological practice (Candemir et al., 2020; Sen et al., 2021; Januszewicz et al., 2022).
ECG results demonstrated subclinical cardiac association in patients with AS, confirming the systemic inflammatory potential of this condition (Grygiel-Górniak et al., 2020; Tański et al., 2021; Hassan & Hatah, 2022). The findings related to the aortic root and valve align with the known predilection of AS for aortitis, leading to chronic inflammation and, in turn, scarring of the aortic wall at the base of the valve cusps, resulting in root dilation and valvular deficits (Grygiel-Górniak et al., 2020; Willerson & Buja, 2020; Silva-Hormazábal & Alsina, 2023). Moreover, diastolic and systolic impairment, diastolic dysfunction is a consequence of myocardial inflammation, which can interrupt ventricular relaxation (Triantafyllou et al., 2021; Guo et al., 2022; Gulhane & Ordovas, 2023; Khalil, 2023), reflecting the disconnect between rheumatic and cardiac disease, because some of these ECG findings were positive in asymptomatic patients (Candemir et al., 2020; Sen et al., 2021; Constantin et al., 2022), necessitating the routine care of AS patients to mitigate long-term morbidity.
Older age and longer disease duration are non-modifiable risk factors; patients with aortic root dilation were older and had 5 more years of disease duration on average compared to those with normal aortic roots (Naser et al., 2023; Singh et al., 2023; Fabris et al., 2025). The long-term effects of insults on elastic aortic tissue lead to continuous dilation over time (Mitchell, 2018; Zhou et al., 2022; Kajanova & Badrov, 2024).
The duration of biologic therapy may be insufficient to halt the progression of subclinical aortopathy in all patients (Williams, 2024). Moreover, the lack of correlation with other extra-articular manifestations (e.g., peripheral arthritis and uveitis) necessitates echocardiographic screening (van der Horst-Bruinsma et al., 2013; Uccello et al., 2024) in older AS patients and those with long disease duration, to enable early diagnosis and management (Toussirot, 2015; Crossfield et al., 2021; Lembo et al., 2023). The high prevalence of AR in 71% of these patients reflects a direct mechanistic link; dilation of the aortic root mechanically dilates the valve base, leading to valvular dysfunction.
Other cardiac involvements, such as diastolic impairment, left ventricular hypertrophy, and mild systolic dysfunction, are consistent with a phenotype of AS cardiomyopathy, which is thought to arise from inflammation, vasculopathy, and secondary hemodynamic collapse from chronic AR (Ciarambino et al., 2021; Januszewicz et al., 2022; Ajmone Marsan et al., 2024; Uccello et al., 2024; Gasimova et al., 2025).
This clustering of cardiac abnormalities in patients with aortic root dilation suggests that the diagnosis of an aortic root abnormality should not be viewed as a singular finding but rather as a cluster of diseases to differentiate from associated progressive valvular and myocardial disease (Willerson & Buja, 2020; Zhou et al., 2022). The progressive nature of aortopathy in AS reflects that the inflammatory damage to the aortic wall is not a single event but a continuous process, in which cumulative inflammation leads to progressive structural deterioration and dilation (Hwang et al., 2021; Assadiasl & Soleimanifar, 2022). This finding solidifies the concept that time is a determinant of cardiac risk in AS. No correlation with the duration of biologic therapy exists, perhaps due to the intrinsic nature of the disease, or it may reflect that treatment was started after irreversible damage had already been initiated.
Conclusion
The study found that aortic root diameter in AS is more frequent in males, and that disease duration and systemic inflammation are associated with greater strength, highlighting a subset of AS patients who may need cardiovascular screening and thereby mitigate the long-term cardiovascular sequelae of this inflammatory condition.
Acknowledgments: The author is grateful to the University of Duhok for the provided support that encourage conducting this study.
Conflict of interest: None
Financial support: None
Ethics statement: The present study registered for approval in the College of Medicine, University of Duhok (Approval Code 10552 on 01 Aug 2024).
