“The treatment for these patients may not be more statins,” she adds. “It may actually mean we should be more aggressive with controlling inflammation.”
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Considering the lack of guidelines, Dr. Liao understands why disease activity isn’t factored into cardiovascular risk stratification. Her clinical research includes serving as a co-investigator in a randomized controlled trial known as TARGET, which is investigating if the tight control of inflammation means lower cardiovascular risk in RA.1 She also is a principal investigator for an ongoing study designed to more closely examine the relationship between cholesterol, inflammation and cardiovascular risk in RA.2
For now, Dr. Liao suggests considering two groups of rheumatology patients.
“For the RA patient who is flaring, where we have a plan—for example, they are on a TNFi, but not responding—we still have a lot of agents we can switch to. For these patients, I wouldn’t necessarily start a statin that day, based on concern for elevated [cardiovascular] risk, unless their cholesterol is clearly elevated,” she says. “I would recommend reassessing their risk after their disease activity is controlled.
“For patients who are already maxed out on RA therapies and their inflammation remains uncontrolled, … I would say let’s get as aggressive as possible with all their risk factors, potentially beyond general population guidelines, particularly with regard to statin use.”
Work with Cardiologists & Others
Dr. Liao, who is co-chair of the ACR’s Health Services Research Abstract Selection Subcommittee, encourages discussions between primary care physicians, rheumatologists and cardiologists. Her institution and others—including the Mayo Clinic, the Cleveland Clinic and Johns Hopkins—have created cardiology-rheumatology clinics that foster communication about patients’ disease history and activity.
And while a formal construct between cardiology and rheumatology may not be feasible in smaller institutions or rural settings, Dr. Liao says having a dedicated cardiology point person “who understands rheumatology patients, knows the drugs we use” can be a good first step to facilitating communication and improved patient care.
“[Access] is a system-wide issue, but it is helpful to get someone into the clinic in a timely manner. The point person doesn’t have to know everything about rheumatic diseases, but should have a sense of our drugs and treatment strategies. That is very helpful,” she says. “I consider that part of access because some people need to get into the clinic right away and some don’t. Having a point person see a young lupus patient with new onset exertional chest pain and history of heavy steroid use right away is important.”