Rania Al Asmar, MBBS: Coronary Artery Disease in Rheumatoid Arthritis

With rheumatoid arthritis patients predisposed to develop premature coronary artery disease (CAD) but no unified management plan, the onus is on clinicians to identify patients at an increased risk and address the issue. 


That is what prompted investigators from the Marshall University School of Medicine to conduct a study assessing whether CAD was apparent before or after diagnosis of rheumatoid arthritis—the results of which were presented at Clinical Congress of Rheumatology (CCR) West 2019 annual meeting in San Diego, CA.

Upon examining data on more than 2200 patients with rheumatoid arthritis, investigators found many of the 233 patients that developed CAD had multiple modifiable risk factors including obesity and smoking status. Of those patients, more than 80% were hypertensive, more than 25% were overweight, and 64% were smokers.

To learn more about these results and what they reveals about the relationship between rheumatology and CAD, MD Magazine® sat down with study author Rania Al Asmar, MBBS, of Marshall University, after her presentation of results.

Al Asmar: So, basically, during inpatient services I came across a lot of patients were females, in their 40s, with pretty extensive coronary artery disease who were rheumatoid arthritis patients. Some of them had four vessel disease, some of them were waiting CABG, and some of them were actually awaiting a heart transplant.

So, I thought that that is really devastating, because these patients are very young, and then I decided to look into what are their risk factors in addition to rheumatoid arthritis, what could we have prevented? Because this is already at a stage where not much can be done with very limited options.

So, this is where we went back and looked at the clinic encounters of patients who had rheumatoid arthritis in any of our offices, whether its primary care, rheumatology or cardiovascular. We looked at what is the total population and what are the population of RA with coronary artery disease, regardless of what stage is it? Is it just a mild MI? Stented, not stented? We just included everyone who was an adult 18 years or older and, basically, we had a very big population of rheumatoid arthritis although our city is pretty small, which is Huntington.

There was more than 2,200 patients with rheumatoid arthritis, but in this specific clinical center, which is just one part of several cardiac clinical centers in the city, there was about 223 patients with rheumatoid arthritis and coexisting coronary disease.

Surprisingly, more than 60% of them were obese, and 66% of them were smokers, 65% of them had family history of coronary artery disease, and, basically, mostly everyone had some elements of metabolic syndrome as well. So hypertension, diabetes, dyslipidemia, were coexisting in a range of a patient between 89% all the way down to 35%, respectively.

This tells you that these patients already without rheumatoid arthritis are at a very huge risk of getting coronary artery disease—let alone that the RA in 75% of the patients was sero-positive and ttcP positive, which means it's more aggressive.

So, basically, I discovered also looking at the primary prevention methods that the doctors used. So, only 5% of patients who had rheumatoid arthritis and then later on developed chronic disease—and despite their risk factors, only 5% on aspirin or statin. So, the primary prevention was not yet instituted sufficiently. Second thing, lifestyle modification, smoking cessation was not yet instituted optimally.

So, when I looked at all the documentation and all the follow ups, there was not much change happening in these patients lives until they were actually struck by an MI. So I thought that this is something that our all the healthcare professionals can work on in their clinics, whether it's primary care, family medicine, rheumatologists, internal medicine, that we need to explain to these patients how serious and debilitating their future coronary artery disease is expected to be—if we don't control the risk factors.