Ajmone Marsan, N., Graziani, F., Meucci, M. C., Wu, H. W., Lillo, R., Bax, J. J., Burzotta, F., Massetti, M., Jukema, J. W., & Crea, F. (2024). Valvular heart disease and cardiomyopathy: Reappraisal of their interplay. Nature Reviews Cardiology, 21(1), 37–50. doi:10.1038/s41569-023-00911-0
Anderson, E., Beier, S., & Desmarais, J. (2024). Certolizumab pegol in the treatment of axial spondyloarthritis. Immunotherapy, 16(8), 501–511. doi:10.2217/imt-2023-0225
Assadiasl, S., & Soleimanifar, N. (2022). An overview to ankylosing spondylitis and spondyloarthropathies. In M. H. Nicknam (Ed.), Ankylosing spondylitis - Axial spondyloarthritis: Cellular, molecular and environmental factors (pp. 3–21). Springer Singapore. doi:10.1007/978-981-16-4733-8_1
Bakland, G., Gran, J. T., & Nossent, J. C. (2011). Increased mortality in ankylosing spondylitis is related to disease activity. Annals of the Rheumatic Diseases, 70(11), 1921–1925. doi:10.1136/ard.2011.151191
Baronio, M. S. H., Hajra, P. S. P., D. M. D., G. V. A. N., & G. B. M. (2020). Etiopathogenesis of sacroiliitis: Implications for assessment and management. Kjp, 33(4), 294–304. doi:10.3344/kjp.2020.33.4.294
Bate, G. B., Adeleye, A. O., Ijanu, E. M., Olalere, E. O., Amoo, A. O., Asaju, C. I., Shiaka, P. G., & Yerima, M. B. (2023). Quality assessment of wastewater: Physicochemical and bacteriological evidence from Dutse Abattoir, North-West Nigeria. World Journal of Environmental Biosciences, 12(3), 58–66. doi:10.51847/5xxrD8Fbka
Bozkurt, B., Colvin, M., Cook, J., Cooper, L. T., Deswal, A., Fonarow, G. C., Francis, G. S., Lenihan, D., Lewis, E. F., McNamara, D. M., et al. (2016). Current diagnostic and treatment strategies for specific dilated cardiomyopathies: A scientific statement from the American Heart Association. Circulation, 134(23), e579–e646. doi:10.1161/CIR.0000000000000455
Candemir, M., Candemir, B., & Ertürk, A. (2020). Evaluation of cardiac autonomic nervous system in patients with ankylosing spondylitis using 12-lead electrocardiography and Holter monitoring. Clinical Rheumatology, 39(9), 2631–2639. doi:10.1007/s10067-020-05046-y
Cantile, T., Lombardi, S., Quaraniello, M., Riccitiello, F., Leuci, S., & Riccitiello, A. (2024). Studying the knowledge and behavior of parents in dealing with children’s dental injuries. Annals of Dental Specialties, 12(2), 1–5. doi:10.51847/FYF9lXJwPt
Chetrit, M., Khan, M. A., & Kapadia, S. (2020). State of the art management of aortic valve disease in ankylosing spondylitis. Current Rheumatology Reports, 22(6), 23. doi:10.1007/s11926-020-00898-4
Ciarambino, T., Menna, G., Sansone, G., & Giordano, M. (2021). Cardiomyopathies: An overview. International Journal of Molecular Sciences, 22(14). doi:10.3390/ijms22147722
Constantin, V. D., Silaghi, A., Epistatu, D., Dumitriu, A. S., Paunica, S., Bălan, D. G., & Socea, B. (2022). Diagnostic and therapeutic insights into colorectal carcinoma. Archives of International Journal of Cancer & Allied Sciences, 2(1), 24–28. doi:10.51847/HojLmKBDvP
Crossfield, S. S. R., Marzo-Ortega, H., Kingsbury, S. R., Pujades-Rodriguez, M., & Conaghan, P. G. (2021). Changes in ankylosing spondylitis incidence, prevalence and time to diagnosis over two decades. RMD Open, 7(3), e001888. doi:10.1136/rmdopen-2021-001888
Del Vescovo, S., Venerito, V., Iannone, C., & Lopalco, G. (2023). Uncovering the underworld of axial spondyloarthritis. International Journal of Molecular Sciences, 24(7). doi:10.3390/ijms24076463
Ebrahimiadib, N., Berijani, S., Ghahari, M., & Pahlaviani, F. G. (2021). Ankylosing spondylitis. Journal of Ophthalmic & Vision Research, 16(3), 462–469. doi:10.18502/jovr.v16i3.9440
Efremov, A. (2023). Relieving psychosomatic pain and negative emotions through dehypnosis. Asian Journal of Individual and Organizational Behavior, 3, 18–24. doi:10.51847/BPFsWgpeFd
