“But if we find this, can we do something different for the patient? I certainly talk to these patients about the risks, and we talk about nonpharmacological ways to improve their endothelial function: diet, exercise and weight loss,” she said. Statins can improve both inflammation and cholesterol levels in these patients, “but should they be used routinely in RA patients? Obviously, the guidelines don’t say so.”12
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Treat Inflammation Aggressively
Long-term corticosteroids have a negative effect on carotid artery thickness, said Dr. Mankad.13 “If you’re using bursts of steroids here and there, maybe it’s OK because you’re driving down the inflammation. But if you’re using them chronically, lots of bad things can happen.” TNF inhibitors appear to have a slightly better effect on CVD risk than non-biologic DMARDs, she said.14
Rheumatologists should watch for clues that suggest a patient needs more extensive cardiovascular screening, she said. “Always have a high index of suspicion and, depending on the patient, watch for the symptoms and signs of heart disease.”
Susan Bernstein is a freelance journalist based in Atlanta.
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- Gabriel SE, Crowson CS, Kremers HM, et al. Survival in rheumatoid arthritis: A population-based analysis of trends over 40 years. Arthritis Rheum. 2003;48(1):54–58.
- Abu-Shakra M, Urowitz MB, Gladman DD, et al. Mortality studies in systemic lupus erythematosus: Results from a single center, II, predictor variables for mortality. J Rheum. 1995 Jul;22(7):1265–1270.
- Haroon NN, Paterson JM, Li P, et al. Patients with ankylosing spondylitis have increased cardiovascular and cerebrovascular mortality: A population-based study. Ann Int Med. 2015 Sep;163:409–416.
- Nicola PJ, Maradit-Kremers H, Roger VL, et al. The risk of congestive heart failure in rheumatoid arthritis: A population-based study over 46 years. Arthritis Rheum. 2005 Feb;52(2):412–420.
- Maradit-Kremers H, Nicola PJ, Crowson CS, et al. Raised erythrocyte sedimentation rate signals heart failure in patients with rheumatoid arthritis. Ann Rheum Dis. 2007;66:77–80.
- Mantel A, Holmqvist M, Andersson DC, et al. Association between rheumatoid arthritis and risk of ischemic and non-ischemic heart failure. J Am Coll Cardiol. 2017 Mar;69(10):1275–1285.
- Davis JM 3rd, Roger VL, Crowson CS, et al. The presentation and outcome of heart failure in patients with rheumatoid arthritis differs from that of the general population. Arthritis Rheum. 2008 Sep;58(9):2603–2611.
- Maradit-Kremers H, Crowson CS, Nicola PJ, et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: A population-based cohort study. Arthritis Rheum. 2005 Feb;52(2):402–411.
- Escalante A, Haas RW, del Rincon I. Paradoxical effect of body-mass index on survival in rheumatoid arthritis: Role of comorbidity and systemic inflammation. Arch Intern Med. 2005 Jul;165(14):1624–1629.
- Roman MJ, Shanker BA, Davis A, et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. New Engl J Med. 2003;349:2399–2406.
- McCarey DW, MacInnes IB, Madhok R, et al. Trial of atorvastatin in rheumatoid arthritis (TARA): double-blind, randomised, placebo-controlled trial. Lancet. 2004;363(9426):2015–2021.
- Giles JT, Post WS, Blumenthal RS, et al. Longitudinal predictors of progression of carotid atherosclerosis in rheumatoid arthritis. Arthritis Rheum. 2011 Nov;63(11):3216–3225.
- Solomon DH, Curtis JR, Saag KG, et al. Cardiovascular risk in rheumatoid arthritis: Comparing TNF-α blockage with non-biologic DMARDs. Am J Med. 2013 Aug;126(8):730e9–730e17.