Cardiovascular disease is the leading cause of death in the world, and mortality due to CVD is increased by 50% in rheumatoid arthritis (RA) patients. The good news is that 90% of cardiovascular disease could be preventable. The question is, are we doing a good enough job as medical professionals monitoring our patients for CV risk?
Dr. George Kitas discussed the challenges in monitoring patients with RA for cardiovascular disease. In order to monitor CV risk we need to look at both individual risk factors and composite risk algorithms.
The classic individual risk factors for CVD include family history, ethnicity, age and gender, which are non-modifiable, whereas modifiable risk factors include smoking, high blood pressure, high cholesterol, obesity, physical inactivity, diabetes, unhealthy diet, and alcohol intake. RA patients have additional risks that need to be considered including anti-ccp antibodies, disease duration, HAQ score and increased inflammatory markers.
When monitoring the patient with RA it's important to recognize that over 70% of RA patients are hypertensive. The scary part is that 40% are undiagnosed and of those who are diagnosed, 80% are suboptimally controlled. RA patients have different BMI thresholds for obesity since they break down muscle and replace it with fat, giving them a higher fat-to-muscle ratio. Medications for RA can have effects on lipids, insulin resistance and homocysteine levels, and smoking is associated with risk factors that are specific to RA. We also must consider inflammation, which may have direct effects on the vasculature.
When looking at composite risk assessments, how useful are these tools? Almost all of the composite risk scores tend to underestimate CV risk in RA patients. In response to this, the EULAR guidelines recommend multiplying conventional risk scores by a factor of 1.5 for RA patients. Clearly there is a need for CV risk assessment tools that are specifically designed for RA.
Dr. Kitas discussed one new RA-specific CV risk calculator. Initial validation studies suggested the new calculator captured RA risk better than traditional scores, but a closer look uncovered some problems. The new calculator overestimates risk compared to observed events, possibly due to the major heterogeneity in CV risk across different countries related to population differences, referral biases, measurement differences and so on.
In conclusion, both classical and novel CV risk factors are important in monitoring RA patients, and both individual and composite disease risk must be assessed. Dr. Kitas recommended increasing awareness of the problems in monitoring CV risk in patients with RA, disseminating this information to health professionals, informing and educating patients, and establishing a system for risk identification.