Fabris, C., Rizzo, E., Bertolissi, S., Casatta, L., Pavan, M., & Toniutto, P. (2025). Modifiable and non-modifiable risk factors and vascular damage progression in type 2 diabetes: A primary care analysis. Journal of Clinical Medicine, 14(9). doi:10.3390/jcm14093155
Gasimova, F. N., Babayeva, G. H., Nur-Mammadova, G. S., Babayeva, L. K., Makhaddin, G. I., Atakishiyeva, V. N., Mammadov, M. Y., & Niftiyev, P. G. (2025). Inflammatory heart disease in patients with rheumatological profile. In D. C. Gaze (Ed.), Inflammatory myocardial diseases. IntechOpen. doi:10.5772/intechopen.1008794
Gentile, P., Aldigeri, R., Mastrofilippo, V., Bolletta, E., Simone, L. De, Gozzi, F., Ragusa, E., Ponti, L., Adani, C., Zanelli, M., et al. (2024). Reggio Emilia (Northern Italy) interdisciplinary uveitis clinic: What we have learned in the last 20 years. Ocular Immunology and Inflammation, 32(8), 1777–1787. doi:10.1080/09273948.2023.2296617
Grygiel-Górniak, B., Oduah, M.-T., Olagunju, A., & Klokner, M. (2020). Disorders of the aorta and aortic valve in connective tissue diseases. Current Cardiology Reports, 22(8), 70. doi:10.1007/s11886-020-01314-0
Gulhane, A., & Ordovas, K. (2023). Cardiac magnetic resonance assessment of cardiac involvement in autoimmune diseases. Frontiers in Cardiovascular Medicine, 10(September), 7–9. doi:10.3389/fcvm.2023.1215907
Guo, L., He, Y., Sun, Y., Chan, J. S. M., You, J., Jia, L., Wang, Q., Ganesan, K., & Chen, J. (2022). Longitudinal study on the characteristics of traditional Chinese medicine (TCM) constitutions and related influencing factors in women in Hong Kong. Journal of Medical Sciences & Interdisciplinary Research, 2(1), 23–35. doi:10.51847/B0MHcO112v
Hassan, F., & Hatah, E. (2022). An analytical exploration of various non-pharmacological approaches utilized in managing diabetes among patients in Malaysia. International Journal of Social Psychology Aspects of Healthcare, 2, 27–37. doi:10.51847/JmKuHOeBQX
Huyen, N. T., Nghi, P. H., Phuong, Đ. T. L., Trang, T. T. T., & Huyen, L. T. (2023). Public debt and prosperity nexus in Asian countries: Nonlinearity and threshold analysis. Journal of Organizational Behavior Research, 8(1), 74–91. doi:10.51847/tw5g65dco8
Hwang, M. C., Ridley, L., & Reveille, J. D. (2021). Ankylosing spondylitis risk factors: A systematic literature review. Clinical Rheumatology, 40(8), 3079–3093. doi:10.1007/s10067-021-05679-7
Januszewicz, A., Mulatero, P., Dobrowolski, P., Monticone, S., van der Niepen, P., Sarafidis, P., Reincke, M., Rexhaj, E., Eisenhofer, G., Januszewicz, M., et al. (2022). Cardiac phenotypes in secondary hypertension. JACC, 80(15), 1480–1497. doi:10.1016/j.jacc.2022.08.714
Kajanova, J., & Badrov, A. (2024). Medical students’ perspectives on trust in medical AI: A quantitative comparative study. Asian Journal of Ethics in Health & Medicine, 4, 44–57. doi:10.51847/36mpdZ9AZ8
Kariri, H. D. H., Radwan, O. A., Somaili, H. E., Mansour, M. E. I., Mathkoor, S. A., & Gohal, K. M. M. (2024). The role of psychological capital in enhancing empowerment among female leadership. Annals of Organizational Culture, Communications and Leadership, 5, 17–27. doi:10.51847/w41TjwMAzM
Khalil, A. M. (2023). Advances in epigenome engineering: Mastering technical approaches for better outcomes. Journal of Medical Sciences & Interdisciplinary Research, 3(2), 21–34. doi:10.51847/iBbxxQHVQH
Klingberg, E., Sveälv, B. G., Täng, M. S., Bech-Hanssen, O., Forsblad-d’Elia, H., & Bergfeldt, L. (2015). Aortic regurgitation is common in ankylosing spondylitis: Time for routine echocardiography evaluation? The American Journal of Medicine, 128(11), 1244–1250.e1. doi:10.1016/j.amjmed.2015.04.032
Lembo, L., Barra, M., & Iriti, A. (2023). Building trust in the application of machine learning algorithms for rare disease diagnosis. Asian Journal of Ethics in Health & Medicine, 3, 26–39. doi:10.51847/Mo7NXmiBnA
