Assessment of cardiovascular risk in rheumatoid arthritis: impact of the new EULAR recommendations on the score cardiovascular risk index

Cardiovascular event in a cohort of rheumatoid arthritis patients in Castilla-La Mancha: Utility of carotid ultrasound

Rheumatoid Arthritis (RA) has a mortality rate 1,3 to 3 times higher than the general population, with cardiovascular mortality accounting for 40-50% of cases. Currently, cardiovascular disease is considered an extraarticular manifestation of RA (OR: 1,5-4,0). Ultrasound measurement of the intima-media thickness (IMT) of the common carotid artery and the presence of atherosclerotic plaques (AP) is a non-invasive method and a surrogate marker of subclinical arteriosclerosis.

OBJECTIVE

To determine if subclinical arteriosclerosis findings through carotid ultrasound can serve as a good predictor of cardiovascular events (CVE) development in a cohort of RA patients over a 10-year period.

METHODOLOGY

A cohort of RA patients seen in the Rheumatology outpatient clinic of a hospital in Castilla La Mancha in 2013 was evaluated. A prospective evaluation for the development of CVE over the following 10 years was conducted, and its correlation with previous ultrasound findings of IMT and AP was analyzed.

RESULTS

Eight (24%) patients experienced a CVE. Three (9%) had heart failure, three (9%) had a stroke, and two (6%) experienced acute myocardial infarction. RA patients who developed a CVE had a higher IMT (0,97 +/- 0.08 mm) compared to the RA patients without CV complications (0,74 +/- 0.15 mm) (p = 0,003). The presence of IMT ≥ 0.9 mm and AP had a relative risk of 12,25 (p = 0,012) and 18,66 (p = 0,003), respectively, for the development of a CVE.

CONCLUSIONS

Carotid ultrasound in RA patients may allow for early detection of subclinical atherosclerosis before the development of CVE, with IMT ≥ 0.9 mm being the most closely associated finding with CVE, unaffected by age.

Stroke risk in rheumatoid arthritis patients: exploring connections and implications for patient care

Rheumatoid arthritis (RA) can independently increase the risk of stroke, affecting both young and adult RA patients. Recent attention has been drawn to the association between stroke and RA, supported by mounting evidence. Given that stroke is a significant and an urgent public health concern, this review aims to highlight the relationship between stroke and RA, covering mechanisms, underlying risk factors, early detection tools, and treatment implications. By uncovering the connection that links RA to stroke, we can pave the way for targeted healthcare practices and the development of preventive strategies for individuals with RA. Therefore, further research is imperative to deepen our understanding of this association and, ideally, guide treatment decisions for individuals at risk of both RA and stroke.

Cardiovascular Risks and Risk Stratification in Inflammatory Joint Diseases: A Cross-Sectional Study

Background

It is well established that patients with inflammatory joint diseases (IJD) have an increased cardiovascular (CV) mortality and morbidity. According to the 2016 EULAR recommendations on CV risk management, rheumatologists should ensure appropriate management of CV risk in rheumatoid arthritis (RA) and other IJDs. The aim was to assess the CV risk and CV disease in Middle-European patients with IJD.

Methods

A retrospective chart review was performed for CV risk factors and CV disease in outpatients of a rheumatology outpatient clinic. CV risk was assessed according to the 2016 European Guidelines on CV disease prevention and also using 2 other approaches to compare the results with data from Norwegian and Spanish cohorts.

