Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications

Abstract

Rheumatoid arthritis is a systemic autoimmune disease characterized by excess morbidity and mortality from cardiovascular disease. Mechanisms linking rheumatoid arthritis and cardiovascular disease include shared inflammatory mediators, post-translational modifications of peptides/proteins and subsequent immune responses, alterations in the composition and function of lipoproteins, increased oxidative stress, and endothelial dysfunction. Despite a growing understanding of these mechanisms and their complex interplay with conventional cardiovascular risk factors, optimal approaches of risk stratification, prevention, and treatment in the context of rheumatoid arthritis remain unknown. A multifaceted approach to reduce the burden posed by cardiovascular disease requires optimal management of traditional risk factors in addition to those intrinsic to rheumatoid arthritis such as increased disease activity. Treatments for rheumatoid arthritis seem to exert differential effects on cardiovascular risk as well as the mechanisms linking these conditions. More research is needed to establish whether preferential rheumatoid arthritis therapies exist in terms of prevention of cardiovascular disease. Ultimately, understanding the unique mechanisms for cardiovascular disease in rheumatoid arthritis will aid in risk stratification and the identification of novel targets for meaningful reduction of cardiovascular risk in this patient population.

A Multicenter, Randomized, Placebo‐Controlled Trial of Atorvastatin for the Primary Prevention of Cardiovascular Events in Patients With Rheumatoid Arthritis

“…CVD remains a major cause of death and is significantly increased in people with RA compared to the general population , a fact recognized by the addition of RA as an independent risk factor in CVD risk algorithms such as QRISK2 and QRISK3 . The relative contribution of classic CVD risk factors and novel mechanisms related to systemic inflammation to the excess CVD mortality of RA is still debated , and there have been no clinical end point trials assessing the effect of statins, or any other primary prevention strategy, in this population. Some small studies have shown that statins reduce surrogate measures of atherosclerotic events, for example, arterial stiffness or carotid plaque , while a few cohort studies have suggested that statin use is associated with survival gains and statin discontinuation with poorer survival in RA.…”

Chronic lung disease in U.S. Veterans with rheumatoid arthritis and the impact on survival

“…The heightened risk of CVD and CVD-related mortality in RA has been well established [5, 17, 18]. As a result, numerous efforts have been undertaken to enhance the identification of CVD and its risk factors as well as treating both RA and modifiable risk factors as a means of preventing premature CVD mortality [26].…”

Disease activity is associated with LV dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease

“…Compared to the general population, patients with RA have a 8-15 year reduced life expectancy [1] due principally to cardiovascular complications, most commonly atherosclerotic diseases and congestive heart failure (CHF) [2]. Although the pathophysiologic mechanism is not clearly defined, the chronic inflammatory state of RA itself seems to play a pivotal role in both vascular changes and impaired myocardial function [3,4]. Previous studies have shown that asymptomatic left ventricular myocardial dysfunction is common, both systolic and diastolic abnormalities at rates of; 45 and 31% respectively [5][6][7][8][9][10].…”