“Who Takes Ownership of the Problem?” Arthritis and Heart Disease a Major Topic for Rheumatologists at ACR 2016

With ever-growing data that the inflammation in rheumatic conditions can go hand-in-hand with cardiovascular inflammation, two different studies presented in press conferences at the 2016 American College of Rheumatology Annual Meeting in Washington, DC sought to broaden rheumatology’s approach to dangerous conditions it may influence.

Speaking on behalf of his team at the VU University Medical Center in Amsterdam, Mike T. Nurmohamed, MD, presented findings from the CARRE study that began in 2001, when data on the relationship between rheumatoid arthritis (RA) and heart problems was far more sparse than it is today.

Their cohort included a random sample of 353 long-term RA patients assessed at three, 10, and 15-year follow-ups.

During the 2,703 person-years of follow-up, they found a rate of 3.6 cardiovascular disease (CVD) events per 100 person-years. The general population assessment put the incidence rate at 1.4 per 100 person-years. In that general population, they found that a number of them had type-2 diabetes, and that risk among RA patients and diabetes patients was similar. Even excluding patients with pre-existing known risk factors for CVD, they found that RA patients were still 70% more at risk than the general population group.

In clinical practice Nurmohamed said this indicated a need for better screening and treatment of RA patients for cardiovascular risk factors, and that there was increasing evidence that certain biologic therapy did decrease cardiovascular risk.

His speech was followed by one from Iris Navarro-Milan of the University of Alabama at Birmingham, who detailed the necessity of exploring hyperlipidemia alongside rheumatoid arthritis. Hyperlipidemia, a concentration of lipids in the blood, is a major risk factor for CVD.

She began her speech by claiming that “One of the most successful stories in rheumatology is the achievement of remission in patients with rheumatoid arthritis. However, this is tempered by the fact that our patients still continue to face a high risk of mortality from cardiovascular disease.”

Previous data suggests that RA patients are under-screened for hyperlipidemia, and they wanted to see if rheumatologists could have an impact in changing that. Over a million Americans have RA, and Navarro-Milan’s study used claims data from both Medicare/Medicaid and private insurance to evaluate the nature of lipid screenings among such patients.

Excluding patients who had previously experienced myocardial infarction (MI), stroke, or coronary heart disease (CHD), as well as those already diagnosed with hyperlipidemia, they identified over 13,000 patients with rheumatoid arthritis. A large majority, 83%, were female.

They found that 18% of the total group did not receive care from a primary care physician (PCP), and among patients older than 65, the number was closer to 30%. In patients who were only treated by a rheumatologist, only 40% were screened for hyperlipidemia, similar to the 42% who exclusively saw a PCP and were screened. Even among those who saw both, only 47% were screened, but they did find that combined care increased likelihood of screening by 32%

She says her group’s work highlights the need for coordination of care, and that despite successes, the rate of remission in RA patients remains low-even by the loosest definitions, still less than a quarter of patients. The question, she asks, is “What are we going to do for the other 75% that do not achieve remission to treat their cardiovascular risk? It’s to still pay attention to their other cardiovascular risk factors, such as hyperlipidemia. We could coordinate care between specialties, but sometimes the issue is: who takes ownership of the problem?”

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