Management of Cardiovascular Disease Risk in Rheumatoid Arthritis

Hypertension

Though not a universal finding, there may be an increased prevalence of hypertension in RA patients.^31,46 Nonsteroidal anti-inflammatory drug (NSAID) and glucocorticoid use may play a role in the development of hypertension, while DMARDs appear to exert a less substantial effect on blood pressure.^47,48 At least one study found that DMARD initiation (particularly for methotrexate and hydroxychloroquine) was associated with significant, albeit small, declines in both systolic and diastolic blood pressure over the first 6 months of treatment.⁴⁹

Despite its potentially higher prevalence in this population, hypertension is both underdiagnosed and undertreated in RA patients.^24,50-52 This is an important deficiency to target because, as in the general population, hypertension is associated with an increased risk of MI (RR, 1.84; 95% CI, 1.38-2.46) and composite CVD outcomes (RR, 2.24; 95% CI, 1.42-3.06) in RA.³⁷ Thresholds for initiation and escalation of antihypertensive therapy are not specific to the RA population; thus, diagnosis and management of hypertension should be informed by the American College of Cardiology/American Heart Association guidelines, treating those with in-office blood pressures exceeding 140/90 mm Hg (> 130/80 mm Hg if aged > 65 years or with concomitant CVD, DM, chronic kidney disease, or 10-year atherosclerotic cardiovascular disease risk > 10%), typically with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, or thiazide diuretics as comorbidities may dictate or allow.⁵³ Also, the use of NSAIDs and glucocorticoids should be minimized, particularly in those with concomitant hypertension.

Physical Activity

Likely due to factors such as articular pain and stiffness, as well as physical limitations, RA patients are more sedentary than the general population.^54,55 In a study of objectively assessed sedentary behavior in RA patients, greater average sedentary time per day and greater number of sedentary bouts (> 20 min) were associated with increased 10-year risk of CVD as assessed by the QRISK2.⁵⁶ Conversely, the beneficial effects of exercise are well documented. Light to moderate physical activity has been associated with improved cardiovascular outcomes, greater physical function, higher levels of HDL, as well as reduced systemic inflammation and disease activity, and improved endothelial function in RA patients.^57-61 While there has been concern that physical activity may result in accelerated joint damage, even high-intensity exercise was shown to be safe without causing significant progression of joint damage.⁵⁸

Obesity, Weight Loss, and Diet

While obesity is clearly associated with CVD risk in the general population, this relationship is much more complex in RA, as underweight RA patients are also at higher risk for CVD and CVD-related mortality.^62-64 One potential explanation for this finding is that pathological weight loss resulting in an underweight body mass index (BMI) is an independent predictor of CVD. In a study of US Veterans with RA, higher rates of weight loss (> 3 kg/m²/year) were associated with increased CVD mortality (HR, 2.27; 95% CI, 1.61-3.19) independent of BMI.⁶⁵ Systemic inflammation in RA can lead to “rheumatoid cachexia,” characterized by decreased muscle mass, increased adiposity, and increased CVD risk despite a normal or potentially decreased BMI.⁶⁶ Practitioners should be mindful of not only current body weight, but also patients’ weight trajectories when counseling on lifestyle practices such as healthy diet and regular exercise in RA patients. For obese individuals with RA, healthy weight loss should be encouraged. Interestingly, bariatric surgery in RA patients may improve RA disease activity in addition to its known effects on body weight and DM.⁶⁷

Counseling on healthy diet with a focus on limiting foods high in saturated- and trans-fatty acids and high glycemic index foods, and increasing consumption of fruits, vegetables, and mono-unsaturated fatty acids is a well-accepted and common practice to help minimize CVD risk in the general population.⁶⁸ No studies to date have investigated the effect of specific diets on CVD risk in RA patients, and thus we recommend adherence to general population recommendations.