Cardiovascular risk in RA

1. Dr.Sahar Gamal El-Din
National Heart Institute

2. • Autoimmune , chronic auto-inflammatory
disease resulting in symmetrical joint
affection (destruction), with the potential for
extra-articular manifestations .
– Eyes, lungs, skin , CNS , heart & GVs .
• The most common form of chronic
inflammatory polyarthritis .
• ~ 1% of population, Female : Male > 3:1.
• Life expectancy for RA patients is 3–10 years
less than that for the general population.
Ann Rheum Dis. 2010 Jan. 69(1):230-3.

3. • RA is associated with an increased risk of
developing CVD by almost two folds, a risk
magnitude comparable to that of type two DM
suggesting that, as in DM , RA is a significant
independent risk factor for premature IHD.
• Like diabetic patients, RA patients are more
likely to develop silent ischemia and SCD.
• There is an excess risk of CVD that occurs
early in the disease course of RA , which may
even pre-date disease onset.
Arthritis Care Res (Hoboken). 2017; 69(10):1510–8.

4. The Link between RA and CVD risk !
• Inflammation plays a key role in CVD.
• Patients with RA appear to have
accelerated atherosclerosis, which is itself
considered an inflammatory condition.
• It may be that the inflammatory process of RA
along with an excess of pro-
inflammatory cytokines such as TNF-α, result
in endothelial activation and up-regulation of
adhesion molecules
Arthritis Res.and Therapy, 14, 2, article R42, 2012.

5. • The autoimmune-mediated inflammation of RA
contributes to increased endothelial
dysfunction, oxidative stress.
• Also , metabolic syndrome is common in both
early and long-standing RA.
• HTN is common & it appears to be under-
diagnosed and under-treated in RA . HTN in RA
may be exacerbated by inflammation and
medication
• Furthermore, the impaired physical activity may
affect the risk of CVD in these patients.
Journal of Rheumatology, vol. 38, no. 1, 29–35, 2011.

6. • Also , RA is associated with a two fold higher
possibility for HF with a worse prognosis than
non-RA patients.
• HFpEF seems to be more prevalent reflecting
the influence of chronic inflammation on the
myocardium causing LV stiffening.
• Similar to CAD, patients with RA are less likely
to present with typical CHF symptoms, are less
likely to receive guideline-concordant care, and
have higher mortality rates following
presentation with CHF.
Autoimmune Rev .2012 ,12: 305–312.

7. • Although accounting for a lower proportion of the
excess CVD morbidity and mortality in RA, the risk
of non-cardiac vascular disease is also increased in
RA patients.
• Large meta-analyses have identified positive
associations between RA with both ischemic and
hemorrhagic stroke.
• Similarly, RA patients appear to have an
approximately 2-fold higher risk of venous
thromboembolic events.
• Less studied than other forms of CVD, PAD may be
increased in RA patients independent of other CVD
and CVD risk factors

8. • The leading causes of death ( ~ 50% ) in
RA patients are related to cardiovascular
events or diseases.
• Furthermore, CV events occur earlier in
RA and are associated with a higher case
fatality than in the general population.
Annu Rev Med. 2013 ; 64: 249–263.

9. • The excess risk of CVD morbidity and
mortality in patients with RA is related to
both traditional and novel CVD risk
factors.
• Novel risk factors include : inflammation,
presence of carotid plaques,
anticitrullinated protein antibody (ACPA)
and rheumatoid factor (RF) positivity, extra-
articular RA manifestations, functional
disability and hypothyroidism.
Rheumatology (Oxford) 2013;52:45–52.

10. • Several algorithms that quantify this risk
are available to use in the general
population, which are also applicable to
patients with RA.
• These models do not account for the
increased CVD risk associated with RA
inflammation.
J Am Coll Cardiol. 2014;63(25 Pt B):2935–59.

11. CVD Risk Algorithms
• Framingham risk score (10 year risk):
Age, HT, smoking, hyperlipidemia.
• SCORE risk system (10 year risk) :
Age, gender, SBP, total cholesterol, & smoking .
• Reynolds risk score (10 year risk):
35 risk factors including traditional and novel
risk factors.
• QRISK-2 calculator (10 year risk):
Uses traditional risk together with RA.
Am J Cardiol. 2012;110(3):420–4.

