Cardiovascular Risk in Rheumatoid Arthritis: Pathogenesis, Screening & Prevention

Standard risk stratification tools to screen for cardiovascular risk underperform when used to assess risk in rheumatoid arthritis patients.

Risk Management

Dr. Giles also reviewed some of the data on the most studied agents linked to a reduction in cardiovascular events in RA patients—methotrexate and tumor necrosis factor (TNF) inhibitors.

Evidence from eight cohort studies shows methotrexate was associated with a 28% reduction in all cardiovascular events. In addition, evidence from 16 cohort studies showed a 30% reduction in all cardiovascular events with TNF inhibitors.⁶  These data support the use of these agents as a strategy for reducing cardiovascular events, said Dr. Giles, emphasizing, however, this support is based only on observational data.

(click for larger image) Table 1: Screening Strategy

Few head-to-head comparisons between these agents have been conducted. Those that have been conducted have not shown any superiority of one agent over another.

Although other cytokine inhibitors may have similar effects to these agents, he said it is “imprudent to make assumptions.”

Dr. Giles pointed out that a recent trial of people without RA but with a history of cardiovascular disease, data showed methotrexate did not confer a benefit in reducing cardiovascular events. This result is generating some controversy. Dr. Giles emphasized the findings could have been affected by the fact the investigators did not select patients with elevated inflammation. “It [methotrexate] also may be better for primary rather than secondary prevention,” he said. “And effects may differ in RA compared with the general population.”

Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.

References

1. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017 Jan;76(1):17–28.
2. Bartels CM, Kind AJ, Everett C, et al. Low frequency of primary lipid screening among Medicare patients with rheumatoid arthritis. Arthritis Rheum. 2011 May;63(5):1221–1230.
3. Giles JT. Cardiovascular disease in rheumatoid arthritis: Current perspectives on assessing and mitigating risk in clinical practice. Best Pract Res Clin Rheumatol. 2015 Aug–Dec;29(4–5):597–613.
4. Goff Jr DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J Am Coll Cardiol. 2014 Jun 24;129(Suppl 2):S49–S73.
5. Roubille C, Richer V, Starnino T, et al. The effects of tumour necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: A systematic review and meta-analysis. Ann Rheum Dis. 2015 Mar;74(3):480–489.