SAN DIEGO—The ACR Convergence 2023 Plenary Sessions highlight select abstracts of interest to the general ACR audience. In one presentation at this year’s Plenary Session 3, Beth Wallace, MD, MSc, a staff physician at the VA Ann Arbor Healthcare System, Michigan, and an assistant professor at the University of Michigan, Ann Arbor, shared important data on the relationship between time-dependent cumulative glucocorticoid exposure and major adverse cardiovascular events (MACE) in a cohort of veterans with rheumatoid arthritis (RA).
Dr. Wallace commenced her talk with an unfortunate truth: “Up to 50% of RA patients in the United States use long-term glucocorticoids despite previous work suggesting they increase the risk of MACE in a dose-dependent way.”1
She and her colleagues previously presented work demonstrating that less than 14 days of glucocorticoid use in a six-month period is associated with a two-thirds increase in the odds of MACE over the following next six months, and 90 days of use was associated with over a two-fold increase. However, studies to date have been limited by the fact that no adjustments were made for the timing of prior glucocorticoid use or dose per unit time, both of which matter when discussing glucocorticoid risk profile.
Wallace et al. conducted a retrospective cohort study using national data from the Veterans Affairs (VA) Corporate Data Warehouse. The researchers included patients with RA who were between 40 and 90 years old and had an initial rheumatology visit between 2010 and 2018. They excluded patients with other rheumatic disorders and prior MACE or equivalent. The primary outcome was time to first MACE, defined as an acute myocardial infarction, stroke or transient ischemic attack, cardiac arrest, coronary revascularization or death from a cardiovascular (CV) cause.
They used pharmacy dispensing data to calculate a weighted cumulative dose (WCD) of oral glucocorticoids (see below), and medical claims data to identify incident MACE.2 They adjusted the model for many baseline (i.e., age, sex, race, BMI, Elixhauser index) and time-varying covariates updated every six months (i.e., tobacco use, VARS-CVD, malignancy claim, lipid-lowering pharmacy claim, opioid claim, methotrexate use, biologic use, hydroxychloroquine use, claim for hospitalized infection, number of rheumatology clinic visits in the past six months), including the VA Risk Score—Cardiovascular Disease (VARS-CVD). The VARS-CVD is an estimate of five-year MACE risk specific to the veteran population that’s generated from multiple variables.3 It’s similar to the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator from the American Heart Association/American College of Cardiology.4