In a recent review, published in June 2020 in the journal Nature Reviews Rheumatology, the authors call for improvements in CVD preventive care in patients with RA. According to the lead author, Anne Grete Semb, MD, PhD, a senior researcher at the Leader Preventive Cardio-Rheumatology Clinic at Diakonhjemmet Hospitaal in Oslo, catching risk factors early is particularly important in people with RA to prevent a fatal cardiac event.
Know the Risk Factors
It’s important to first understand why patients with RA need to be extra vigilant in monitoring their CVD risk factors. According to Katherine Liao, MD, the codirector of the cardiovascular rheumatology clinic at Brigham and Women’s Hospital in Boston, who was not involved with the review, people with RA need to be conscious of the same traditional CVD risk factors as the general population, including high cholesterol, high blood pressure, diabetes, obesity, and smoking. But patients with RA have an added threat. Increased inflammation in patients who have RA exacerbates their risk of developing fatal atrial fibrillation (afib), heart attack, stroke, and heart failure, even when other risk factors are kept at bay. “Although rheumatoid arthritis is a chronic inflammatory joint disease, the inflammation isn’t just in the joints,” Dr. Liao explains. “Patients get it in their entire body, and it does a lot of things, particularly to the vascular system.” According to the Cleveland Clinic, inflammation narrows arteries, leading to high blood pressure and reducing the amount of blood that goes to the heart. Liao says this is particularly dangerous when a patient already has plaque buildup, which can clog the artery and cause a stroke or heart attack. According to Dr. Semb, people with RA also prematurely develop atherosclerosis, or plaque buildup on the arterial walls, which causes the arteries to harden and is a major factor in coronary artery disease (CAD), the most deadly type of heart disease.
A Flare-up Can Skew Test Results
When patients are screened, it’s important that inflammation is taken into account, since this can lead to a skewed prognosis, says Liao. Based on observational data, it appears that as inflammation increases in RA patients, their cholesterol levels seem to decrease, although their risk for heart disease is still going up, she explains. Adjusting for this can be difficult even when doctors aren’t aware of the inherent risk RA poses for CVD, or the affect inflammation has on cholesterol levels. “Inflammation is dynamic, not static, and that is why it’s harder to put a finger on it,” says Liao. “Screening for lipids should be done in patients with RA ideally when their disease is under control; otherwise the cholesterol and LDL levels can be spuriously low.”
Less Awareness Leads to Fewer Screenings
Although skewed test results during a screening can be an issue, Semb says that not being screened at all is a bigger problem, and one that is common in most Western countries. “The awareness of the elevated risk is little known among both patients and medical professionals even though this risk has been known in the medical community since the 1990s,” explains Semb, noting that as a result, these patients typically aren’t screened and treated for CVD risk factors as much as patients with other diseases, such as diabetes, that put them at high risk. According to Liao, while RA is the most common autoimmune joint disease, it impacts only 2 percent of Americans. “Whereas diabetes is an epidemic,” she says. Semb explains that because RA is a chronic disease, patients routinely see their rheumatologist, and because of this, may seek preventive care through a primary care physician less often. According to a study published in April 2018 in the journal Current Rheumatology Reports, 75 percent of RA visits occur in specialty clinics. In addition, another study published in April 2018, in the journal BMC Rheumatology, found that although several CVD risk factor calculators are available to physicians, most do not include RA as a risk factor. “I think that in every community in the Western world today, there is a lot more responsibility put on the patient themselves to know about their disease, to know their lipid and glucose levels and make sure their physician is measuring these,” says Semb, who also notes the importance of not smoking, eating a low-cholesterol diet, and getting 30 minutes of physical activity daily. “It’s been shown in several publications that physical activity reduces pain in RA patients,” she says. She advises people to start slow, with walking or low-impact exercise classes.
Getting on the Right Medications
According to Liao, doctors may be reluctant to cause adverse drug interactions when treating high blood pressure or cholesterol. “We are trying to dance around all of the risks and benefits,” she says. Semb notes that some patients may be reluctant to take additional medications such as statins out of fear of adding to the medications they already take for RA. But if medication is needed, patients should not forego addressing their CVD risk in favor of not taking additional medication, she says, noting that medication can be extremely safe and effective in treating heart disease risk factors. “The clinical benefit is huge, because what these people die of is cardiovascular disease. They don’t die of their joint disease,” says Semb.
