Cardiovascular Disease in Rheumatoid Arthritis

Grant H. Louie, MD, MHS, FACR

By: Grant H. Louie, MD, MHS, FACR

Cardiovascular disease (CVD) remains the leading cause of death in the UnitedStates. Rheumatoid arthritis (RA) is now fast becoming considered a major CVD risk factor among traditional ones, such as high blood pressure and high cholesterol. RA no longer is thought of as a disease of only joints.

RA is a chronic condition in which the body’s own immune system attacks its own joints by mistake. This results in joint inflammation. Patients experience joint pain and swelling that can make doing normal daily functions more difficult. Dressing, holding a utensil to eat, and getting up and down stairs may be harder to do without help. Untreated disease eventually may lead to permanent joint damage and severe physical disability.

Cardiovascular Disease in Rheumatoid Arthritis

Because RA is a systemic disease, other organs and tissues in addition to joints can be affected. A growing number of medical research studies have reported on the harmful effects of RA on heart health. The arteries that supply oxygen and nutrients to the heart can get blocked in patients with RA even when they do not have major CVD risk factors. This can lead to a heart attack and possibly even death.

Patients with RA have a higher CVD burden compared to the general population. It is estimated that their CVD risk is increased by 1.5 to 2 times. Most doctors believe that having untreated or undertreated RA is what leads to heart disease rather than having RA itself. This belief is similar to cases of patients with high blood pressure. If left untreated, high blood pressure can lead to severe heart disease.

Patients with chronically active RA are more likely to have heart attacks than those with controlled disease. Researchers believe the heart arteries become permanently damaged from inflammation over many years. How this happens exactly is not well understood. But researchers think the lining of the heart arteries gets damaged from direct inflammation. This contributes to hardening and blockage of the passageway for the heart to receive the necessary constant supply of oxygen and nutrition it needs. Harmful forms of cholesterol are often higher in patients with RA. Medicines such as non-steroid anti-inflammatory drugs (NSAIDs) and steroids used to treat RA also have been associated with higher risk of CVD.

“Rheumatologists have learned that the best way to lower the risk of heart disease in patients with RA is to first control joint inflammation.”

Rheumatologists have learned that the best way to lower the risk of heart disease in patients with RA is to first control joint inflammation. They may use traditional medicines that lower the immune system, such as methotrexate. If RA remains active, patients may be placed on a biologic that further dampens the body’s immune response. Research studies have shown that RA patients who have less inflammation in their bodies than those with more inflammation are less likely to have heart disease. Patients with RA should be examined carefully to see if they have traditional CVD risk factors. These should be identified and treated aggressively.

Much more research is needed to develop a CVD risk calculator that takes into consideration the presence of RA. There are a number of such risk predictors already, however, these do not factor in RA. Armed with this knowledge, both patients and their doctors will gain a better appreciation of the effect of RA on heart health. This can lead to a meaningful dialogue on ways to lower CVD risk. Rheumatologists are encouraged to identify RA as early as possible and treat it as aggressively as possible. The ultimate goal is to achieve disease remission. RA patients also should be screened regularly for traditional CVD risk factors and get those under control.

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Adey A. Berhanu, MD, FACR, RHMSUS

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