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Therapy Insight: managing cardiovascular risk in patients with rheumatoid arthritis

Nature Clinical Practice Rheumatology volume 2, pages 320–329 (2006)Cite this article

Abstract

Chronic low-grade inflammation was recognized during the past decade as an important risk factor for the development of atherosclerosis and, more recently, for the development of heart failure. Patients with rheumatoid arthritis (RA) are at increased risk of morbidity and mortality from ischemic cardiovascular events and heart failure. Epidemiologic and clinical studies indicate that RA is an independent risk factor for cardiovascular disease, which suggests that chronic exposure to high levels of inflammatory mediators contributes to this enhanced risk. The relative contribution of conventional risk factors to the acceleration of cardiovascular disease does not seem to be increased in patients with RA compared with control populations. Nonetheless, some preclinical laboratory measures of risk factors (e.g. insulin sensitivity) are adversely modulated in the context of the highly inflammatory rheumatoid microenvironment. Discerning the net effect of RA therapies on cardiovascular disease is also challenging because, theoretically, their biologic effects could either promote or attenuate atherosclerosis and ventricular dysfunction; however, available data suggest a beneficial effect on cardiovascular morbidity and mortality in patients with RA. This review provides an overview of the potential influence of RA and its treatment on the development and progression of cardiovascular disease, and outlines some preliminary recommendations for prevention and management of this complication in patients with RA.

Key Points

  • Individuals with rheumatoid arthritis (RA) are at an increased risk of cardiovascular events, particularly ischemic heart disease and heart failure, and death from cardiovascular disease

  • An increased prevalence of atherosclerosis and myocardial dysfunction in patients with RA is only partially explained by conventional cardiovascular risk factors, suggesting that RA-related factors such as chronic high-grade systemic inflammation might be contributory

  • In the absence of evidence-based approaches (such as those provided by clinical trials) for the prevention and management of cardiovascular disease risk in patients with RA, aggressive control of both synovitis and conventional cardiovascular risk factors is advised in all patients

  • Treatment goals for conventional cardiovascular risk factors should center around an assessment of the 10-year coronary artery disease risk of individual patients with RA, with all patients assessed as at least intermediate risk

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Figure 1: Progression of atherosclerosis.
Figure 2: Risk factors assessed in a sample of studies of cardiovascular morbidity and mortality in patients with rheumatoid arthritis.

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Acknowledgements

This work was supported in part by an American College of Rheumatology Clinical Investigator Fellowship Award (JT Giles), an Arthritis National Research Foundation Award (JT Giles), and a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (JM Bathon).

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Authors and Affiliations

  1. Instructor in Medicine in the Division of Rheumatology,

    Jon T Giles, Wendy Post, Roger S Blumenthal & Joan M Bathon

  2. Associate Professor of Medicine,

    Jon T Giles, Wendy Post, Roger S Blumenthal & Joan M Bathon

  3. Associate Professor of Medicine in the Division of Cardiology,

    Jon T Giles, Wendy Post, Roger S Blumenthal & Joan M Bathon

  4. Director of the Johns Hopkins Arthritis Center and a Professor of Medicine in the Division of Rheumatology at the Johns Hopkins University, Baltimore, MD, USA

    Jon T Giles, Wendy Post, Roger S Blumenthal & Joan M Bathon

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  1. Jon T Giles
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Correspondence to Joan M Bathon.

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Competing interests

JT Giles has declared no competing interests. W Post has received honoraria from Merck and Pfizer. R Blumenthal has received honoraria from Merck, Pfizer, Schering Plough, Astra Zeneca and KOS Pharmaceuticals. JM Bathon receives grant support from the National Institutes of Health, Bristol Myers Squibb, Centocor, Amgen, IDEC/Biogen and Roche, and is a consultant to Abbott Laboratories and Biowa.

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Giles, J., Post, W., Blumenthal, R. et al. Therapy Insight: managing cardiovascular risk in patients with rheumatoid arthritis. Nat Rev Rheumatol 2, 320–329 (2006). https://doi.org/10.1038/ncprheum0178

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