The first step in CV risk assessment is to acknowledge that there is, in fact, a risk. Rheumatoid Arthritis (RA) should be regarded as a condition associated with a higher risk for cardiovascular disease (CVD). The increased risk appears to be due to both an increased prevalence of traditional risk factors (e.g., smoking, hypertension, diabetes, and elevated cholesterol) and the presence of inflammatory disease.
Unfortunately, recording of CVD risk factors by rheumatologists for patients with RA is low (36%). (Biomed Res Intl 2014 in press).
Is recording traditional CVD risk factors going to help my patients? The answer is yes and no. Unfortunately, all traditional risk scores perform poorly in women and in patients with RA. The Framingham Risk Score (FRS), Reynolds Risk Score (RRS), and the Systemic Coronary Risk Evaluation (SCORE) all underestimate CVD risk in RA patients whereas the Q-Risk-II score overestimates the risk (Am J Cariol 2012). However, the Q-Risk-II score is the only one to include RA as a risk factor.
Furthermore, a recent publication (A&R 2014) found that 60% of RA patients with existing coronary artery calcification are missed by traditional risk factors. Even patients with early RA were found to have higher coronary artery calcification. This risk was further compounded by advancing age.
In RA, the presence of carotid plaques on ultrasound conferred a 2.5 (unilateral plaque) to 4 (bilateral plaques) times increased risk of MI independent of traditional risk factors. These patients may not have been identified as "high risk" based on traditional CVD risk factors but they were still at considerably increased risk for CVD. It is quite clear that we are underestimating cardiac risk in RA patients using traditional risk factors.
What are rheumatologists supposed to do? EULAR tells us we should multiply the traditional cardiac risk by 1.5 for patients with RA. However, this is based purely on expert opinion. If you ask the pragmatic Dr. Janet Pope, she’ll say to just put everyone on a statin. Truthfully, it may not be that bad of an idea.
The Rosuvastatin in Rheumatoid Arthritis (RORA) study investigated the use of rosuvastatin in 86 patients with inflammatory joint disease who also had carotid plaques. A significant reduction in carotid plaque height (0.19 mm) was observed after 18 months of rosuvastatin treatment. A significant reduction in LDL-c (~2 mmol/L) was achieved, which would result in a 40% reduction in CVD based on traditional risk factor scoring.
To be a little more scientific, consider the following:
Measure traditional risk factors at least once a year including (a) blood pressure, (b) fasting blood glucose, and (c) cholesterol & triglycerides
Counsel RA patients about smoking cessation
Counsel about diet and weight control
Treat the underlying RA with aim of remission and normalization of CRP
If it seems like a lot to add on to your plate, it is. As rheumatologists we’re becoming vaccination experts, infectious disease experts, some of us are amateur dermatologists, a few dabble with respirology, and now cardiology? Clearly, we are the prototypical chronic disease management physicians. And guess what you need to properly manage chronic disease … a good team!