Results

Out of 432 patients, the prevalence of CV disease reached from 8.7% in spondyloarthritis (SpA) and 12.8% in psoriatic arthritis (PsA) to 18.7% in patients with RA. The number of CV risk factors did not differ between patients with RA, SpA, PsA, and non-inflammatory rheumatic disease (NIRD) (with 1.68 ± 0.13, 1.70 ± 0.13, 2.04 ± 0.16, and 1.78 ± 0.34, respectively). CV risk assessment could be performed in 82 patients after exclusion because of missing data and age. Stratification according to ESC guidelines showed low in 50%, moderate in 12.2%, high in 20.7%, and very high CV risk in 17.1% of patients aged between 40 and 65 years. CV risk in the Middle-European patients with IJD was higher than in the German general population (p = 0.004), and similar to the Norwegian patients with IJD, although patients with Middle-European PsA were at higher risk than the Norwegian patients (p = 0.045). Compared to the Spanish patients, Middle-European patients with IJD were more likely assigned to the high- to a very high-risk group (34.2 vs. 16.2%, p < 0.001), especially in RA disease (49.1 vs. 21%, respectively, p < 0.001).

Discussion

High prevalence of established CV disease together with high CV risk in patients with IJD urges for increased vigilance for CV risk factors followed by appropriate interaction by the treating physicians. The prospective use of an international CV risk assessment tool will allow not only estimation of the individual CV risk but also provide data for direct comparisons with the general population and other international cohorts.

The improvement in aerobic capacity, disease activity, and function in patients with rheumatoid arthritis following cardiac rehabilitation program: A single-center, controlled study

Objectives

This study aims to evaluate the effect of cardiac rehabilitation (CR) on disease activity, functional status, fitness, and modified cardiovascular disease (CVD) risk factors in patients with rheumatoid arthritis (RA) with a moderate disease activity.

Patients and methods

This single-center, controlled study included a total of 60 female RA patients (mean age 57.5 years; range, 50 to 64 years) with moderate disease activity according to the Disease Activity Score-28 (DAS28) between January 2014 and June 2015. The patients were divided into two equal groups as those receiving CR program (n=30) and those receiving home exercise program (HEP; n=30). The patients were evaluated at baseline, at Weeks 10 and 24 using exercise tolerance test (i.e., The Metabolic Equivalent of Task [MET] and maximal oxygen uptake [VO2 max]), Six-Minute Walk Test (6MWT), DAS28, Health Assessment Questionnaire (HAQ), modified Systematic Coronary Risk Evaluation (mSCORE), Short Form Health Survey-36 (SF-36), and Beck Depression Inventory (BDI).

Results

There was a significant improvement in the VO2 max (p<0.001), MET (p<0.001), DAS28 (p<0.001), HAQ (p<0.001), BDI (p=0.005), SF-36 physical function (p=0.039), pain (p<0.001) and vitality subscale scores (p=0.008), and 6MWT (p<0.001), after the initial and repetitive exercise programs in the CR group compared to the HEP group. At the end of Week 24, full compliance with HEP was higher in the patients with CR group, compared to the HEP group (p<0.001). There was no significant effect of supervised exercise program on the mSCORE, although systolic blood pressure (p=0.033) and resting heart rate (p=0.049) were significantly improved in the CR group versus HEP group.

Conclusion

Based on our study results, supervised exercise program cannot reduce CVD risk as assessed by the mSCORE, although it improves physical fitness, disease activity, and functional outcomes which may reduce traditional CVD risk factors in patients with RA.

What role does rheumatoid arthritis disease activity have in cardiovascular risk?

Rheumatoid arthritis (RA) is associated with a 1.3 to 3-fold increase in mortality, being the major cause of death from cardiovascular complications (40%-50%). Therefore, the initial approach should include cardiovascular risk (CVR) assessment using algorithms adapted for this population. Although, SCOREM is an important advance, there are data indicating that subclinical atherosclerosis may be underdiagnosed.

OBJECTIVE

To estimate the strength of association between carotid ultrasound and SCOREM in this population, as well as the implication of disease activity.

METHODOLOGY

Cross-sectional, observational, analytical study performed at the General Hospital of Ciudad Real, Spain, between June 2013 and May 2014. The evaluation of CVR was performed and, according to SCOREM, the population was divided into low and high (medium, high and very high) risk. We studied the presence of subclinical atherosclerosis in low-risk patients.

