Energized by the dancing last night, Dr. Stephanie Keeling gave a great review on managing cardiovascular (CV) co-morbidities in patients with rheumatoid arthritis (RA). She was able to provide useful methods for evaluating CV risk in the clinic setting and the role of treating to target in ameliorating these risks.
What is the increased CV risk in RA? A meta-analysis of 17 studies showed a pooled standardized mortality ratio of 1.6 with a 60% increased risk of CV death in RA versus the general population. There is a wide body of research that shows increased risk of CV-associated death, myocardial infarction, congestive heart failure, and peripheral arterial disease in patients with inflammatory disease, including SLE, RA, PsA, AS and psoriasis.
Why do inflammatory arthritis patients have higher CV risk? The reasons are likely multifactorial including medications, traditional risk factors, and chronic inflammation. Medications such as steroids and NSAIDs increase risk whereas MTX, hydroxychloroquine and biologics are likely protective. More recently, there has been evidence that treatment improves lipid profiles and decreases CV risk. RA patients have a unique lipid profile with decreased HDLc and Apolipoprotein A-1, higher TC/HDLc ratio, and oxidative LDLs.
What are other risk factors? Monocytes, TNF-a, polymorphonuclear leukocytes (infiltrate plaque and factors), matrix metalloproteinases, inflammatory cytokines and chemokines all have a pathogenic role in atherogenesis, both in promoting foam cell development (a key player in plaque development) and promoting plaque destabilization.
Should rheumatologists be the ones managing traditional CV risk factors? Is that our job? This is one of current controversies in patient management. Whose role is it? If you wanted to do this, here is a potential plan:
Start with collecting a Risk Score. There are a variety to choose from including the Framingham Score, and Q Risk Calculator (from UK – incorporates RA).
According to Canadian Cardiovascular Guidelines (2009), all patients with inflammatory disease should have CV risk calculated and traditional risk factors modified.
EULAR guidelines (2010) recommended annual CV risk assessment, using a validated score and multiply by 1.5 if disease duration is >10 years, positive serology, or extra-articular manifestations.
If risk is elevated, then try to manage modifiable risks:
Hypertension ->Measure blood pressure. You could treat this yourself (guidelines/algorithm available ) or defer management to an internist or GP
Smoking -> Discuss smoking cessation. Available treatments include Champix, Wellbutrin, Nicotine patch, etc. Most provinces offer smoking cessation programs.
Diabetes -> Annual fasting glucose, annual HbA1c. If abnormal, refer back to GP or other specialist (endocrine, IM) for management.
Weight -> Measure regularly. Discuss diet and other weight loss options.
Lipids -> Measure at baseline and annually. Treat with statin if elevated.
Treat underlying disease and inflammation
Data from Europe showed treat to target leads to less co-morbidity, reduced CV risk and better work productivity.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio