Coronary Microvascular Dysfunction in Rheumatoid Arthritis Compared to Diabetes Mellitus and Association With All‐Cause Mortality

Abstract

Objective Coronary microvascular dysfunction (CMD) is a predictor of cardiac death in diabetes mellitus (DM) independent of traditional cardiovascular (CV) risk factors. Rheumatoid arthritis (RA) is a chronic inflammatory condition, with excess CV risk compared to the general population, in which CMD is hypothesized to play a role; however, there are limited data on CMD in RA and any association with clinical outcomes. The objective of this study was to compare the prevalence of CMD in RA to that in DM and to test the association with all‐cause mortality. Methods We performed a retrospective cohort study using data from a registry of all patients undergoing stress myocardial perfusion positron emission tomography as part of routine clinical care from 2006 to 2017. The inclusion criterion was a normal perfusion scan. Patients with RA or DM were classified using previously published approaches. Coronary flow reserve (CFR) was calculated for all patients in the registry and linked with mortality data. CMD was defined as CFR <2.0. Results We studied 73 patients with RA and 441 patients with DM. Among patients with a normal perfusion scan, the prevalence of CMD in RA was similar to that in DM (P = 0.2). CMD was associated with increased risk for all‐cause mortality in RA (hazard ratio 2.4 [95% confidence interval 1.4–4.2]) as well as increased risk for cardiac‐related death at rates similar to those in DM. Conclusion These findings suggest an important role for CMD as a potential contributor to excess CV risk and mortality in RA, as previously observed in DM, as well as evidence for a mechanistic link between inflammation and cardiovascular disease.

Myocardial Dysfunction and Heart Failure in Rheumatoid Arthritis

“…Recio‐Mayoral et al (70) also reported lower (impaired) MFR in RA and systemic lupus erythematosus patients versus controls ( P < 0.001) as demonstrated by cardiac PET‐CT, and MFR correlated inversely with disease activity (r = −0.65, P < 0.001). Microvascular dysfunction is a well‐documented complication of diabetes mellitus; Liao et al reported similar rates of impaired MFR in RA patients and diabetes mellitus patients (54% and 64%, respectively), and MFR <2 was significantly associated with all‐cause mortality (HR 2.43 [95% CI 1.40, 4.22]) (71). Amigues and colleagues (72) reported a mean MFR of <2.5 in 29% of RA patients without clinical CVD, and a mean MFR of <2.0 in 12%.…”

Predictors of recurrent angina in patients with no need for secondary revascularization

“…The TIMI frame count has been demonstrated to be useful in detecting coronary fl ow changes in patients with stent implantation [22] or impaired coronary microcirculation in patients who have impaired flow and increased burden of coronary atherosclerosis. [23] Previous observations have reported that females, [11,24,25] elderly patients, diabetes mellitus patients, [26,27] and patients with an elevated BMI [28] have been more likely to develop coronary microcirculation dysfunction. These reports are consistent with our study.…”

Non-Obstructive Coronary Artery Disease in Women: Current Evidence and Future Directions

“…Chronic inflammatory conditions also pose greater risk of cardiovascular disease - patients with rheumatoid arthritis face a 1.5 fold higher risk than the general population [ 39 ]. One study looked at the incidence of decreased CFR, considered a surrogate for microvascular function among rheumatoid arthritis (RA) and diabetes mellitus (DM) patients.…”