Impaired Long-Term Outcomes After Myocardial Infarction Compounded by Glucocorticoid Use in RA

Patients with rheumatoid arthritis (RA) have a poorer prognosis after myocardial infarction (MI) than patients without RA, and longer RA disease duration and glucocorticoid use before MI are associated with higher mortality and recurrent MI, according to a study published in Rheumatology.1 The study also found that methotrexate use was associated with a lower stroke risk after MI.

“While MI short-term outcomes are comparable among patients with and without RA, who have similar MI characteristics and rates of revascularization, the major difference in outcomes comes in the long term, offering a window of opportunity for secondary prevention,” investigators stated. “Patients with RA who suffer a myocardial infarction could benefit from a comprehensive evaluation and optimization of treatment to improve long-term outcomes.”

In this nationwide, cohort register study in Finland, Antti Palomaki, MD, of Turku University Hospital, and colleagues, investigated the long-term outcomes of MI among 1614 patients with RA and 8070 baseline-matched patients without RA. The researchers looked at mortality, recurrent MI, stroke and revascularization, along with the impact of glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) on outcomes after MI.

During a median follow-up of 7.3 years, patients with RA had a significantly increased long-term mortality after MI compared with those without RA. The 14-year mortality risk after MI was 80.4% and 72.3%, respectively (HR 1.25; CI 1.16-1.35; p < 0.0001). After discharge from the initial MI, patients with RA were at higher risk of a new MI (HR 1.22; CI 1.09-1.36; p = 0.0001) and revascularization (HR 1.28; CI 1.10-1.49; p = 0.002). However, the stroke rate after MI did not differ between the groups.

Further, RA duration and corticosteroid use before MI, but not methotrexate or biologic DMARD use, were associated with higher mortality (p < 0.001) and new MI (p = 0.009). A higher dosage of corticosteroids prior to MI was associated with higher long-term mortality (p = 0.002) and methotrexate use was associated with a reduced stroke risk (p = 0.034).

“Secondary prevention with statins was less frequent in patients with RA, and given the survival disadvantage, secondary prevention in RA warrants particular attention,” concluded investigators. “Methotrexate is the anchor drug of RA treatment, and our results support the role of methotrexate also among RA patients with previous MI.”

Seropositivity was not associated with a worse prognosis, a finding investigators suggest supports cardiovascular disease risk management equally in seropositive and seronegative RA patients.

Reference:

Palomäki A, Kerola AM, Malmberg M, Rautava P, Kytö V. Patients with rheumatoid arthritis have impaired long-term outcomes after myocardial infarction - a nationwide case-control registry study [published online ahead of print, 2021 Mar 1]. Rheumatology (Oxford). 2021;keab204. doi:10.1093/rheumatology/keab204