Rheumatoid arthritis cardiovascular risk
Patients with rheumatoid arthritis (RA) have an increased risk of cardiac complications such as heart attack, high blood pressure, heart failure and stroke. How big is this risk, what are the reasons for it, and what are the potential treatments?
The increased risk of heart disease in RA is thought to result from inflammation of the blood vessels and deposition of fat, a process known as atherosclerosis. Accelerated atherosclerosis has been found in the carotid arteries of RA patients, and if you have a raised erythrocyte sedimentation rate (ESR), you will have a greater risk of heart disease. The changes that happen are similar to those in type 2 diabetes. Studies have found higher levels of T white blood cells, part of the immune system, in patients with RA.
Some RA medications may also increase the risk. For example, celecoxib, a COX-2 inhibitor used to treat joint pain, can increase the risk of heart disease by increasing the clotting ability of blood. However, non-steroidal anti-inflammatory drugs such as naproxen seem to have the opposite effect and reduce the risk of heart disease.
Low body mass index
Although obesity is known to be a risk factor for heart disease, rheumatoid cachexia, or wasting of muscles and loss of fat due to inflammation, also increases the risk. This has been described as a U-shaped relationship, especially amongst older women. It may be that the inflammation in RA leads to a process known as “accelerated aging” which speeds up atherosclerosis and heart disease.
Rheumatoid heart failure
Heart failure (HF) results from slightly different mechanisms. Even when other risk factors are eliminated (including blood pressure, smoking, diabetes and alcohol abuse), if you have RA, you still have an increased risk of HF. This may be due to damage to the heart muscles from inflammatory proteins such as tumour necrosis factor alpha and interleukins, rheumatoid lung disease which puts extra strain on the heart or other factors. If you have RA and HF, you may also need extra treatment for your heart failure, as you are more at risk of complications, longer hospital stays and reduced function due to RA.
If you have RA, you have an increased chance of experiencing angina, as well as high blood pressure and heart attacks.
People with RA have a higher risk of death from cardiac causes. One clinical trial found this was approximately three times greater if they did not take steroids and two and half times greater if they take steroids. Another measured the risk to be two times greater, similar to the effects of diabetes. Similar results were shown in the Rochester Epidemiology Project linked to the Mayo Clinic which looked at the risk of death in patients with RA and investigated the coronary arteries of those patients who had died. They found a greater risk of death, largely attributable to cardiovascular causes, in those who had RA, and more atherosclerosis in the coronary arteries at autopsy.
Risk factors for cardiac damage include high ESR scores, large joint swelling, RA lung disease, alcoholism, history of heart disease, family history and vasculitis (inflammation of small blood vessels leading to rashes or kidney problems).
The European League Against Rheumatism has developed recommendations for how often the cardiac risk in RA should be measured. They suggest a yearly review of blood tests such as blood sugar, cholesterol, blood pressure, body mass index and smoking status is carried out.
Dr Kimberley Liang explains the importance of assessing cardiac disease on Global News Network:
Treatments for identified risk factors for heart disease are usually managed in the same way as with patients without RA. For instance, high blood pressure is treated with antihypertensive medication such as angiotensin-converting enzyme inhibitors (ACE inhibitors e.g. enalapril) or calcium channel blockers (CCBs e.g. verapamil).
If there are no local guidelines, the Systematic COronary Risk Evaluation (SCORE) chart can be used. This has been developed by the European Society of Cardiology and was based on data from over 250,000 patients. It can be found at http://www.escardio.org/communities/EACPR/toolbox/health-professionals/Pages/SCORE-Risk-Charts.aspx. Your doctor can use this to determine whether you are high or low risk, and what the appropriate treatment is.
As well as controlling these risk factors, careful control of inflammation with RA medications such as disease-modifying anti-rheumatic drugs and biologic agents can have knock-on impacts on cardiac risk status.
More non-traditional factors that have also been studied include clotting factors such as fibrinogen, von Willebrand factor (vWF), tissue plasminogen activator antigen (t‐PA), fibrin D‐dimer, plasminogen activator inhibitor (PAI‐1) and plasma viscosity. These can increase the risk of heart attack, stroke and pulmonary embolism (blood clots in the lungs), and are also raised in RA.
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Written by Dr Anne Parfitt-Rogers, Medical Writer, UK