The jury is still out on just how cardiovascular risk should be screened and managed in rheumatoid arthritis patients, but it is clear that the risk is increased and must be addressed.
Patients with RA are known to have a lower probability of survival than do controls, and a major cause of excess death is from cardiovascular disease. In one study, silent MI occurred more often in RA patients, and sudden death was more likely in these patients (Arthritis Rheum. 2005;52:402-11). In another study, survival among patients with acute cardiac syndrome was substantially reduced in RA vs. non-RA patients (Ann. Rheum. Dis. 2006;65:348-53).
Some experts say RA is now equivalent to diabetes in terms of the extent to which it confers cardiovascular risk, according to Dr. Joan Bathon, director of the division of rheumatology at Columbia University, New York.
The European League Against Rheumatism has proposed multiplying conventional cardiovascular risk models by 1.5 when risk is assessed in RA patients, said Dr. Bathon (Ann. Rheum. Dis. 2010;69:325-31).
This approach is not well validated, and may not be widely used, she said. But the proposal illustrates the importance of focusing on cardiovascular risk in RA patients. It suggests that considering RA as a risk factor equivalent to diabetes – at least for making decisions about LDL cholesterol goals – is a reasonable strategy, she said.
Consider yearly cardiovascular risk screening, she said. The benefits of imaging and biomarkers are unclear, and no guidelines are in place. As a management strategy, aspirin therapy might be useful, but should be considered in the context of the patient's other medications. Statins are a potential management tool, but questions remain about whether all RA patients should be treated regardless of LDL cholesterol level, Dr. Bathon said.
Definite treatment strategies for RA patients include weight management for overweight patients, to help reduce inflammation, as well as exercise for all RA patients, because good quality muscle building will help restore insulin sensitivity and reduce fat depots that are the most inflammatory. Tight blood pressure control and tight RA control are imperative, Dr. Bathon said.
She noted that conventional risk factors do not fully explain the excess risk in RA patients, and that inflammation probably plays a role.
Dr. Bathon said she had no disclosures.