Rheumatoid arthritis increases cardiovascular risks as much as diabetes does, but guidelines and quality indicators fail to adequately address cardiovascular disease prevention for RA patients, authors of the first systematic review on the topic wrote in Arthritis Care & Research.
To date, only one guideline has focused entirely on the topic, and guidelines are too general to be used in adherence or quality improvement efforts, Dr. Claire Barber of the division of rheumatology at the University of Calgary (Alta.) and her associates reported. Furthermore, just four quality indicators have targeted CVD risk in RA patients, the investigators found (Arthritis Care Res. 2014 July 29 [doi:10.1002/acr.22419]).
The researchers searched MEDLINE, EMBASE, CINAHL, Web of Science, and other sources to find 16,064 abstracts on CVD or RA since 2008 that mentioned guidelines or quality indicators. Of these, they fully reviewed 808 manuscripts, and scored 10 guidelines with the six-domain Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument, they said.
Only two guidelines recommended using a cardiovascular risk score, and only one, from the European League Against Rheumatism, suggested adjusting that score to account for RA, the researchers said. The guidelines also lacked thresholds for treating modifiable risk factors and did not clarify whether such thresholds should be lower than for the general population, they added.
Furthermore, the recommendations did clearly guide clinicians on monitoring or treating side effects of drugs such tocilizumab – which can cause dyslipidemia – and leflunomide, which can cause hypertension, said the investigators.
Levels of supporting evidence for guidelines also varied, and many recommendations lacked high-level evidence, particularly related to diet and exercise, the researchers said.
The four quality indicators included general screening for comorbidities, formal estimation of CVD risk, exercise, and minimizing use of steroids, the investigators said. The measures "did not cover the recognized breadth of CVD preventive care in RA," they added.
Future research should focus on how best to evaluate CVD risk in RA patients and should determine thresholds for lipid-lowering medications and other treatments, the investigators said. In the meantime, they recommended developing quality indicators for preventing CVD in RA based on the guidelines reviewed and on general population recommendations.
The research was supported by grants from Alberta Innovates Health Solutions, UCB Canada, the Canadian Rheumatology Association, and the Arthritis Society. The authors did not disclose conflicts of interest.