Elsevier

Joint Bone Spine

Volume 81, Issue 4, July 2014, Pages 298-302
Joint Bone Spine

Review
Cardiovascular risk in rheumatoid arthritis

https://doi.org/10.1016/j.jbspin.2014.01.009Get rights and content

Abstract

The objectives of this review are to discuss data on the cardiovascular risk increase associated with rheumatoid arthritis (RA), the effects of RA treatments on the cardiovascular risk level, and the management of cardiovascular risk factors in patients with RA. Overall, the risk of cardiovascular disease is increased 2-fold in RA patients compared to the general population, due to the combined effects of RA and conventional risk factors. There is some evidence that the cardiovascular risk increase associated with nonsteroidal anti-inflammatory drug therapy may be smaller in RA patients than in the general population. Glucocorticoid therapy increases the cardiovascular risk in proportion to both the current dose and the cumulative dose. Methotrexate and TNFα antagonists diminish cardiovascular morbidity and mortality rates. The management of dyslipidemia remains suboptimal. Risk equations may perform poorly in RA patients even when corrected using the multiplication factors suggested by the EUropean League Against Rheumatism (EULAR) (multiply the score by 1.5 when two of the following three criteria are met: disease duration longer than 10 years, presence of rheumatoid factor or anti-cyclic citrullinated peptide (CCP) antibodies, and extraarticular manifestations). Doppler ultrasonography of the carotid arteries in patients at moderate cardiovascular risk may allow a more aggressive approach to dyslipidemia management via reclassification into the high-risk category of patients with an intima-media thickness greater than 0.9 mm or atheroma plaque.

Section snippets

Epidemiological data

Excess mortality has been convincingly documented in patients with RA compared to the general population [1]. Cardiovascular disease explained about 50% of the excess mortality in RA patients in a meta-analysis of 24 mortality rate studies published between 1970 and 2005 [2]. Both cardiac and cerebrovascular events contributed to the excess mortality, in both females and males [2]. The relationship between disease duration and cardiovascular risk remains debated. A meta-analysis found no

Pathophysiology

Conventional risk factors, which are best evaluated using cardiovascular risk equations, are more common in RA but do not fully explain the increased cardiovascular risk [4], as adjusting for conventional cardiovascular risk factors induces only a very small decrease in the relative risk (RR) of cardiovascular events in RA patients [4], [5], [6]. Proinflammatory cytokines (IL-1, TNF-α, IL-6, and IL-17) promote atherogenesis and may explain the increased development of atheroma in RA [11]. Thus,

Cardiovascular risk management

Recommendations for cardiovascular risk management in RA were issued recently (Table 1) [31].

Conclusion

RA is undoubtedly a risk factor for cardiovascular disease. Although the pathophysiological mechanisms underlying this effect remain unclear, rigorous disease activity control combined with careful minimization of all conventional cardiovascular risk factors are crucial.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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