Research Identifies Potential Markers for ASCVD Risk in People With Rheumatoid Arthritis

Brittany N. Weber, MD, PhD

Credit: Brigham and Women's

High-sensitivity cardiac troponin (hs-cTnT) may be a useful marker to improve CV risk assessment among patients with rheumatoid arthritis (RA) with overall low estimated atherosclerotic cardiovascular disease (ASCVD) risk.¹

“From a clinical standpoint, the identification of patients with RA who have a higher CV risk, prompting initiation of CV prevention medications (ie, statins), remains a challenge. Future studies are needed to examine the association of hs-cTnT and existing atherosclerotic plaque among asymptomatic patients with RA to determine the utility of screening specific populations using hs-cTnT in the clinic. Overall, these findings suggest that hs-cTnT may be a useful marker to improve CV risk assessment among patients with RA with overall low estimated ASCVD risk,” lead investigator Brittany N. Weber, MD, PhD, Heart and Vascular Center, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, and colleagues wrote.¹

Weber and colleagues studied 331 patients with RA in a longitudinal observational cohort study, the Brigham and Women’s Hospital Rheumatoid Arthritis Sequential Study (BRASS), in which participants are assessed every 6 months for RA disease activity, blood samples are collected yearly, and high-sensitivity C-reactive protein (hsCRP) is measured annually. They sought to identify potential markers for ASCVD risk, as people with RA have a 1.5-times higher risk than the general population.²

They selected the earliest available blood sample for each subject and excluded those without samples or who were on a statin or lipid-lowering therapy in the year prior or up to the date of blood sample collection to identify subclinical risk in patients not on these standard primary prevention CV therapies.

The investigators measured hs-cTnT and routine lipids at baseline; these data were used to estimate the 10-year ASCVD risk at baseline. The primary outcome was MACE (acute coronary syndrome, stroke, and CV death) and the secondary outcome was all-cause mortality, obtained by linked electronic health record (EHR) data. Patients were followed for up to 10 years or until MACE, death, or last EHR encounter. Associations were analyzed by Cox proportional hazards and adjusted by baseline ASCVD risk score and hsCRP.

There were 293 participants included, with a mean age of 57.9 years and a median RA disease duration of 12.0 years. Most (83.1%) were female and 65.9% (193/293) were anti-CCP positive. Participants were receiving RA treatments at baseline including methotrexate (55.9%), tumor necrosis factor inhibitor (TNFi; 42.3%), and oral glucocorticoids (26%).¹

Participants had a low prevalence of CV risk factors, including hypertension (22.7%), diabetes mellitus (4.8%), hyperlipidemia (9.1%), and active smoking (7.9%). The median hsCRP at baseline was 4.35 (IQR, 1.09-18.29) and the median Disease Activity Score in 28 joints based on CRP (DAS28-CRP) was 3.32 (moderate disease activity), for an overall median calculated 10-year ASCVD risk of 3.87% (IQR, 1.18-9.87).¹

Out of the 293 participants, 117 (35.3%) had detectable hs-TnT (median,8.98 mg/dL; range, 7.49-12.96). A total of 16 MACE (4.8%) events and 50 all-cause deaths (15.1) occurred in 10 years. Detectable hs-cTnT was significantly associated with future MACE (hazard ratio [HR], 7.13 [95% CI, 2.29-22.10]), and this association remained significant after adjusting for ASCVD risk and log hsCRP (HR, 4.29 [95% CI, 1.31-14.10]; P = 0.02), as well as baseline ASCVD risk and DAS28-CRP (HR, 5.79 [95% CI, 1.49-22.40]).¹

The investigators also found that detectable hs-cTnT was associated with all-cause mortality (HR, 7.2 [95% CI, 4.85-10.90]) including after adjusting for baseline ASCVD risk and log hsCRP (HR, 4.18 [95% CI, 2.60-6.72]), and baseline ASCVD risk and DAS28-CRP (HR, 4.74 [95% CI, 2.20-10.20]). ASCVD risk score alone was also significantly associated with MACE (HR, 1.06 [95% CI, 1.02-1.10]).¹

“Although this is one of the largest studies of patients with RA with hs-cTnT and MACE outcomes, the relatively low event rate observed may be explained in part by patients who receive primary care or present with MACE outside of the hospital system. The low event rate may also reflect contemporary data suggesting a decrease in CV events among patients with RA, a trend observed in the general population secondary to preventive measures and public health initiatives. However, the increased CV mortality observed in RA compared to the general population remains,” Weber and colleagues wrote.¹

REFERENCES

1. Weeber BN, Weisenfeld D, Jeffway M, et al. The Association Between High-Sensitivity Cardiac Troponin T and Major Adverse Cardiovascular Events in Rheumatoid Arthritis. J Rheumatol. 2024, 51 (9) 942-944; DOI: 10.3899/jrheum.2024-0168
2. Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis 2012;71:1524-9