RESULTS

Of the total of 119 RA patients, 73.1% had traditional risk factors. Thirty-eight patients were excluded because of a previous cardiovascular event, diabetes mellitus and/or nephropathy. Atheromatous plaque was observed in 14.63% of the low-risk population. The factor with the strongest association to the presence of subclinical atherosclerosis was a moderate or high activity of RA measured by the simplified disease activity index with an odds ratio of 4.95 (95% CI: 1.53-16.01).

CONCLUSIONS

Although there was an acceptable correlation between the presence of subclinical atherosclerosis and SCOREM, there was a considerable proportion of atheromatous plaques in low-risk patients. Disease activity was the risk factor most closely associated with increased CVR.

Cardiovascular risk management in rheumatoid arthritis: A large gap to close

OBJECTIVE

Rheumatoid arthritis (RA) portends significant cardiovascular morbidity and mortality. We therefore determined how often rheumatologists screened for and managed cardiovascular risk factors in RA patients, and the barriers to doing so.

METHODS

We examined 300 patient charts from 10 university-affiliated rheumatology practices, to ascertain if they had been screened, treated and/or referred over a 3-year period. We subsequently distributed a national survey to Canadian rheumatologists to elucidate challenges in performing optimal cardiovascular risk modification.

RESULTS

Most patients were screened for hypertension. Forty-one per cent were found to be hypertensive; however, the majority of these patients were neither treated nor referred to another provider for management. A small minority of patients were screened for diabetes and/or hyperlipidaemia, and these were usually not addressed if abnormal. Men were referred more frequently than women. Consistent with these findings, the majority of rheumatologists from the national survey felt that they did not manage cardiovascular risk adequately; 79.4% cited a lack of time as a major barrier, and 82.5% felt that it should be managed by the primary care provider.

CONCLUSION

There is marked underdiagnosis and undertreatment of cardiac risk in RA. Several major barriers exist, including lack of time. Most rheumatologists feel that this aspect of care is the responsibility of primary care physicians.

Marked underdiagnosis and undertreatment of hypertension and hypercholesterolaemia in rheumatoid arthritis

OBJECTIVE

To investigate the prevalence of underdiagnosis and undertreatment of traditional cardiovascular risk factors in RA patients.

METHODS

RA patients ⩽70 years of age without cardiovascular disease (CVD) or diabetes mellitus were included. Systolic blood pressure and a fasting lipid profile were measured. The 10-year CVD risk was estimated using the Dutch Cardiovascular Risk Management (CVRM) guideline and EULAR modifications of the Systemic Coronary Risk Evaluation tables.

RESULTS

A total of 327 patients were included (female gender: 68%). The mean age was 53 (11) years [mean (s.d.)]. The median disease duration was 7 years (inter quartile range: 2-14 years). According to the CVRM guideline, 52% of the patients had a CVD risk ⩾20% and according to the EULAR guidelines, 18% of the patients had a CVD risk ≥ 20%. Low-density lipoprotein cholesterol (LDL-C) >2.5 mmol/l was found in >80% of the patients with a CVD risk ⩾10% as estimated by both the CVRM and EULAR guidelines, and 32-42% of the patients with a CVD risk ⩾10% had a systolic blood pressure >140 mmHg, depending on the risk model used. Statins were used in 6% and antihypertensives in 23-25%, and 50-86% of these patients did not reach the recommended treatment targets.

CONCLUSION

Regardless of the adapted risk assessment model used, untreated hypertension and hypercholesterolaemia were frequently found in RA patients with increased CVD risk. Treatment of these cardiovascular risk factors deserves more attention in RA.

TRIAL REGISTRATION

The Dutch Trial Register, www.trialregister.nl, NTR3873.

Assessment of cardiovascular risk in patients with rheumatoid arthritis using the SCORE risk index

INTRODUCTION

Rheumatoid arthritis is an autoimmune disease that causes systemic involvement and is associated with increased risk of cardiovascular disease.

