TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

A new study published in PLoS One suggests that it may be time to produce new algorithms for assessing cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA). Investigators at the University of Leeds found associations with some but not all types of CVD in those with RA, suggesting a need for new prognostic models.

The researchers analyzed data from 12,120 individuals with RA and 121,191 individuals without RA. The subjects were 18 years of age or older and were matched by age and sex. All participants were registered with general practices in England that contribute data to CArdiovascular research using LInked Bespoke stud-
ies and Electronic health Records (CALIBER). 

The study included patients with prospectively recorded RA who were seen between January 1997 and March 2010. The investigators used multivariable random effects Poisson regression models and examined the association between RA and the initial presentation of 12 types of CVD.


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The researchers found that CVD developed in 2525 persons with RA and in 18,146 persons without RA during a median follow-up of 4.2 years. Interestingly, the investigators found no association with cerebrovascular disease, abdominal aortic aneurysm, or unstable angina in those with RA.  

However, rates of myocardial infarction were significantly higher in those with RA (adjusted incidence ratio [IRR] = 1.43; 95% confidence interval [CI] 1.21-1.70). Rates of unheralded coronary death (IRR = 1.60; 95% CI 1.18-2.18) and heart failure (IRR = 1.61; 95% CI 1.43-1.83), cardiac arrest (HR = 2.26; 95% CI 1.69-3.02), and peripheral arterial disease (HR = 1.36; 95% CI 1.14-1.62) were also higher for those with RA.

“In this contemporary cohort study comparing rates of the first lifetime presentation of the 12 most common symptomatic cardiovascular diseases between people with and without RA, we observed between 36% and two-fold higher incidence rates of myocardial infarction, unheralded coronary death, heart failure, cardiac arrest, and peripheral arterial disease in individuals diagnosed with the disease,” lead study investigator Mar Pujades-Rodriguez, a University Academic Fellow at Leeds Institute of Biomedical and Clinical Sciences at the University of Leeds, England, in an interview with Rheumatology Advisor.

She said that the size of the estimates was generally similar to that observed in people with diabetes and did not differ between men and women. The increased risk for different types of CVD present at both early stages of RA and 10 years or more after diagnosis suggests that the mechanism by which RA increases the risk for CVD is not exclusively related to a cumulative inflammatory burden of disease activity, said Dr Pujades-Rodriguez.

“The observed lower risk of stable angina together with the increased risk of unheralded coronary death in the rheumatoid arthritis population might result from undiagnosed symptoms by patients who suffer from chronic pain and frequently use analgesic drugs. These findings suggest that some deaths could be averted if patients are adequately informed of the high risk of unrecognized coronary disease and are educated on how to recognize the symptoms,” Dr Pujades-Rodriguez told Rheumatology Advisor.

Summay and Clinical Applicability

This study provides evidence that those with RA have an increased risk for several common clinical presentations of CVD, and it supports the importance of regular evaluation, patient education, and adequate management of CVD risk in this population. It also informs the choice of cardiovascular endpoints for risk prediction models and for trials involving those with RA.

 “We suggest that future research aimed at improving existing or developing new prognostic algorithms for patients with rheumatoid arthritis[should be] designed to predict composite endpoints of fatal and non-fatal myocardial infarction, heart failure, cardiac arrest, and peripheral arterial disease, and [to] exclude cerebrovascular diseases. The same considerations would apply when clinical trials evaluating the efficacy of drugs or strategies to prevent cardiovascular disease development in patients with rheumatoid arthritis are designed,” Dr Pujades-Rodriguez concluded.

Limitations and Disclosures

These findings were limited by the possibility of diagnosis misclassification, or mistaken diagnostic code entered into the electronic health record, and the relatively short study follow-up period.

The authors of this study did not disclose any possible conflicts of interest or funding.

Reference

1. Pujades-Rodriguez M, Duyx B, Thomas SL, et al. Rheumatoid arthritis and incidence of twelve initial presentations of cardiovascular disease: a population record-linkage cohort study in England. PLoS One. 2016;11(3):e0151245.

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