Managing Cardiovascular Risk in Patients With Rheumatoid Arthritis

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EULAR suggests caution when using NSAIDs and prescribing only the lowest effective dose for steroids. But other RA medications may lower CVD risk.
EULAR suggests caution when using NSAIDs and prescribing only the lowest effective dose for steroids. But other RA medications may lower CVD risk.

Patients living with rheumatoid arthritis (RA) also have an increased risk of cardiovascular disease (CVD). Although RA and CVD share some common risk factors, inflammation makes RA an independent risk factor for CVD. 1,2

“Shared risk factors like obesity and inactivity may contribute, but inflammation is the key reason why people with RA have double the risk of cardiovascular disease,” said Harry D. Fischer, MD, chief of rheumatology at Mount Sinai Beth Israel in New York City. 

Chronic inflammation has an important role in atherogenesis and may exacerbate other cardiovascular risk factors. Several CVD risk score models are used to assess risk in the general population, but these algorithms may underestimate the risk of CVD in people with RA. 1,3

Assessing CVD Risk in RA

“We don't have a risk calculator specific for RA. The European League Against Rheumatism (EULAR), suggests using one of the existing risk calculators, such as the Framingham Risk Score or the Systematic Coronary Risk Evaluation algorithm, and multiplying the score by 1.5 to approximate the risk for people with RA,” said Jeffrey Curtis, MD, professor of rheumatology at the University of Alabama School of Medicine in Birmingham.

Commonly used guidelines for CVD risk may include risk factors such as age, race, high blood pressure, lipid profile, diabetes, and smoking status. They usually do not include specific markers of inflammation such as high-sensitivity C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). 1,2,3

A 2015 study, published in the Annals of the Rheumatic Diseases, attempted to recalibrate the Systematic Coronary Risk Evaluation (SCORE) algorithm by reweighing some traditional CVD risk factors and adding some risk predictors specific to RA. These included rheumatoid factor status, anti-cyclic citrullinated peptide status, ESR, and swollen joint count. Unfortunately, the predictive value of the adapted SCORE in 1,016 RA patients was not any more predictive of future CVD than the original SCORE algorithm. 1

Coming up with guidelines to predict CVD in RA is complicated. Another study, also published in the Annals of the Rheumatic Diseases in 2015, examined the association of serum lipids and inflammatory markers of coronary heart disease in a cohort of more than 37,000 RA patients in the Veterans Health Administration system. 

The study found no clear association between low-density lipoprotein cholesterol and coronary heart disease. But high-density lipoprotein cholesterol was inversely proportional to stroke and heart attack risk. Elevated CRP and ESR were associated with increased risk of stroke and heart attack. 2

Best Practice for Managing CVD Risk in RA

Until a better tool comes along for assessing RA-specific CVD risk, aggressive management of inflammation and aggressive treatment of traditional risk factors is the best practice.

 “Rheumatologists do this naturally when they search for disease activity. Reducing disease activity reduces inflammation, which is probably the best way to reduce cardiovascular risk,” said Fischer. 

“Another consideration is when to use statins in patients with RA. If traditional risk scores should be multiplied by 1.5, can you make a case for a similar approach to the statin risk calculator suggested by the American Heart Association? Should the threshold for statins be lower in RA? That is a hot topic. There is an ongoing study to see if an RA-specific risk calculator might be appropriate for statin use,” said Curtis. 

The Role of RA Medications in CVD Risk

Both NSAIDs and steroids are known to increase CVD risk in general, and these are medications commonly used in RA. EULAR suggests caution when using NSAIDs and prescribing only the lowest effective dose for steroids. But other RA medications may lower CVD risk. 1 

“Methotrexate is known to lower inflammation and CVD risk. In fact, there is study going on to see if methotrexate can lower CVD risk in people without RA,” said Curtis.

The TNF inhibitors and the new biologic RA drugs may also reduce cardiovascular risk, but understanding their long-term effects on CVD is still a work in progress. “The biologics are still a wild card. They may increase lipids while still decreasing CVD risk. We need more studies to find out if the increase in lipids is clinically significant,” said Fischer.

“Evaluating CVD risk in RA is still a conundrum. What is important for primary care providers to know is that they may be in a better position to understand and implement the current cholesterol guidelines than rheumatologists. This is an evolving area where rheumatology and primary care can benefit from collaborative management,” said Curtis. 

Medically reviewed by: Pat F. Bass III, MD, MS, MPH

References

1.     Arts EEA, et al. Ann Rheum Dis. 2015; DOI: 10.1136/annrheumdis-2014-206879 

2.     Navarro-Millan I, et al. Ann Rheum Dis. 2015; DOI: 10.1136/annrheumdis-2013-204987

3.     Peters MJL.  Ann Rheum Dis, 2010, 69:325-331 

 

 

 

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