FORT LAUDERDALE, FLA. — Patients with systemic lupus erythematosus and rheumatoid arthritis should be considered in a cardiovascular risk category equivalent to that of patients with diabetes, with aggressive management of risk factors, particularly dyslipidemia, according to experts.
It is not yet clear whether the increased incidence of coronary artery disease (CAD) in patients with lupus and rheumatoid arthritis (RA) is a result of rheumatic factors that drive the atherosclerotic process, or if risk factors in the milieu of rheumatic disease cause patients to be more vulnerable, Dr. Daniel Edmundowicz said.
“But in any case, the process is driven by dyslipidemia,” he said.
“We are born with LDL cholesterol levels around 35–40 mg/dL, and a lab result that says you are normal at 130 mg/dL is wrong—that's average but it's abnormal for homo sapiens, and if you are vulnerable you are in trouble,” he said.
Because of this vulnerability, “many of us feel that patients with rheumatologic diseases should be considered CHD [coronary heart disease] risk equivalents,” said Dr. Edmundowicz, director of preventive cardiology at the University of Pittsburgh Medical Center's Cardiovascular Institute.
“CHD risk equivalent” is the designation given by the National Cholesterol Education Program (NCEP) to people with diabetes and conditions such as peripheral artery disease who have a high prevalence of CAD events such as fatal and nonfatal myocardial infarction.
Currently, NCEP practice guidelines suggest that patients who are CHD risk equivalents be treated aggressively with regard to their risk factors such as cholesterol.
“In my opinion, patients with rheumatologic diseases should be reaching the same aggressive risk factor goals, which would mean non-HDL cholesterol less than 130 mg/dL or less than 100 mg/dL for patients who already have CAD, and LDL cholesterol of less than 100 mg/dL or less than 70 mg/dL if they already have CAD,” he said.
For many patients, meeting these goals will require statins, Dr. Edmundowicz said at a meeting sponsored by RHEUMATOLOGY NEWS and Skin Disease Education Foundation.
“Over the past 20 years, we have demonstrated that statin therapy is safe, and there now are effective and inexpensive generic lipid-lowering drugs. With a 40-mg dose of simvastatin you can get almost a 40% reduction in LDL,” he said.
But with aggressive statin therapy it is important to realize that titration of the drugs provides minimal additive benefits and can increase toxicity. “If you start your patient on 40 mg of simvastatin and then raise it to 80 mg you are probably only going to get an additional 5% of lowering of lipoproteins but you are much more likely to get myalgias,” he said.
Additive or combination lipid therapy is now becoming much more popular, utilizing agents that have different mechanisms of action. For example, blocking cholesterol uptake with ezetimibe and absorbing biliary cholesterol with bile acid sequestrants can provide very effective lowering of LDL, he said.
Attention also must be paid to lowering blood pressure, smoking cessation, and increasing physical activity. Benefits of exercise training in patients with RA and lupus include improvements in aerobic capacity, endurance, and strength, and can help decrease joint swelling and pain, increase social activity, and reduce depression and anxiety.
Of course, these patients have considerable limitations, with restricted joint range of motion and deconditioning, but even small inroads in exercise training can be very beneficial, he said. “You can't forget these things,” he said. “Atherosclerosis is killing our patients. The charge to a community of physicians who take care of very-high-risk patients like yours is not to leave it to the other guy.”
Dr. Edmundowicz disclosed that he is a consultant to GNC, Merck & Co., Schering Plough, and Takeda. SDEF and this news organization are owned by Elsevier.