OBJECTIVE

To analyze the prediction index of 10-year risk of a fatal cardiovascular disease event in female RA patients versus controls.

METHODS

Case-control study with analysis of 100 female patients matched for age and gender versus 100 patients in the control group. For the prediction of 10-year risk of a fatal cardiovascular disease event, the SCORE and modified SCORE (mSCORE) risk indexes were used, as suggested by EULAR, in the subgroup with two or more of the following: duration of disease ≥10 years, RF and/or anti-CCP positivity, and extra-articular manifestations.

RESULTS

The prevalence of analyzed comorbidities was similar in RA patients compared with the control group (p>0.05). The means of the SCORE risk index in RA patients and in the control group were 1.99 (SD: 1.89) and 1.56 (SD: 1.87) (p=0.06), respectively. The means of mSCORE index in RA patients and in the control group were 2.84 (SD=2.86) and 1.56 (SD=1.87) (p=0.001), respectively. By using the SCORE risk index, 11% of RA patients were classified as of high risk, and with the use of mSCORE risk index, 36% were at high risk (p<0.001).

CONCLUSION

The SCORE risk index is similar in both groups, but with the application of the mSCORE index, we recognized that RA patients have a higher 10-year risk of a fatal cardiovascular disease event, and this reinforces the importance of factors inherent to the disease not measured in the SCORE risk index, but considered in mSCORE risk index.

Management of hyperlipidemia among patients with rheumatoid arthritis in the primary care setting

BACKGROUND

Rheumatoid arthritis (RA) has been associated with an increased risk of cardiovascular morbidity and mortality but this has not translated to optimal management of traditional cardiovascular risk factors such as hyperlipidemia. The objectives of this study were to 1) determine the prevalence of screening for hyperlipidemia in patients with RA followed by primary care practitioners (PCP); 2) examine initiation of lipid-lowering therapy in patients with an indication, and 3) assess whether proposed modifications to cardiovascular risk calculations change the percentage of RA patients with an indication for therapy.

METHODS

We performed a retrospective cohort study using an academic medical center-based medical record database in the United States. Patients with RA defined by the presence of at least one ICD-9 code between 2005-2010 and followed by a PCP within the health care system were included. The positive predictive value of ICD-9 codes for accurately identifying patients with RA was 96.7%. Descriptive statistics were used to report the prevalence of screening and use of lipid-lowering therapy among those with an indication. Factors associated with not receiving lipid screening were examined using logistic regression models. Indication for and receipt of therapy were then assessed before and after the application of the European Union League Against Rheumatism (EULAR) recommended multiplier to the Framingham risk score.

RESULTS

Among 1,056 patients with RA followed by PCPs and eligible for lipid screening, lipid screening was ordered for 539 (51%) within the 3-year follow-up period. Patients with diabetes, hypertension, chronic kidney disease, obesity or age >50 were more likely to be screened. Of those with lipid results (N = 290), 25 (9%) patients had an indication for lipid-lowering therapy based on Adult Treatment Panel III guidelines. Ten (40%) patients with an indication for lipid-lowering therapy received therapy did not receive therapy. Applying the EULAR multiplier only changed the indication for lipid-lowering therapy in two patients.

CONCLUSIONS

Screening and management of traditional cardiovascular risk factors, including hyperlipidemia, need to be optimized.

Rheumatoid Arthritis, Anti-Cyclic Citrullinated Peptide Positivity, and Cardiovascular Disease Risk in the Women's Health Initiative

OBJECTIVE

To evaluate the incidence of cardiovascular disease (CVD) morbidity and mortality over the course of 10 years among the more than 160,000 postmenopausal women in the Women's Health Initiative (WHI) in relation to self-reported rheumatoid arthritis (RA), taking disease-modifying antirheumatic drugs (DMARDs), anti-cyclic citrullinated peptide (anti-CCP) positivity, rheumatoid factor (RF) positivity, CVD risk factors, joint pain, and inflammation (white blood cell count and interleukin-6 levels).

