A position statement by the Cardiovascular Pharmacotherapy Working Group of the European Society of Cardiology introduces a new prospective algorithm for the estimation of cardiovascular risk (CVR) and lipid management in rheumatoid arthritis (RA). The position statement, published in the European Heart Journal Cardiovascular Pharmacotherapy, also discusses strategies for monitoring lipid parameters and offers recommendations for dyslipidemia management in patients with RA.

Lipid Management Recommendations for Patients With Rheumatoid Arthritis

The position statement from the European Society of Cardiology is largely based on opinion, primarily due to the small amount of data available from randomized controlled trials regarding lipid management in RA. According to the working group, recommendations for lipid management in RA can follow principles similar to the recommendations for patients with diabetes. Patient education, with an emphasis on lifestyle, may be helpful for reducing CVR in this patient population without incurring a high cost burden.

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Lipid Profile and Cardiovascular Risk Assessment

While it’s uncertain when monitoring of lipid status and total CVR should occur, the committee suggests these measures should be monitored in the assessment of RA. Assessment of modifiable CVR factors (CVRFs), such as diabetes and hypertension is recommended. If changes in lifestyle and treatment occur, CVR re-evaluation is also suggested. Inclusion of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride concentrations in routine lipid screening is also recommended in lipid management of patients with RA.

Cardiovascular Risk Stratification in Rheumatoid Arthritis

The position statement also provides recommendations for CVR stratification in RA based on 2016 European Society of Cardiology central venous pressure (CVP) guidelines that incorporate general, as well as RA-specific CVRFs and carotid ultrasound guidance. In these recommendations, the primary treatment target is low-density lipoprotein cholesterol.

An algorithm for CVR estimation presented in the paper uses several clinical variables, including age, gender, cholesterol levels, blood pressure, smoking, and geographic area. Patients categorized with “low-risk RA” are considered to have seronegative, nonerosive RA without extra-articular manifestations, are in remission for >one year (long-term; Clinical Disease Activity Index [CDAI] ≤2.8 or Simplified Disease Activity Index [SDAI] ≤3.3 or Disease Activity Score 28 Joints – Erythrocyte Sedimentation Rate [DAS28-ESR] ≤2.6), lack of active arthritis or persistently elevated C-reactive protein or ESR, have well-preserved physical function, and lack of high cumulative disease activity.

Additionally, patients in the low-risk RA category are not using glucocorticoids and do not have a high cumulative glucocorticoid dose (≥40 g). In all individuals with low-risk RA, the goal for low-density lipoprotein cholesterol is ≤3 mmol/L (115 mg/dL).

The writing committee wrote that the proposed categorization strategy may reduce undertreatment of patients in the high-risk RA category and/or overtreatment of patients in the low-risk RA category vs other current strategies that do not reclassify patients with RA “into higher CVR categories and/or do not distinguish between RA populations with different CVR levels.”

Carotid Ultrasound

According to the position statement, current methods of CVR estimation do not sufficiently predict carotid plaques in RA. Carotid ultrasonography is suggested as a meaningful method for identifying carotid plaques, particularly in patients in the low to high categories of the European Society of Cardiology.

Carotid ultrasound, which can be performed by devices for musculoskeletal imaging, represents a feasible and economically sound noninvasive approach, especially in patients with dubious CVR. The committee also states that the ankle-brachial index can also be helpful for CVR estimation. Carotid ultrasound may also be helpful for reclassifying patients into the very-high European Society of Cardiology CVR-category.

Individualization of Cardiovascular Risk Estimation

The  position statement authors also suggest that CVR estimation should be individualized, with a focus on comorbidities, lifestyle, body mass index, biologic age, and psychosocial factors. A patient’s lifestyle should also be taken into account with lipid management and estimation of CVR. Education, counseling, and support for incorporating healthy lifestyle behaviors are also recommended for patients with RA. Healthy lifestyle components may include increasing physical activity, beginning and maintaining a healthy diet, optimizing weight/waist circumference, quitting smoking, limiting sedentary activities, and finding ways to manage stress.

Statins

The statement also suggests that patients with diabetes who are aged >40 years should use statins. These medications may also be appropriate for patients with diabetes who are younger than age 40 years if pronounced CVR is detected. Non-high-density lipoprotein cholesterol targets include <2.6 mmol/L (<100 mg/dL) for very high CVR, <3.3 mmol/L (<130 mg/dL) for high CVR, and <3.8 mmol/L (<145 mg/dL) for low/moderate CVR.

Although statins can cause adverse effects in patients with RA, the committee recommends monitoring for these effects similar to the way clinicians monitor statin-related effects in the general population. Further research is needed to determine which regimens are the most appropriate for patients with RA with regard to safety and cardioprotective effects.

Disclosure: None of the study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Hollan I, Ronda N, Dessein P, et al. Lipid management in rheumatoid arthritis: a position paper by the Cardiovascular Pharmacotherapy Working Group of European Society of Cardiology [published online August 9, 2019]. Eur Heart J Cardiovasc Pharmacother. doi:10.1093/ehjcvp/pvz033