Heart Disease Dogs Arthritis Patients

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 myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA 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).

In fact, RA is now considered by some experts to be equivalent to diabetes mellitus 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 (EULAR) has proposed that conventional cardiovascular risk models be multiplied 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 at this point, according to Dr. Bathon. But the proposal illustrates the importance of focusing on cardiovascular risk in RA patients. Furthermore, it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for making decisions about LDL cholesterol goals – is a reasonable strategy, she said.

She also said that a potential screening strategy involves yearly cardiovascular risk screening. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place. Some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness – and the calculation of a coronary artery calcium score using CT – may be useful in patients older than 40 years.

As for potential management strategies, aspirin therapy might be useful but should be considered in the context of other medications the patient is taking.

Statins are also 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 – which will 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 also imperative, Dr. Bathon said.

She noted that conventional cardiovascular risk factors do not fully explain the excess risk in RA patients, and that inflammation probably plays an important role.

"We also have to think about ourselves," she said, referring to whether rheumatologists are aggressive enough in their management of cardiovascular risk in RA patients.

There is some question as to whether the increased risk in RA patients, compared with controls, is a result of less-aggressive treatment, she said.

Dr. Bathon had no disclosures relevant to her presentation.

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 myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA 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).

In fact, RA is now considered by some experts to be equivalent to diabetes mellitus 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 (EULAR) has proposed that conventional cardiovascular risk models be multiplied 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 at this point, according to Dr. Bathon. But the proposal illustrates the importance of focusing on cardiovascular risk in RA patients. Furthermore, it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for making decisions about LDL cholesterol goals – is a reasonable strategy, she said.

She also said that a potential screening strategy involves yearly cardiovascular risk screening. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place. Some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness – and the calculation of a coronary artery calcium score using CT – may be useful in patients older than 40 years.

As for potential management strategies, aspirin therapy might be useful but should be considered in the context of other medications the patient is taking.

Statins are also 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 – which will 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 also imperative, Dr. Bathon said.

She noted that conventional cardiovascular risk factors do not fully explain the excess risk in RA patients, and that inflammation probably plays an important role.

"We also have to think about ourselves," she said, referring to whether rheumatologists are aggressive enough in their management of cardiovascular risk in RA patients.

There is some question as to whether the increased risk in RA patients, compared with controls, is a result of less-aggressive treatment, she said.

Dr. Bathon had no disclosures relevant to her presentation.

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 myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA 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).

In fact, RA is now considered by some experts to be equivalent to diabetes mellitus 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 (EULAR) has proposed that conventional cardiovascular risk models be multiplied 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 at this point, according to Dr. Bathon. But the proposal illustrates the importance of focusing on cardiovascular risk in RA patients. Furthermore, it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for making decisions about LDL cholesterol goals – is a reasonable strategy, she said.

She also said that a potential screening strategy involves yearly cardiovascular risk screening. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place. Some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness – and the calculation of a coronary artery calcium score using CT – may be useful in patients older than 40 years.

As for potential management strategies, aspirin therapy might be useful but should be considered in the context of other medications the patient is taking.

Statins are also 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 – which will 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 also imperative, Dr. Bathon said.

She noted that conventional cardiovascular risk factors do not fully explain the excess risk in RA patients, and that inflammation probably plays an important role.

"We also have to think about ourselves," she said, referring to whether rheumatologists are aggressive enough in their management of cardiovascular risk in RA patients.

There is some question as to whether the increased risk in RA patients, compared with controls, is a result of less-aggressive treatment, she said.

Dr. Bathon had no disclosures relevant to her presentation.