Coronary artery disease in rheumatoid arthritis: Implications for prevention and management
- Katherine P Liao, MD, MPH
Katherine P Liao, MD, MPH
- Assistant Professor
- Harvard Medical School
- Paul Cohen, MD, PhD
Paul Cohen, MD, PhD
- Assistant Professor
- The Rockefeller University
- Section Editors
- Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
- Section Editor — Rheumatoid Arthritis
- Emeritus Professor of Rheumatology, Imperial College London
- Visiting Professor, Oxford University
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
The prevalence of atherosclerotic coronary artery disease (CAD) is increased in patients with chronic inflammatory rheumatic diseases, particularly rheumatoid arthritis (RA) and systemic lupus erythematosus . Some differences exist in the presentation of CAD in this setting, and the increased risk of CAD has implications for drug therapy, although the clinical manifestations and diagnostic approach to CAD are generally similar in patients with or without RA. (See "Coronary artery disease in rheumatoid arthritis: Pathogenesis, risk factors, clinical manifestations, and diagnostic implications", section on 'Clinical manifestations' and "Coronary artery disease in rheumatoid arthritis: Pathogenesis, risk factors, clinical manifestations, and diagnostic implications", section on 'Diagnosis and screening'.)
The preventive and therapeutic implications specifically related to CAD in patients with RA will be reviewed here. The epidemiology, pathogenesis, risk factors, clinical manifestations, and diagnosis of CAD in patients with RA, and other cardiac manifestations of RA including pericarditis, myocarditis, atrioventricular block, valvular regurgitation, embolic events, and rheumatoid nodules, are presented separately. (See "Coronary artery disease in rheumatoid arthritis: Pathogenesis, risk factors, clinical manifestations, and diagnostic implications" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Cardiac disease' and "Rheumatoid nodules", section on 'Cardiac nodules'.)
The key elements in the prevention of coronary artery disease (CAD) in patients with rheumatoid arthritis (RA) are aggressive management of traditional risk factors and optimization of antiinflammatory and immunomodulatory therapy to achieve effective disease control. (See 'General prevention measures' below and 'DMARDs for control of inflammation due to RA' below.)
This approach is consistent with recommendations of the European League Against Rheumatism (EULAR) . The prevention (whether primary or secondary) and treatment of CAD are generally similar in patients with and without RA, but are influenced by factors particular to RA and similar disorders. Efforts have been made to try to quantify the increase in risk in patients with RA, which results from multiple interacting factors (See 'Risk estimation' below and "Coronary artery disease in rheumatoid arthritis: Pathogenesis, risk factors, clinical manifestations, and diagnostic implications", section on 'Pathogenesis' and "Coronary artery disease in rheumatoid arthritis: Pathogenesis, risk factors, clinical manifestations, and diagnostic implications", section on 'Risk factors'.)
Some issues of particular concern in RA that may affect cardiovascular disease (CVD) risk include:
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- Risk estimation
- General prevention measures
- - Blood pressure control
- - Exercise
- - Lipid lowering with statins
- - Low-dose aspirin
- Implications for RA therapeutic drug selection
- - Nonsteroidal antiinflammatory drugs
- Our approach to NSAID use
- NSAID effects on CVD risk
- - Limiting glucocorticoid exposure
- - DMARDs for control of inflammation due to RA
- TREATMENT OF ANGINA AND ACUTE CORONARY SYNDROMES
- SUMMARY AND RECOMMENDATIONS