METHODS

Anti-CCP and RF were measured in a sample of WHI participants with self-reported RA (n = 9,988). RA was classified as self-reported RA plus anti-CCP positivity and/or taking DMARDs. Anti-CCP-negative women with self-reported RA and not taking DMARDs were classified as having "unverified RA."

RESULTS

Age-adjusted rates of coronary heart disease (CHD), stroke, CVD, fatal CVD, and total mortality were higher in women with RA than in women with no reported RA, with multivariable-adjusted hazard ratios of 1.46 (95% confidence interval [95% CI] 1.17-1.83) for CHD and 2.55 (95% CI 1.86-3.51) for fatal CVD. Among women with RA, anti-CCP positivity and RF positivity were not significantly associated with higher risk of any outcomes, despite slightly higher risk of death for those who were anti-CCP positive than for those who were anti-CCP negative. Joint pain severity and CVD risk factors were strongly associated with CVD risk, even in women with no reported RA. CVD incidence was increased in women with RA versus women with no reported RA at almost all risk factor levels, except for low levels of joint pain or inflammation. Among women with RA, inflammation was more strongly associated with fatal CVD and total mortality than with CHD or CVD.

CONCLUSION

Among postmenopausal women, RA was associated with 1.5-2.5-fold higher CVD risk. CVD risk was strongly associated with CVD risk factors, joint pain severity, and inflammation, but not with anti-CCP positivity or RF positivity.

Prevention of stroke in rheumatoid arthritis

OPINION STATEMENT

Recognizing that systemic inflammation is a major contributor to the increased risk of cardiovascular disease (CVD), including stroke, in rheumatoid arthritis (RA) serves as the basis for prevention strategies for cerebrovascular disease in RA. In addition to traditional cardiovascular risk factors, recognize that RA may be an independent risk factor for cerebrovascular accident (CVA). The risk of CVD should be assessed in each patient with RA, utilizing modified risk score calculators. Careful monitoring and control of systemic inflammation should be undertaken in conjunction with assessing each patient's CVD risk, acknowledging the benefits and risks of specific RA-directed therapies. Emphasis should be given to early and aggressive control of inflammation in RA patients, particularly those with seropositivity, increased inflammatory markers, long disease duration (>10 years), and/or extra-articular manifestations. In RA patients requiring glucocorticoid therapy, attempts should be made to use or wean to the minimal effective dose (preferably less than 7.5 mg/day). It should be recognized that both disease-modifying antirheumatic drugs (DMARDs), particularly methotrexate, and tumor necrosis factor (TNF)-alpha inhibitors partially mitigate the risk of CVD. In patients with inadequate control of inflammation with DMARDs, consideration should be given to switch to anti-TNF agents earlier in the disease process. Modifiable risk factors should be addressed as per guidelines for the general population. Active RA may be considered as a risk equivalent to diabetes mellitus when applying these guidelines. With regard to lipid management and use of statin therapy, further studies are required given the apparent "lipid paradox" in RA. Use of aspirin for primary prevention in RA has not been well studied; however, when aspirin is used for secondary prevention, one should recognize that concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) may decrease the antiplatelet effect. Given the cardiovascular risk associated with NSAIDs, the lowest possible dose for the shortest time should be used.

Patients' Experiences of Nurse-Led Screening for Cardiovascular Risk in Rheumatoid Arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) have increased morbidity and mortality due to cardiovascular disease (CVD). Screening for cardiovascular risk is recommended by the European League Against Rheumatism (EULAR). There is a lack of evidence of the experiences of RA patients who are screened for CVD. Such information is important in order to organize and further develop screening programmes for CVD in patients with RA. The aim of the present study was to explore RA patients' experiences of participation in nurse-led screening for CVD and to identify key issues for the future organization of screening programmes.

