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Coronary artery disease in rheumatoid arthritis: Implications for prevention and management

Authors
Katherine P Liao, MD, MPH
Paul Cohen, MD, PhD
Section Editors
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
Paul L Romain, MD

INTRODUCTION

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 [1]. 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'.)

PREVENTION

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) [2]. 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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Literature review current through: Nov 2016. | This topic last updated: Thu Jun 30 00:00:00 GMT+00:00 2016.
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References
Top
  1. Crowson CS, Liao KP, Davis JM 3rd, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J 2013; 166:622.
  2. Peters MJ, Symmons DP, McCarey D, et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis 2010; 69:325.
  3. Crowson CS, Matteson EL, Roger VL, et al. Usefulness of risk scores to estimate the risk of cardiovascular disease in patients with rheumatoid arthritis. Am J Cardiol 2012; 110:420.
  4. Kawai VK, Chung CP, Solus JF, et al. The ability of the 2013 American College of Cardiology/American Heart Association cardiovascular risk score to identify rheumatoid arthritis patients with high coronary artery calcification scores. Arthritis Rheumatol 2015; 67:381.
  5. Hippisley-Cox J, Coupland C, Vinogradova Y, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008; 336:1475.
  6. Arts EE, Popa C, Den Broeder AA, et al. Performance of four current risk algorithms in predicting cardiovascular events in patients with early rheumatoid arthritis. Ann Rheum Dis 2015; 74:668.
  7. Solomon DH, Greenberg J, Curtis JR, et al. Derivation and internal validation of an expanded cardiovascular risk prediction score for rheumatoid arthritis: a Consortium of Rheumatology Researchers of North America Registry Study. Arthritis Rheumatol 2015; 67:1995.
  8. Smolen JS, Kalden JR, Scott DL, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group. Lancet 1999; 353:259.
  9. Strand V, Cohen S, Schiff M, et al. Treatment of active rheumatoid arthritis with leflunomide compared with placebo and methotrexate. Leflunomide Rheumatoid Arthritis Investigators Group. Arch Intern Med 1999; 159:2542.
  10. McCarey DW, McInnes IB, Madhok R, et al. Trial of Atorvastatin in Rheumatoid Arthritis (TARA): double-blind, randomised placebo-controlled trial. Lancet 2004; 363:2015.
  11. Ridker PM, Solomon DH. Should patients with rheumatoid arthritis receive statin therapy? Arthritis Rheum 2009; 60:1205.
  12. Schoenfeld SR, Lu L, Rai SK, et al. Statin use and mortality in rheumatoid arthritis: a general population-based cohort study. Ann Rheum Dis 2016; 75:1315.
  13. Rollefstad S, Ikdahl E, Hisdal J, et al. Rosuvastatin-Induced Carotid Plaque Regression in Patients With Inflammatory Joint Diseases: The Rosuvastatin in Rheumatoid Arthritis, Ankylosing Spondylitis and Other Inflammatory Joint Diseases Study. Arthritis Rheumatol 2015; 67:1718.
  14. Peters MJ, van Halm VP, Voskuyl AE, et al. Does rheumatoid arthritis equal diabetes mellitus as an independent risk factor for cardiovascular disease? A prospective study. Arthritis Rheum 2009; 61:1571.
  15. Choy E, Sattar N. Interpreting lipid levels in the context of high-grade inflammatory states with a focus on rheumatoid arthritis: a challenge to conventional cardiovascular risk actions. Ann Rheum Dis 2009; 68:460.
  16. Tannenbaum H, Bombardier C, Davis P, et al. An evidence-based approach to prescribing nonsteroidal antiinflammatory drugs. Third Canadian Consensus Conference. J Rheumatol 2006; 33:140.
  17. Goodson NJ, Brookhart AM, Symmons DP, et al. Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients. Ann Rheum Dis 2009; 68:367.
  18. Lindhardsen J, Gislason GH, Jacobsen S, et al. Non-steroidal anti-inflammatory drugs and risk of cardiovascular disease in patients with rheumatoid arthritis: a nationwide cohort study. Ann Rheum Dis 2013.
