Naveed Sattar, MD, professor of metabolic medicine at the University of Glasgow, Scotland, said that the risk for vascular disease in patients with rheumatic disease accrues early. In his presentation at the ACR Clinical Research Conference here at the 2009 ACR/ARHP Annual Scientific Meeting, Dr. Sattar said there are compelling reasons to screen for cardiovascular risk in patients older than age 40 who have rheumatic disease.
“These patients are more likely to die before they get to the hospital if they have a myocardial infarction,” he said. “They are less likely to be symptomatic and are more likely to have ischemic heart disease, receive less treatment for hypertension, and develop more congestive heart failure.” If these patients survive the myocardial infarction and make it to the hospital, they have a 30-day mortality rate of about 50% to 90%, he said.
In an overview of how inflammation leads to cardiovascular disease, Muredach Reilly, MBBCh, assistant professor of medicine and pharmacology in the cardiovascular medicine division at the Hospital of the University of Pennsylvania in Philadelphia, said that changes in signaling via mechanical transduction and hypercholesterolemia induce endothelial cell dysfunction that then promotes inflammation and fatty streak formation.
When there is progression from fatty streaks to late lesions, cells in the lesions produce chemokines, cytokines, and growth factors, eventually resulting in vulnerable plaques that are prone to rupture and thrombotic events.
Assess Cardiovascular Risk
Dr. Sattar said that cardiovascular risk should be regularly assessed in patients with RA and that treatment should be given for existing risk factors, such as increased cholesterol or hypertension. Several factors are believed to be responsible for the increased risk of cardiovascular disease among patients with rheumatoid disease.
Most importantly, systemic inflammation, which can be high in RA, is an independent risk factor for cardiovascular disease that interacts with the more traditional risk factors. Patients with RA and ischemic heart disease share several risk factors, including smoking, obesity, and low physical activity, he said.
Vascular disease also tends to be undertreated in patients with RA because patient inactivity may lead to few symptoms. Several current drug therapies, such as glucocorticoids and nonsteroidal antiinflammatory drugs/coxibs, may contribute to increased risk.
High-grade inflammation affects multiple tissues and leads to endothelial dysfunction, dyslipidemia, more oxidative stress, increased levels of homocysteine, and insulin resistance. These effects accelerate atherogenesis and myocardial microvascular abnormalities, Dr. Sattar said.1