METHODS

Three qualitative focus group interviews were carried out with 14 outpatients diagnosed with RA. The participants were stratified into groups, depending on whether they had a low-to-moderate or high ten-year risk of cardiovascular death according to the European Systematic Coronary Risk Evaluation (SCORE) system. Data were analysed using meaning condensation to identify key themes.

RESULTS

Five themes were identified: reactions to receiving the invitation to the screening consultation; screening consultation adapted to needs and RA; duration reflected needs; screening consultation brought a sense of relief; and motivation and sense of control. Regardless of their CV risk, the participants found it important that the screening consultation was adapted to their needs and their illness as RA had a major impact on their daily life.

CONCLUSIONS

When planning future screening programmes for CVD for patients with RA, it is important that the screening consultation is individualized and tailored to patients' needs and their RA. Copyright © 2015 John Wiley & Sons, Ltd.

Prediction of cardiovascular risk in rheumatoid arthritis: performance of original and adapted SCORE algorithms

OBJECTIVES

Predictive performance of cardiovascular disease (CVD) risk calculators appears suboptimal in rheumatoid arthritis (RA). A disease-specific CVD risk algorithm may improve CVD risk prediction in RA. The objectives of this study are to adapt the Systematic COronary Risk Evaluation (SCORE) algorithm with determinants of CVD risk in RA and to assess the accuracy of CVD risk prediction calculated with the adapted SCORE algorithm.

METHODS

Data from the Nijmegen early RA inception cohort were used. The primary outcome was first CVD events. The SCORE algorithm was recalibrated by reweighing included traditional CVD risk factors and adapted by adding other potential predictors of CVD. Predictive performance of the recalibrated and adapted SCORE algorithms was assessed and the adapted SCORE was externally validated.

RESULTS

Of the 1016 included patients with RA, 103 patients experienced a CVD event. Discriminatory ability was comparable across the original, recalibrated and adapted SCORE algorithms. The Hosmer-Lemeshow test results indicated that all three algorithms provided poor model fit (p<0.05) for the Nijmegen and external validation cohort. The adapted SCORE algorithm mainly improves CVD risk estimation in non-event cases and does not show a clear advantage in reclassifying patients with RA who develop CVD (event cases) into more appropriate risk groups.

CONCLUSIONS

This study demonstrates for the first time that adaptations of the SCORE algorithm do not provide sufficient improvement in risk prediction of future CVD in RA to serve as an appropriate alternative to the original SCORE. Risk assessment using the original SCORE algorithm may underestimate CVD risk in patients with RA.

Impact of rheumatoid arthritis on receiving a diagnosis of hypertension among patients with regular primary care

OBJECTIVE

Despite numerous studies reporting increased cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA), the impact of RA on managing modifiable CVD risk factors remains understudied. We tested the hypothesis that RA is a risk factor for not receiving a hypertension diagnosis.

METHODS

Using a cohort design, we studied adult patients with and without RA/inflammatory arthritis from a large academic multispecialty practice. All were seen regularly in primary care and met clinical guideline hypertension criteria, but lacked prior hypertension diagnosis/treatment. The primary outcome was time to International Classification of Diseases, Ninth Revision code for hypertension or elevated blood pressure, or antihypertensive medication prescription. Kaplan-Meier survival curve analysis and Cox proportional hazards modeling were used to examine the impact of RA on diagnosis of hypertension.

RESULTS

Among 14,974 patients with undiagnosed hypertension, 201 patients had RA codes. RA patients had equivalent primary care visits and more total visits compared to patients without RA. At the end of the study, the likelihood of hypertension diagnosis was 36% in RA patients compared to 51% in patients without RA. In adjusted Cox models, RA patients had a 29% lower hypertension diagnosis hazard (hazard ratio 0.71, 95% confidence interval 0.55-0.93), reflecting more undiagnosed hypertension than with other comorbidities.