Lindström, U., Olofsson, T., Wedrén, S., Qirjazo, I., & Askling, J. (2019). Biological treatment of ankylosing spondylitis: A nationwide study of treatment trajectories on a patient level in clinical practice. Arthritis Research & Therapy, 21(1), 128. doi:10.1186/s13075-019-1908-9
Machate, D. J., Figueiredo, P. S., Marcelino, G., Guimarães, R. D., Hiane, P. A., Bogo, D., Pinheiro, V. A., de Oliveira, L. C., & Pott, A. (2022). Impact of fresh coconut oil on the gastrointestinal microbiome and hematological/biochemical parameters in Wistar rats. Special Journal of Pharmacognosy, Phytochemistry & Biotechnology, 2, 1–7. doi:10.51847/q69gWhtCds
Mehrzad, K., Yazdanpanah, F., Arab, M., Ghasemi, M., & Radfar, A. (2022). Relationship between stress, anxiety, and depression with happiness in students of Bam medical university in 2019. Journal of Advanced Pharmacy Education & Research, 12(2), 51–56. doi:10.51847/dJZ1dCmMK6
Mitchell, G. F. (2018). Aortic stiffness, pressure and flow pulsatility, and target organ damage. Journal of Applied Physiology, 125(6), 1871–1880. doi:10.1152/japplphysiol.00108.2018
Moutsopoulos, H. M., & Zampeli, E. (2021). Inflammatory arthritides. In H. M. Moutsopoulos & E. Zampeli (Eds.), Immunology and rheumatology in questions (pp. 51–75). Springer International Publishing. doi:10.1007/978-3-030-56670-8_3
Nagdalian, A., Askerova, A., Blinov, A., & Shariati, M. A. (2024). Evaluation of the toxicity of copper oxide nanoparticles toward pea seeds. World Journal of Environmental Biosciences, 13(3), 23–30. doi:10.51847/A2gMbUMBUD
Naser, J. A., Michelena, H. I., Lin, G., Scott, C. G., Lee, E., Kennedy, A. M., Noseworthy, P. A., Pellikka, P. A., Nkomo, V. T., & Pislaru, S. V. (2023). Incidence, risk factors, and outcomes of atrial functional mitral regurgitation in patients with atrial fibrillation or sinus rhythm. European Heart Journal - Cardiovascular Imaging, 24(11), 1450–1457. doi:10.1093/ehjci/jead199
Ncube, M., Sibanda, M., & Matenda, F. R. (2023). The influence of AI and the pandemic on BRICS nations: South Africa’s economic performance during crisis. Annals of Organizational Culture, Communications and Leadership, 4, 17–24. doi:10.51847/lrMvYTE3OF
Nguyen, D. T., & Hoang, T. H. (2022). The influence of organizational capabilities on operational efficiency: A study of Vietnamese businesses. Asian Journal of Individual and Organizational Behavior, 2, 15–20. doi:10.51847/PapKxH2ZYU
Petronis, Z., Pliatkute, I., Janovskiene, A., & Leketas, M. (2023). The relationship between cervical spine abnormalities and temporomandibular joint internal disorders: A systematic review of literature. Annals of Dental Specialties, 11(4), 20–28. doi:10.51847/sGUN5P9OQA
Rutten, F. H., Taylor, C. J., Brouwer, J. R., & Hobbs, F. D. R. (2022). Optimizing diagnosis and treatment of congestive heart failure in primary health settings. Annals of Pharmacy Practice & Pharmacotherapy, 2, 1–5. doi:10.51847/fV3G1GDG03
Sakhnenkova, T. I., Abdul-Kadyrova, L. R., Akhilgova, Z. A., Brovikova, A. A., Markov, O. O., & Saribekyan, A. A. (2023). Morphological and biochemical analysis of a 3D scaffold based on biocompatible polymer for tissue engineering. Journal of Advanced Pharmacy Education & Research, 13(3), 29–33. doi:10.51847/v8o0GbXJdN
Sen, G., Gordon, P., & Sado, D. M. (2021). Cardiac manifestations of rheumatological disease: A synopsis for the cardiologist. Heart, 107(14), 1173–1181. doi:10.1136/heartjnl-2019-316460
Shoghi, B., & Kian, H. (2022). The role of managers in developing creativity and managing talent. Journal of Organizational Behavior Research, 7(2), 18–29. doi:10.51847/uy31rvfml2
Silva-Hormazábal, M., & Alsina, Á. (2023). Exploring the impact of integrated education on medical sciences: A comprehensive review. Annals of Pharmacy Education, Safety & Public Health Advocacy, 3, 30–36. doi:10.51847/h9MdCIGsUf
