Review articleVascular disease in rheumatoid arthritis: From subclinical lesions to cardiovascular risk
Introduction
Rheumatoid arthritis is one of the most prevalent inflammatory diseases in the general population. While the most important pathogenic lesion is the inflammatory synovitis, the extraarticular features are equally important, considering the fact that inflammation has a systemic magnitude. From this point of view, a large spectrum of cardiac and vascular involvements in RA (i.e. valvular, myocardial and pericardial disease, coronary artery disease, myocardial infarction, stroke, heart failure, vasculitis lesions, cardiac rheumatoid nodules, echocardiographic abnormalities as diastolic dysfunction and pulmonary hypertension) was already described.
The vasculitic lesions – the presence of the inflammatory lesions in the vessel walls – although not very frequent, were the first reported. Thus, for decades, the vascular disease in RA was synonymous with the presence of rheumatoid vasculitis. During the last years, accumulation of new data made evident the existence of great diversity of vascular involvement in RA (Table 1), which encompasses the entire spectrum of vascular lesions and the clinical manifestations determined by these lesions. Among these, large longitudinal studies performed in the last years reported a high prevalence of atherosclerosis related lesions in the patients with RA and their enormous importance regarding the long-term prognostic. Regardless the vascular territory involved (coronary, cerebral, renal or peripheral arteries), the presence of these lesions leads to the occurrence of specific symptoms and, finally, to an increased prevalence of cardiovascular disease and increased mortality. Moreover, nowadays most authors consider the improvement of this increased cardiovascular risk as one of the most important measures in the global management of patients with RA, and therefore some specific recommendations regarding this issue were released [1].
The aim of this article is to review the most important vascular lesions in patients with RA, especially those related to atherosclerosis and associated with an increased cardiovascular risk, and the most clinically relevant measures to improve this risk.
Section snippets
Rheumatoid vasculitis
Classically, the main vascular involvement in RA was considered the rheumatoid vasculitis. Regarded as an extraarticular feature, rheumatoid vasculitis is relatively rare and has specific clinical manifestations, diagnostic criteria and therapeutic approaches (corticosteroids, immunosupressors and, recently, the biologic therapies). The importance of subclinical vasculitis lesions, reported at systematic biopsies, is unclear until now. The pathogenic criteria for the diagnostic of rheumatoid
Atherosclerotic vascular disease
Recent studies showed the great importance of atherosclerosis related lesions in patients with RA. In these patients, the atherosclerotic lesions occur earlier and have a more rapid evolution than in general population and some authors proposed the terms “accelerate atherosclerosis” or “premature atherosclerosis” to underline the magnitude of this process in RA. Thus, beyond clinically overt cardiovascular disease, most authors reported the importance of subclinical or silent vascular disease
Traditional cardiovascular risk factors
All these observations linking RA to an increased atherosclerotic burden and cardiovascular risk raise several physiopathological hypotheses. The traditional risk factors were the first studied when the cardiovascular risk in patient with RA became evident. However, the prevalence of traditional cardiovascular risk factors was found to be similar in patients with RA and controls, except for smoking which was more prevalent in RA, and the impact of these factors is less important in RA than
How to detect cardiovascular disease in patients with RA?
In daily clinical practice, the detection of cardiovascular disease in patients with RA must follow the guidelines available in general population. The European Society of Cardiology guideline regarding the cardiovascular risk assessment in general population recommends the use of a SCORE chart and emphasized the higher risk of those with evidence of pre-clinical atherosclerotic disease [86].
In patients with overt cardiovascular disease, the diagnostic modalities are the same than in general
The treatment of RA and the cardiovascular risk
Glucocorticoid therapy was associated with an increased risk for hypertension [87], [88] and for cardiovascular events [89]. Davis et al. reported an increased risk for adverse cardiac events following glucocorticoid treatment in patients positive for rheumatoid factor (RF) and not in those negative for RF [90]. However, the influence of different doses and durations of treatment regarding the cardiovascular risk is still incompletely elucidated. The treatment with low doses of prednisolone was
Improvement of vascular disease with statins in patients with RA
Statins, largely used in clinical practice for their hypolipemiant effects but also having some anti-inflammatory properties, were used in patients with RA in order to reduce the inflammation and disease activity [108] and to improve the vascular function. Using the results of the large primary and secondary prevention trials with statins in general population, it is reasonable to think that their use in patients with RA might improve also the cardiovascular risk.
The treatment with statins
Global cardiovascular risk management in patients with RA
Generally, the goals of treatment in patients with RA are the control of inflammation at the joints level and the prevention of irreversible joint destructions. In the same time, the majority of the guidelines emphasized the great importance of the comorbidities management, among which the cardiovascular disease has a great importance. The cardiovascular risk stratification process must be performed ever since diagnosis and the efforts to improve this risk must advances in parallel with the
Conclusions
In patients with RA, vascular function and structure might be altered leading to an increased prevalence for cardiovascular disease and for cardiac death (see Fig. 1). The subclinical vascular disease encompasses a large spectrum of functional (as endothelial dysfunction, increased vascular stiffness or reduced coronary flow reserve) and structural damage (as an increased intima-media thickness or a high prevalence of asymptomatic plaques). In these patients, there is also a high prevalence of
Learning points
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Rheumatoid arthritis affects primarily the joints, but a large spectrum of extra-articular features was described. Among these extra-articular features, cardiovascular disease has a great importance regarding the long-term prognosis in patients with RA.
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The vascular involvement in RA might be silent or subclinical, and these morphological or functional alterations might be considered as an early stage of atherosclerosis.
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In RA a high prevalence of ischemic heart disease and particularly of
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2012, American Journal of CardiologyCitation Excerpt :In addition, selection bias could have been present in the observational study. The unfavorable pathophysiologic changes that promote the atherosclerosis accompanying RA, coupled with the increasing evidence of plaque instability in RA,1,7–12 suggest that patients with RA might be at an increased risk of restenosis after intervention. Although they did not reach significant levels, we consistently found greater rates of rehospitalization for repeat PCI among the patients with RA compared to the controls.
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2011, International Journal of Cardiology