Heart Disease Often Missed in Rheumatoid Arthritis

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In patients with rheumatoid arthritis, ultrasonography of carotid arteries helps predict cardiovascular disease risk, but scores from cardiovascular disease risk calculators developed for use in the general population may need to be adapted, according to a review recently published in Nature Review Rheumatology.

“Although this high risk of cardiovascular disease has been known for decades, patients with rheumatoid arthritis receive poorer primary and secondary cardiovascular disease preventive care than other high-risk patients, and an unmet need exists for improved cardiovascular disease preventive measures for patients with rheumatoid arthritis,” wroteAnne Grete Sem, M.D., Ph.D., of Diakonhjemmet Hospital in Oslo, Norway.

In this review, Dr. Sem and colleagues aimed to provide a roadmap of atherosclerotic cardiovascular disease risk management and prevention in patients with rheumatoid arthritis.

Patients with rheumatoid arthritis have an increased risk of most types ofcardiovascular disease, but there are no rheumatoid arthritis-specific recommendations for cardiovascular disease risk prediction in the United States. However, the current European League Against Rheumatism (EULAR) recommendations advise that patients with rheumatoid arthritis should be screened every five years for cardiovascular disease risk factors, taking into account that such factors are influenced by changes in rheumatoid arthritis disease activity and antirheumatic treatment.

More than 360 unique cardiovascular disease prediction models have been developed. However, risk calculators developed for the general population, such as the Framingham Risk Score (FRS) and the Systematic Coronary Risk Evaluation (SCORE) calculator, produce gross underestimations of cardiovascular risk in patients with rheumtoid arthritis. Efforts have been made to develop rheumatoid arthritis-specific cardiovascular disease risk calculators, but their efficiency has not been proven. Clinicians recommend the use a cardiovascular disease risk algorithm developed for their specific population, such as the American College of Cardiology and American Heart Association Pooled Cohort Equation risk calculator (ACC/AHA PCE) in the United States and the SCORE calculator in Europe. The EULAR recommends that for rheumatoid arthritis patients, cardiovascular risk estimation be performed using a 1.5 multiplication factor to the SCORE risk estimate, but this multiplication factor needs to be validated for use in the Unites States.

“Age, sex and smoking status are recorded routinely in rheumatology outpatient clinics; therefore, only blood pressure and lipid measurements need to be added to the recording in the clinic to enable a cardiovascular disease risk evaluation to be performed using the SCORE calculator,” the authors wrote.“If the SCORE calculator was implemented as part of the electronic patient record system, the 10-year risk of cardiovascular disease could be automatically calculated and would be available to the rheumatologist when the patient attended a consultation.”

EULAR recommends that screening for asymptomatic atherosclerotic plaques via carotid ultrasonography should be performed as part of cardiovascular disease risk evaluation for all patients with rheumatoid arthritis. However, there is no clear recommendation for the use of coronary CT angiography (CCTA) and coronary artery calcium scoring (CAC)forthese patients.

For cardiovascular disease risk prevention, patients with rheumatoid arthritis are treated as the general population, but some specific drug–drug interactions can occur in patients with rheumatoid arthritis. In patients with active rheumatoid arthritis, interleukin 6 (IL-6) might suppress cytochrome P450 (CYP) activity and increase the bioavailability of certain drugs. Tocilizumab, an IL-6 inhibitor, might reverse the suppression of CYP3A4 activity, and increase the clearance of statins metabolized by this cytochrome. However, the authors noted that there is limited evidence on interactions involving antirheumatic drugs and lipid-lowering drugs.

Further, the doses of statins or antihypertensive medications required to attain lipid or blood pressure goals is not affected by inflammation and antirheumatic medication use in patients with rheumatoid arthritis. However, the authors noted that further investigation is needed on whether medications such as monoclonal antibodies targeting cytokines or conventional synthetic disease-modifying anti-rheumatic drugs will affect the development of atherosclerosis or cardiovascular disease outcomes in rheumatoid arthritis patients.

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REFERENCE

Anne Grete Semb, Eirik Ikdahl, Grunde Wibetoel, et al. “Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis.” Nature Review Rheumatology. June 3, 2020. https://doi.org/10.1038/s41584-020-0428-y