CONCLUSION

Among patients meeting guideline-based hypertension criteria, RA patients were less likely to be diagnosed despite more visits than those without RA. Given heightened CVD risks in RA and the importance of hypertension diagnosis as a first step toward controlling risk, rheumatologists should collaborate to improve rates of diagnosis for this modifiable CVD risk factor.

Cardiovascular risk in rheumatoid arthritis: recent advances in the understanding of the pivotal role of inflammation, risk predictors and the impact of treatment

Risk of cardiovascular (CV) disease is increased among RA patients. High inflammatory burden associated with RA appears to be a key driver of the increased cardiovascular risk. Inflammation is linked with accelerated atherosclerosis and associated with a paradoxical inversion of the relationship between CV risk and lipid levels in patients with untreated RA, recently coined the lipid paradox. Furthermore, the inflammatory burden is also associated with qualitative as well as quantitative changes in lipoproteins, with the anti-inflammatory and atheroprotective roles associated with high-density lipoprotein cholesterol significantly altered. RA therapies can increase lipid levels, which may reflect the normalization of lipids due to their inflammatory-dampening effects. However, these confounding influences of inflammation and RA therapies on lipid profiles pose challenges for assessing CV risk in RA patients and interpretation of traditional CV risk scores. In this review we examine the relationship between the increased inflammatory burden in RA and CV risk, exploring how inflammation influences lipid profiles, the impact of RA therapies and strategies for identifying and monitoring CV risk in RA patients aimed at improving CV outcomes.

Nurse management of cardiovascular risk factors in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, multi-system inflammatory disease. The incidence and prevalence of RA varies considerably between geographic areas and over time; the prevalence of RA in adults aged > 20 years in Spain is around 0.5% (Carmona et al, 2002). People with RA also have extra-articular manifestations, presenting an increased cardiovascular morbidity and mortality risk; therefore, cardiovascular risk screening and management strategies are necessary in individuals with RA. The importance of interventions in the management of people with RA and cardiovascular risk factors is recognised by the European League Against Rheumatism (EULAR) recommendations (Peters et al, 2010). Rheumatology specialist nurses are well placed to include routine cardiovascular risk assessment for people with RA attending clinic, and to provide educational interventions to reduce cardiovascular risk, such as smoking cessation, weight loss, eating a balanced, low-fat diet and exercising regularly.

The Framingham Risk Score underestimates the extent of subclinical atherosclerosis in patients with psoriatic disease

AIM

To investigate the usefulness of carotid atherosclerosis assessment in cardiovascular risk stratification of patients with psoriatic disease compared with the Framingham Risk Score (FRS).

METHODS

Patients with psoriatic arthritis (PsA) and psoriasis alone (PsC), who had no previous history of cardiovascular disease, chronic kidney disease or diabetes mellitus were recruited. They underwent assessment of their cardiovascular risk factors and the FRS was calculated. Based on the FRS, the participants were classified into low, intermediate and high-risk categories. Ultrasound assessment of the carotid artery was performed, and carotid intima-media thickness (cIMT) and total plaque area (TPA) were measured. Patients were stratified into three ultrasound-based risk categories (low, intermediate and high) according to the severity of atherosclerosis. The extent of reclassification from FRS-based category into US-based risk category was assessed.

RESULTS

A total of 226 patients with psoriatic disease were assessed. FRS correlated moderately with TPA (r=0.36) and cIMT (r=0.37) and explained only 19% of their variability. 56.1% of the patients in the FRS-based low to intermediate risk groups were found to have carotid plaques. 55.9% of the patients from the FRS-based intermediate risk category were reclassified into an ultrasound-based high-risk category, while 47.1% of the patients in the FRS-based low-risk category were reclassified into a higher US-based risk group. The extent of reclassification into a higher risk category was particularly high among patients with PsA.

