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Assessing atherosclerosis in rheumatologic disease: management strategies may need to include reduction of cardiac risk.

Article Excerpt
In the past decade, evidence increasingly has suggested a higher prevalence of atherosclerotic cardiovascular disease (CVD) in patients with autoimmune rheumatologic conditions. Because the role of inflammation in atherogenesis has been appreciated, a positive association of CVD with chronic inflammatory diseases is not surprising. However, the pathogenesis of atherosclerosis in these patients is complex and appears to involve both traditional and disease-related CVD risk factors.

Physicians who are managing patients with rheumatologic disease should be aware of this increase in CVD risk. Medical management of the rheumatologic disease with drugs associated with lower risk of CVD events ultimately may minimize morbidity and mortality related to atherosclerosis. Patients also should be counseled about the benefits of altering modifiable risk factors, such as cigarette smoking, diet, and a sedentary lifestyle.

In this article, we examine the evidence that links CVD with 3 common rheumatologic diseases: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and spondyloarthropathy (SpA).Understanding these connections may provide insights that can help the physician reduce the patient's cardiac risk and successfully address the special challenges created by concomitant CVD and rheumatologic disease.

ASSOCIATED RHEUMATOLOGIC DISEASES

Rheumatoid arthritis

RA is a chronic, systemic autoimmune disease that affects about 1.3 million Americans. (1) Life expectancy is reduced by 7 to 23 years. CVD is the leading cause of death in patients with RA, accounting for nearly 40% of deaths. (2)

Numerous reports consistently have shown an increase in the risk of myocardial infarction (MI) in patients who have RA compared with persons who do not. In a study of 236 patients with RA compared with 4635 non-RA participants in a population-based cohort, the incidence rate ratio for CVD events (MI and revascularization procedures) was 3.96 (95% confidence interval [CI], 1.86-8.43) after adjusting for traditional CVD risk factors. (3)

In the Nurse's Health Study, which compared CVD event rates among the 527 women in whom RA had developed with the CVD event rates among the non-RA participants, the adjusted relative risk (RR) for MI was 2.0 (95% CI, 1.23-3.29). For those women who had had RA for 10 years or more, the adjusted RR of MI was 3.10 (95% CI, 1.64-5.87). (4)

In another prospective cohort study, 17,738 patients with RA were compared with 3001 patients who had noninflammatory rheumatologic disorders. The hazard ratio of first MI was 1.9 (95% CI, 1.2-2.9, P = .005). (5)

Evidence also suggests an increase in risk of cerebrovascular accident, or stroke, in patients with RA. In a nested case-control study within a longitudinal databank, 269 patients with first stroke were matched with up to 20 controls for each case. Of the 67 ischemic strokes, 41 were in patients with RA. The odds ratio for the risk in all-category stroke and in ischemic stroke in RA was 1.64 (95% CI, 1.16-2.30,P = .005) and 2.66 (95% CI 1.24-5.70, P = .012), respectively. (6) Although the risk of stroke was found to be increased in the participants with RA in the Nurse's Health Study, this increased risk was not statistically significant. (4)

All together, these studies show an increase in risk of CV events related to multiple arterial beds in patients with RA. The increase in risk may be 2-...

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