Cardiovascular Risk in Patients with Rheumatoid Arthritis

Chicago—In patients with rheumatoid arthritis (RA), the length of disease duration does not appear to aggravate or contribute to cardiovascular risk, but very low disease activity sustained over time may actually have a beneficial effect on the increased cardiovascular risk in these patients. “It is important for clinicians to realize that it is not important whether the patient has been sick for 2 years or 15, but that attention for regular screening and primary prevention for cardiovascular disease [CVD] is important,” said lead author of the study, Elke Arts, MSc, junior researcher in the department of rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands, who presented the study during a news conference at the ACR meeting. Ms. Arts and her colleagues conducted the study to investigate the relationship between duration of inflammation and risk of CVD in patients with RA. Although it is known that patients with RA are at increased risk of CVD and that inflammation may be an independent risk factor for CVD, it is still unclear how inflammation influences CVD risk in these patients. Ms. Arts said that the level of inflammation does not seem to contribute to CVD risk in RA patients, citing the lack of significant contribution of height of disease activity on myocardial infarction. However, duration of disease may be more important, as suggested by European League Against Rheumatism recommendations that identify duration of RA disease of ≥10 years as a CVD risk factor. Using data from the Nijemgen early RA cohort, the investigators identified all RA patients with a follow-up of ≥6 months with no cardiovascular history and included them in the study. The time-averaged Disease Activity Score using 28 joint counts (DAS28) was calculated for each patient. Using Kaplan-Meier survival analysis, log-rank testing, and Cox proportional hazards regression, the investigators estimated the effect of disease duration on the risk of developing a first cardiovascular event (myocardial infarction, transient ischemic attack, stroke, and heart failure) including age, sex, and DAS28 as covariates. The incidence of CVD within the first 10 years of the disease was compared with the incidence after the first 10 years. The study included 855 patients with 6388 patient-years. The majority of study participants were female, the mean age was 54 years, 76% were rheumatoid factor positive, and the mean baseline DAS28 was 5.0. Among the total cohort, there were 91 cardiovascular events during follow-up that included myocardial infarction, heart failure, and cerebrovascular accident. The study found no correlation between disease duration or level of disease activity and risk of a cardiovascular event as represented by the lack of change in CVD risk over disease duration based on the course of hazards over time. No difference in survival was found during the first 10 years of disease compared with after 10 years of disease duration (P=.56). In patients with very low disease activity (DAS28<2.9), however, survival was significantly different compared with patients with active disease (P=.038). According to Ms. Arts, this survival difference in patients with very low disease highlights the possibility that sustained remission may exert a positive influence on the risk of CVD.