The management of cardiovascular disease risk in patients with rheumatoid arthritis

ABSTRACT

Introduction

Rheumatoid Arthritis (RA) is a chronic inflammatory disorder associated with an increased incidence and prevalence of cardiovascular disease (CVD), including myocardial infarction and heart failure. In addition to traditional risk factors, evidence suggests inflammation is critical to the pathophysiology of both conditions. Despite the association being well-recognised, challenges remain in managing cardiovascular risk in RA.

Areas Covered

This manuscript analyses the association between CVD and RA and explores the limitations in evaluating cardiovascular risk in RA with available risk assessment tools. The authors review the optimal management of traditional risk factors such as hypertension and dyslipidaemia and contemporary risk factors such as inflammation and analyse the cardiovascular impact of RA medications.

Expert opinion

Analysis points to the critical role of inflammation in the pathogenesis of RA and CVD. It is well established that conventional disease-modifying anti-rheumatic drugs (DMARDs) improve cardiovascular outcomes; however, underlying risk often remains underappreciated. The authors suggest there remains an opportunity to improve mortality and morbidity with the early recognition and of at-risk populations and the timely initiation of appropriate cardiovascular and anti-inflammatory medications. More research is necessary into the role that imaging may play in stratifying risk and in the longer-term cardiovascular impact of biological DMARDs.

Keywords:

• Cardiovascular Risk
• Rheumatoid Arthritis
• DMARD

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Article highlights

• CVD is a significant cause of increased mortality and morbidity in RA, and a high index of suspicion of early or significant CVD is necessary when managing these patients.

• Aside from typical risk factors, inflammation is critical to the pathogenesis of atherosclerosis and the elevation of cardiovascular risk in RA.

• Widely available cardiovascular risk calculators have inaccuracies in estimating cardiovascular risk when used in those with RA, leading to challenges in identifying and managing the specific at-risk cohort of patients.

• Medications used to treat RA may either mitigate or elevate underlying cardiovascular risk. For example, NSAID and glucocorticoids are shown to elevate underlying cardiovascular risk and must be used with caution, whereas methotrexate and IL-6 inhibitors such as Tocilizumab have demonstrated improved cardiovascular outcomes.

• Further research is needed to understand the long-term effect of newer biologic RA treatment and its effect on cardiovascular risk.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded