Some rheumatologists argue that they are responsible for monitoring and treating only rheumatic disease and that internists or cardiologists should manage cardiovascular risk factors. My co-researchers and I believe that such a posture is not justified.
The presence of either SLE or RA constitutes a sufficiently potent risk factor for ASCVD that more aggressive goals for risk factor modification need to be adopted and vigorously pursued, goals analogous to the American Heart Association recommendations for risk reduction in diabetes mellitus.21-23 (See Table 1, above right). Furthermore, we believe that it is the rheumatologist’s responsibility to address the increased propensity to cardiovascular disease in SLE and RA patients, either directly or by advising the patient’s internist.
Treatment Goals
The practical implications of a more aggressive strategy relate to achieving lower targets for blood pressure and LDL cholesterol as recently established by the American Heart Association.21-23 The standard goal had been to maintain blood pressure <140/90 mmHg with lifestyle modification and, if necessary, pharmacological therapy, whereas <130/80 mmHg is the more aggressive stance. It must be noted that in certain clinical situations, especially among the elderly, vigorous measures to lower blood pressure carry their own risks.
The former targets for LDL cholesterol are <160 mg/dL in the setting of less than two risk factors, <130 mg/dL in the setting of at least two risk factors, and less than <100 mg/dL (or, possibly, <70 mg/dL) in the presence of clinical ASCVD or its equivalent (i.e., diabetes). We suggest, in keeping with the new recommendations, that LDL cholesterol be lowered to <100 mg/dL in SLE and RA patients, and to <70 mg/dL or lower in patients with documented ischemic events.
TABLE 1: Strategies to Reduce ASCVD in Patients with SLE and RA
- Hypertension Goal: BP <130/80 mmHg Method: ACE inhibitors
- Hyperlipidemia Goal: LDL <100 mg/dL, particularly if preclinical ASCVD is present Method: statins
- Hyperglycemia Method: maintain normal fasting plasma glucose
- Smoking cessation Method: nicotine replacement and formal cessation programs
- Weight management Goal: BMI <25 kg/m2
- Physical activity Goal: at least 30 minutes/day, three to four times/week
Because dietary changes are often inadequate to achieve these goals, pharmacological therapy is often required, with an HMG-CoA reductase inhibitor (statin) the drug of first choice. Statins are particularly attractive because they effectively lower LDL cholesterol (without lowering the HDL fraction) and also decrease levels of C-reactive protein, in patients with documented coronary artery disease.
The use of antimalarial agents in the treatment of SLE may provide an additional beneficial effect on serum lipid levels. Aspirin therapy is recommended for primary prevention for ASCVD in men; it is, as yet, of unproven benefit in women and not recommended for primary prevention in women with SLE or RA.