Singh, N., Pradhan, P., Giri, R., & Satapathy, D. (2023). Ki-67 expression as a complementary marker for histopathological grading of astrocytic tumors. Archives of International Journal of Cancer & Allied Sciences, 3(2), 5–10. doi:10.51847/u7xvxvsgKS
Tam, L. T., An, H. T. T., Linh, T. K., Nhung, L. T. H., Ha, T. N. V., Huy, P. Q., & Luc, P. T. (2023). The Impact of COVID-19 on Value Co-Creation Activities: A Study of Economics Students in Vietnam. Annals of Organizational Culture, Leadership and External Engagement Journal, 4, 25-34. doi:10.51847/QeaHrAoLoL
Tański, W., Gać, P., Chachaj, A., Sobieszczańska, M., Poręba, R., & Szuba, A. (2021). Selected clinical parameters and changes in cardiac morphology and function assessed by magnetic resonance imaging in patients with rheumatoid arthritis and ankylosing spondylitis without clinically apparent heart disease. Clinical Rheumatology, 40(11), 4701–4711. doi:10.1007/s10067-021-05777-6
Tański, W., Świ\katoniowska-Lonc, N., Dudek, K., & Jankowska-Polańska, B. (2021). Benefit of biological drugs for quality of life in patients with ankylosing spondylitis: A systematic review and meta-analysis of clinical trials. In M. Pokorski (Ed.), Best practice in health care (pp. 63–78). Springer International Publishing. doi:10.1007/5584_2020_611
Toussirot, É. (2015). Diagnosis and management of late-onset spondyloarthritis: Implications of treat-to-target recommendations. Drugs & Aging, 32(7), 515–524. doi:10.1007/s40266-015-0280-y
Triantafyllou, C., Nikolaou, M., Ikonomidis, I., Bamias, G., Kouretas, D., Andreadou, I., Tsoumani, M., Thymis, J., & Papaconstantinou, I. (2021). Effects of anti-inflammatory treatment and surgical intervention on endothelial glycocalyx, peripheral and coronary microcirculatory function and myocardial deformation in inflammatory bowel disease patients: A two-arms two-stage clinical trial. Diagnostics, 11(6). doi:10.3390/diagnostics11060993
Trung, N. D., Diep, N. T., Huy, D. T. N., Mai, H. L. T., & Thanh, T. V. (2022). Assessment of industrial cluster infrastructure and recommendations for improvement in Hanoi, Vietnam. Annals of Organizational Culture, Communications and Leadership, 3, 40–48. doi:10.51847/ghwShR5782
Uccello, G., Bonacchi, G., Rossi, V. A., Montrasio, G., & Beltrami, M. (2024). Myocarditis and chronic inflammatory cardiomyopathy, from acute inflammation to chronic inflammatory damage: An update on pathophysiology and diagnosis. Journal of Clinical Medicine, 13(1). doi:10.3390/jcm13010150
van der Horst-Bruinsma, I. E., Zack, D. J., Szumski, A., & Koenig, A. S. (2013). Female patients with ankylosing spondylitis: Analysis of the impact of gender across treatment studies. Annals of the Rheumatic Diseases, 72(7), 1221–1224. doi:10.1136/annrheumdis-2012-202431
Venerito, V., Del Vescovo, S., Lopalco, G., & Proft, F. (2023). Beyond the horizon: Innovations and future directions in axial-spondyloarthritis. Archives of Rheumatology, 38(4), 491–511. doi:10.46497/ArchRheumatol.2023.10580
Willerson, J. T., & Buja, L. M. (2020). Inflammation injury and selected disease processes causing aortic root and aortic valvular inflammation. In B. A. Carabello (Ed.), Valvular heart disease (pp. 51–70). Springer London. doi:10.1007/978-1-4471-2840-3_4
Williams, K. J. (2024). Eradicating atherosclerotic events by targeting early subclinical disease: It is time to retire the therapeutic paradigm of too much, too late. Arteriosclerosis, Thrombosis, and Vascular Biology, 44(1), 48–64. doi:10.1161/ATVBAHA.123.320065
Xie, B., Liu, Y., Li, X., Yang, P., & He, W. (2023). Enhancing the dissolution rate of dolutegravir sodium using nanosuspension technology and a 32 factorial design. Pharmaceutical Sciences & Drug Design, 3, 12–19. doi:10.51847/2uCOYf3jPn
Zhou, Z., Cecchi, A. C., Prakash, S. K., & Milewicz, D. M. (2022). Risk factors for thoracic aortic dissection. Genes, 13(10). doi:10.3390/genes13101814