12. • Expanded Cardiovascular Risk Prediction
Score for Rheumatoid Arthritis (ERS-RA):
 It includes RA-related variables such as :
1. Clinical Disease Activity Index (CDAI)
> 10 versus ≤10).
2. Disability (modified Health Assessment
Questionnaire disability index > 0.5 versus ≤0.5).
3. Daily prednisone use and disease duration
(≥10 versus < 10 years) .
in addition to traditional CV risk factors
Arthritis & rheumatology. 2015;67(8):1995–2003.

13. European League Against
Rheumatism EULAR
recommendations for CVD
risk management in patients with
RA : 2015/2016 update

14. 1. Disease activity should be controlled
optimally in order to lower CVD risk in
all patients with RA.
2. CVD risk assessment is recommended
for all patients with RA at least once
every 5 years and should be reconsidered
following major changes in
antirheumatic therapy.
Ann Rheum Dis. 2017;76(1):17–28.

15. 3. CVD risk estimation for patients with RA
should be performed according to national
guidelines or SCORE CVD risk prediction
model should be used if no national
guideline is available.
4. TC and HDLc should be used in CVD risk
assessment in RA & lipids should ideally be
measured when disease activity is stable or
in remission. Non-fasting lipids
measurements are also acceptable.
Ann Rheum Dis. 2017;76(1):17–28.

16. • The relationship between serum lipid levels
and CVD risk is non-linear and potentially
paradoxical in RA (Lipid Paradox). Patients
with RA with highly active disease generally
have lower serum TC and LDLc levels
compared with the general population, while
their CVD risk is elevated.
• These patients also have reduced serum levels
of HDLc and higher levels of triglycerides as
compared with healthy controls.
Arthritis Care Res (Hoboken) 2013 ;65:2046–50.

17. 5. CVD risk prediction models should be
adapted for patients with RA by a 1.5
multiplication factor, if this is not already
included in the model.
6. Screening for asymptomatic atherosclerotic
plaques by use of carotid ultrasound may
be considered as part of the CVD risk
evaluation in patients with RA.
Ann Rheum Dis. 2017;76(1):17–28.

18. 7. Lifestyle recommendations should
emphasise the benefits of a healthy diet,
regular exercise and smoking cessation.
 A history of smoking is associated with
a moderate increased risk of RA onset.
8. CVD risk management should be carried
out according to national guidelines in
RA, antihypertensives and statins may
be used as in the general population.
Ann Rheum Dis. 2017;76(1):17–28.

19. 9. Prescription of NSAIDs in RA should be
with caution, especially for patients with
documented CVD or in the presence of
CVD risk factors.
10.Corticosteroids: for prolonged treatment,
the glucocorticoid dosage should be kept
to a minimum and a glucocorticoid taper
should be attempted in case of remission
or low disease activity; the reasons to
continue glucocorticoid therapy should be
regularly checked.
Ann Rheum Dis. 2017;76(1):17–28.

21. Multiple Choice Questions

22. 1. Patients with RA have an almost _____
increased risk of having a major
cardiovascular event, according to the
findings of a cohort study.
A. 2-fold
B. 5-fold
C. 10-fold

23. 2. According to the EULAR 2015/2016 updated
recommendations for CVD management in
patients with RA, when using CVD risk
prediction models, which one of the following
multiplicative factors should be used, if not
already accounted for in the existing model?
A. 0.75
B. 1.5
C. 2.5
D. There is no recommended multiplicative factor

24. 3. True or false : Smoking increases the
risk of developing RA.
A. True
B. False

25. 4. True or False. Accelerated
cardiovascular disease accounts for up
to 50% of deaths in patients with RA.
A. True
B. False

26. E. Which of the following is rare but
serious complication caused by
rheumatoid vasculitis ?
A. Stroke.
B. Myocardial infarction.
C. Intestinal infarction.
D. All of the above .