Cardiovascular risk in rheumatoid arthritis: assessment, management and next steps

Abstract

Rheumatoid arthritis (RA) is associated with increased cardiovascular (CV) morbidity and mortality which cannot be fully explained by traditional CV risk factors; cumulative inflammatory burden and antirheumatic medication-related cardiotoxicity seem to be important contributors. Despite the acknowledgment and appreciation of CV disease burden in RA, optimal management of individuals with RA represents a challenging task which remains suboptimal. To address this need, the European League Against Rheumatism (EULAR) published recommendations suggesting the adaptation of traditional risk scores by using a multiplication factor of 1.5 if two of three specific criteria are fulfilled. Such guidance requires proper coordination of several medical specialties, including general practitioners, rheumatologists, cardiologists, exercise physiologists and psychologists to achieve a desirable result. Tight control of disease activity, management of traditional risk factors and lifestyle modification represent, amongst others, the most important steps in improving CV disease outcomes in RA patients. Rather than enumerating studies and guidelines, this review attempts to critically appraise current literature, highlighting future perspectives of CV risk management in RA.

Vascular Involvement in Rheumatoid Arthritis

“…But during inflammation, these molecules develop functional and structural changes, becoming atherogenic and promoting endothelial dysfunction. Some drugs used in RA treatment may increase lipid levels: DMARDs, TNF-α inhibitors, tocilizumab, and IL-6 receptor blocker [8].…”

“…Endothelial-dependent vasodilation, mediated by nitric oxide release, is impaired in insulin resistance individuals. They display high levels of endothelin and plasminogen activator inhibitor in plasma [8].…”

“…Obesity is associated with other cardiovascular risk factors, as atherogenic dyslipidemia, high blood pressure, insulin resistance, and low grade inflammation, generating endothelial dysfunction. But in RA an association between low body mass (secondary to high rheumatoid inflammation, generating rheumatoid cachexia) and cardiovascular events, too, is described [8].…”

“…RA-related risk factors are identified and characterized in these patients [6,7]. In RA patients, the cardiovascular risk is obtained by the multiplication of measured risk (SCORE, Framingham) by a factor of 1.5, if two of the three following criteria are fulfilled (RA evolution >10 years, positivity of RF or ACPA, extra-articular involvement) [8].…”

Improved clinical outcomes and physical activity in patients with rheumatoid arthritis treated with originator adalimumab in routine clinical practice

“…Despite exercise being considered beneficial and safe for RA patients, this group is less physically active than the general population [4][5][6]. Moreover, compared with the general population, RA patients also have a reduced health-related quality of life (HRQoL) [7], and are at greater risk of cardiovascular morbidity and mortality due to cumulative inflammatory burden and multiple other risk factors [8][9][10].…”