I Have Rheumatoid Arthritis - Why Is My Rheumatologist Concerned About My Heart

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Women with rheumatoid arthritis (RA) have high rates of non fatal heart attacks. This occurs even without traditional risk factors being present. (Solomon, et al. Circulation 2003; 107: 1303-1307). The same is probably true for men with RA as well.

Methotrexate appears to lower the mortality suggesting that some RA treatments might help reduce cardiovascular risk.(Choi, et al. Lancet. 2002; 359: 1173-1177)

Another study used carotid ultrasound to detect atherosclerotic plaque (hardening of the arteries) in patients with RA. They found atherosclerosis was three times more common in RA patients compared with controls at all ages. The difference was even more striking for younger RA patients. (Roman, et al. Ann Intern Mede. 2006; 144: 249-256)

The conclusions drawn from multiple studies are that RA is an extremely potent risk factor for the development of atherosclerosis. More aggressive goals for risk factor modification should be instituted.

Practically speaking, it’s important to assess all risk factors in patients with RA. Control of hyperlipidemia and high blood pressure is mandatory. Dietary measures are primary. If dietary changes don’t work, then statin therapy maybe needed. These drugs lower LDL cholesterol (“bad” cholesterol) and reduce levels of C-reactive protein. If a patient has diabetes, tight control of blood sugar is extremely important. Discontinuation of cigarette smoking, proper weight management, and a regular exercise program are all valuable. While aspirin therapy has been shown to be effective prophylaxis for men, it has not been shown to be effective for primary prevention in women.

The controversial role of non-steroidal anti-inflammatory drugs (NSAIDS) as far as being risk factors themselves is another dilemma that has not been fully resolved. One European study presented at the American College of Rheumatology meeting in Washington, D.C. in November 2006 indicated that NSAIDS might even be protective in some instances becasue of their anti-inflammatory effect.

What is clear is that chronic inflammation is an important force in causing premature hardening of the arteries. Whether or not more aggressive means of systemic control of RA- such as with anti-TNF drugs and other biologic therapies- will be helpful in reducing atherosclerosis is the subject of continuing study. Preliminary evidence suggests thatr tighter control of RA is helpful for reducing atherosclerosis.

Until more is known, it is important for patients with RA to know that their rheumatologists will be paying closer attention to their arterial status. Perhaps the use of surrogate methods of detection of atherosclerosis such as carotid ultrasound may be useful in detecting patients at high risk.

Dr. Wei (pronounced “way”) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians. For more information on arthritis and related conditions, go to: Arthritis Treatment