BOSTON – Heart failure appears to be treated less aggressively in people with concomitant rheumatoid arthritis, based on the results of a community-based cohort study.
The findings, which were reported at the annual meeting of the American College of Rheumatology, showed that treatment disparities may account for some of the excess cardiovascular mortality in RA patients.
Optimizing the treatment of heart failure in RA could lead to improved survival and should be a priority, according to one of the study's investigators, Dr. John M Davis III of the Mayo Clinic in Rochester, Minn.
“The clinical implication is that we need to maintain a high index of suspicion for signs and symptoms of heart failure, order appropriate work-up, and consider cardiovascular referral and/or therapies,” he said in an interview.
Dr. Davis and his colleagues studied 309 patients, 103 with and 206 without RA. Their mean age was 78 years, and all had heart failure as defined by Framingham criteria. Medical charts were reviewed for data on the use of echocardiograms and the prescription of cardiovascular drugs, including ACE inhibitors, β-blockers, and diuretics, both before and after heart failure diagnosis. The researchers used chi-square tests and logistic regression models to examine the differences between the two groups.
The prevalence of ischemic heart disease was 24% in those with RA and 40% in those without. Hypertension was less prevalent in the RA patients (60% vs. 70%), but smoking was more prevalent (55% vs. 44%).
Fewer than half (47%) of the RA patients and 61% of those without RA received an echocardiogram within 90 days of their heart failure diagnosis, a significant difference. The difference persisted after adjusting for ischemic heart disease, hypertension, and smoking, Dr. Davis stated, noting that the odds ratio for receiving an echocardiogram among RA patients, compared with those without RA, was 0.53. In addition, 40% of the heart failure patients with RA and 84% of those without RA received cardiovascular medications within 60 days following diagnosis.
“The signs and symptoms of heart failure appear to be more subtle in the RA population, so there may be some difficulty in terms of recognition,” he said in an interview. Other disease factors might mask heart failure symptoms. “[Arthritis] patients' sedentary status limits the ability to develop exertional symptoms; interstitial lung changes can confound the pulmonary exam for edema; and swelling in the ankles could be interpreted as arthritis and not edema,” he said. In addition, long medication lists might discourage adding cardiovascular treatments and introduce compliance issues in patients.