  19. Hall FC, Dalbeth N. Disease modification and cardiovascular risk reduction: two sides of the same coin? Rheumatology (Oxford) 2005; 44:1473.
  20. Solomon DH, Avorn J, Katz JN, et al. Immunosuppressive medications and hospitalization for cardiovascular events in patients with rheumatoid arthritis. Arthritis Rheum 2006; 54:3790.
  21. Park YB, Choi HK, Kim MY, et al. Effects of antirheumatic therapy on serum lipid levels in patients with rheumatoid arthritis: a prospective study. Am J Med 2002; 113:188.
  22. Liao KP, Cai T, Gainer VS, et al. Lipid and lipoprotein levels and trend in rheumatoid arthritis compared to the general population. Arthritis Care Res (Hoboken) 2013; 65:2046.
  23. Navarro-Millán I, Charles-Schoeman C, Yang S, et al. Changes in lipoproteins associated with methotrexate or combination therapy in early rheumatoid arthritis: results from the treatment of early rheumatoid arthritis trial. Arthritis Rheum 2013; 65:1430.
  24. Charles-Schoeman C, Fleischmann R, Davignon J, et al. Potential mechanisms leading to the abnormal lipid profile in patients with rheumatoid arthritis versus healthy volunteers and reversal by tofacitinib. Arthritis Rheumatol 2015; 67:616.
  25. Rao VU, Pavlov A, Klearman M, et al. An evaluation of risk factors for major adverse cardiovascular events during tocilizumab therapy. Arthritis Rheumatol 2015; 67:372.
  26. McInnes IB, Thompson L, Giles JT, et al. Effect of interleukin-6 receptor blockade on surrogates of vascular risk in rheumatoid arthritis: MEASURE, a randomised, placebo-controlled study. Ann Rheum Dis 2015; 74:694.
  27. Strang AC, Bisoendial RJ, Kootte RS, et al. Pro-atherogenic lipid changes and decreased hepatic LDL receptor expression by tocilizumab in rheumatoid arthritis. Atherosclerosis 2013; 229:174.
  28. Westlake SL, Colebatch AN, Baird J, et al. The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review. Rheumatology (Oxford) 2010; 49:295.
  29. Georgiadis AN, Voulgari PV, Argyropoulou MI, et al. Early treatment reduces the cardiovascular risk factors in newly diagnosed rheumatoid arthritis patients. Semin Arthritis Rheum 2008; 38:13.
  30. Reiss AB, Carsons SE, Anwar K, et al. Atheroprotective effects of methotrexate on reverse cholesterol transport proteins and foam cell transformation in human THP-1 monocyte/macrophages. Arthritis Rheum 2008; 58:3675.
  31. Choi HK, Hernán MA, Seeger JD, et al. Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. Lancet 2002; 359:1173.
  32. Jacobsson LT, Turesson C, Gülfe A, et al. Treatment with tumor necrosis factor blockers is associated with a lower incidence of first cardiovascular events in patients with rheumatoid arthritis. J Rheumatol 2005; 32:1213.
  33. Dixon WG, Watson KD, Lunt M, et al. Reduction in the incidence of myocardial infarction in patients with rheumatoid arthritis who respond to anti-tumor necrosis factor alpha therapy: results from the British Society for Rheumatology Biologics Register. Arthritis Rheum 2007; 56:2905.
  34. Douglas KM, Pace AV, Treharne GJ, et al. Excess recurrent cardiac events in rheumatoid arthritis patients with acute coronary syndrome. Ann Rheum Dis 2006; 65:348.
  35. Mantel Ä, Holmqvist M, Jernberg T, et al. Rheumatoid arthritis is associated with a more severe presentation of acute coronary syndrome and worse short-term outcome. Eur Heart J 2015; 36:3413.
  36. Maradit-Kremers H, Nicola PJ, Crowson CS, et al. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum 2005; 52:722.
  37. Goodson NJ, Symmons DP, Scott DG, et al. Baseline levels of C-reactive protein and prediction of death from cardiovascular disease in patients with inflammatory polyarthritis: a ten-year followup study of a primary care-based inception cohort. Arthritis Rheum 2005; 52:2293.
  38. Poole CD, Conway P, Currie CJ. An evaluation of the association between C-reactive protein, the change in C-reactive protein over one year, and all-cause mortality in chronic immune-mediated inflammatory disease managed in UK general practice. Rheumatology (Oxford) 2009; 48:78.