Journals club - Rheumatoid arthritis and cardiovascular disease risk

By Dr Louise Newson on the 16 October 2009

The current guidelines and evidence base

Key trials

One meta-analysis showed that rheumatoid arthritis (RA) is associated with a 50 per cent increase in risk of cardiovascular death compared with the general population (Arthritis Rheum 2008; 59: 1,690-7).
Women with RA are twice as likely to suffer from an MI as those without (Curr Opin Rheumatol 2006; 18: 289-97).
Increased inflammation associated with RA appears to contribute substantially to increased cardiovascular mortality, rather than traditional risk factors for cardiovascular disease (Am J Med 2008; 121: S9-14).
One study found that prolonged use of treatments such as methotrexate, sulfasalazine, leflunomide, glucocorticoids and TNF-alpha blockers appeared to be associated with a reduced risk of cardiovascular disease (Arthritis Res Ther 2008; 10: R30).
Methotrexate has been shown to reduce overall cardiovascular mortality in patients with RA (Lancet 2002; 359: 1,173-7).

Evidence base

There is some evidence that statins may be protective against the development of RA in patients who have hyperlipidaemia (Ann Rheum Dis 2009; 68: 546-51).

Statin treatment has been shown to have a beneficial effect on disease activity and swollen joints in RA patients, in addition to improving plasma markers of inflammation, such as CRP and ESR (Clin Rheumatol 2008; 27: 281-7).

The trial of atorvastatin for the prevention of cardiovascular events in RA (TRACE RA trial) has commenced, which will investigate whether statins reduce cardiovascular events and deaths in patients with RA.

However, results are not expected until 2014.

Guidelines

The British Society for Rheumatology guideline for the management of RA in the first two years of the disease has proposed that GPs extend their cardiovascular screening to involve patients with RA (Rheumatology 2009; 48: 436-9).

The NICE guidance on statins for the prevention of cardiovascular events recommends statins are to be commenced in line with cardiovascular risk tables as for patients without RA.

However, an assessment of cardiovascular risk using the JBS-2 risk assessment tables will actually underestimate risk for patients with RA (Br J Cardiol 2009; 16: 113-5).

The cardiovascular risk calculator QRISK2 may provide a more accurate estimate for the risk of patients with RA (BMJ 2008; 336: 1,475-82).

Contributed by Dr Louise Newson, a GP in the West Midlands Useful websites

Key points
RA is an independent risk factor for cardiovascular disease. Patients with RA should have regular screening for cardiovascular disease. Drugs to treat RA may actually reduce excess cardiovascular risk. Statins may be beneficial for patients with RA.

Key points