CONCLUSIONS

Ultrasound assessment of subclinical atherosclerosis may improve risk stratification of patients with psoriatic disease, particularly of those with PsA.

Results from systematic screening for cardiovascular risk in outpatients with rheumatoid arthritis in accordance with the EULAR recommendations

AIM

To investigate risk factors for the development of cardiovascular disease (CVD) and estimate the risk of cardiovascular death in rheumatoid arthritis (RA) patients in accordance with EULAR recommendations.

MATERIALS AND METHODS

Outpatients with RA ≤85 years of age from a Danish hospital were invited to participate. Patients' risk of cardiovascular death was calculated according to the SCORE system, based on total cholesterol/high-density lipoprotein (HDL) ratio, smoking habits, blood pressure, age and gender. The SCORE was adjusted based on disease duration, IgM-RF/anti-CCP positivity and the presence of extra-articular manifestations. Factors such as history of CVD, hypertension or diabetes mellitus (DM), fasting glucose, exercise habits, body mass index (BMI) and waist circumference were explored.

RESULTS

836 patients participated; 71.5% women; mean (SD) age 64.3 years (12.0); 152 (19.1%) were already diagnosed with CVD and 74 (9.0%) with DM. Among the 644 patients without CVD or DM, 158 (24.5%) were smokers, 229 (35.8%) had a systolic blood pressure ≥140, 397 (65.6%) total cholesterol ≥5.0 mM/L, 326 (55.4%) low-density lipoprotein cholesterol ≥3.0 mM/L, 18 (4.0%) women and 19 (12.1%) men had a HDL-cholesterol level below 1.2/1.0 mM/L. BMI was >25 in 409 (63.8%). Waist circumference was above 80/94 cm in 297 (63.3%) of female and 111 (63.8%) of male patients, respectively, and 418 (64.9%) exercised ≤5 times a week. Among patients without DM, 14.3% had a fasting glucose ≥6.0 mmol/L. The SCORE was ≥5 in 122 (20.2%). They were referred to follow-up by their GP and community advice services.

CONCLUSIONS

Systematic screening revealed several risk factors that needed medical follow-up or support to initiate lifestyle changes.

Carotid ultrasound is useful for the cardiovascular risk stratification of patients with rheumatoid arthritis: results of a population-based study

OBJECTIVE

To determine if the use of carotid ultrasonography (US) may improve the stratification of the cardiovascular (CV) risk in rheumatoid arthritis (RA).

METHODS

A set of 370 consecutive patients without history of CV events were studied to assess carotid intima-media thickness (cIMT) and plaques. As previously proposed, CV risk was calculated according to the modified EULAR systematic coronary risk evaluation (mSCORE) for RA that was adapted by the application of a multiplier factor of 1.5 in those patients fulfilling ≥ 2 of 3 specific criteria.

RESULTS

The mean disease duration was 9.8 years, 250 (68%) had rheumatoid factor/anticyclic citrullinated peptide positivity and 61 (17%) extra-articular manifestations. 43 were excluded because they had type 2 diabetes mellitus or severe chronic kidney disease. CV risk was categorised in the remaining 327 RA patients according to the mSCORE: mild (96 cases; 29.3%), moderate (201; 61.5%) and high/very high risk (30; 9.2%). Only five patients were reclassified as having high/very high CV risk when the mSCORE was applied. Severe carotid US abnormalities (cIMT >0.90 mm and/or plaques) were uncommon in patients with low mSCORE (13%). Nevertheless, in patients with moderate mSCORE, severe carotid US abnormalities were observed in 63% of cases. A model that included a chart mSCORE risk ≥ 5% plus the presence of severe carotid US findings in patients with moderate mSCORE risk (≥ 1% and <5%) yielded high sensitivity for high/very high CV risk (93 (95% CI 88 to 96)).

CONCLUSIONS

Our results support the use of carotid US in the assessment of CV risk in patients with RA.