Patients with RA continue to have an increased risk of cardiovascular (CV) death. While CV mortality in the general population has decreased over time,it has not changed dramatically in people with RA, resulting in a widening "mortality gap" (A&R 2007). The good news is that individuals diagnosed with RA from 1995-2007 have shown an improvement in survival compared with incident cases from 1955-1994 (ACR 2009).
Ischemic Heart Disease (IHD)
The prevalence of IHD is increased in patients with RA even at the time of diagnosis. RA patients have a 3-fold increase in hospitalized MI and a 5-fold increase in silent MI at the time of diagnosis (A&R 2005). Over time the risks of MI, angina, and sudden cardiac death increase in RA patients. Mortality after an MI is also significantly higher in patients with RA with a Standardized Mortality Ratio (SMR) of 1.47.
Congestive Heart Failure (CHF)
The cumulative incidence of CHF is significantly higher in patients with RA even after controlling for IHD and other cardiac risk factors. Furthermore, we are more likely to see CHF in RA patients with preserved ejection fractions (>50%). Mortality after CHF is also increased, with a 2.6-fold higher 30-day mortality. RA patients tend to be managed less aggressively for CHF, and they have higher rates of hospitalization and longer hospital stays.
With all of this data, what have we learned about predicting and preventing heart disease in people with RA? Traditional CV risk factors do not fully account for the increase in CV disease in all RA patients. The Framingham Risk Score performs well in seronegative individuals, but in seropositive RA, it does not perform well at all.
One interesting finding is that as inflammatory markers increase (e.g., ESR) a higher TChol/HDL ratio actually confers a lower CV risk (weird). This is a paradoxical finding. Inflammatory markers are stong independent risk factors for CV disease in patients with RA.