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Murphy L, Saab MM, Cornally N, McHugh S, Cotter P. Cardiovascular disease risk assessment in patients with rheumatoid arthritis: A scoping review. Clin Rheumatol 2024; 43:2187-2202. [PMID: 38733423 PMCID: PMC11189331 DOI: 10.1007/s10067-024-06996-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/19/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Patients with rheumatoid arthritis (RA) have an increased risk of developing cardiovascular disease (CVD). Identification of at-risk patients is paramount to initiate preventive care and tailor treatments accordingly. Despite international guidelines recommending all patients with RA undergo CVD risk assessment, rates remain suboptimal. The objectives of this review were to map the strategies used to conduct CVD risk assessments in patients with RA in routine care, determine who delivers CVD risk assessments, and identify what composite measures are used. The Joanna Briggs Institute methodological guidelines were used. A literature search was conducted in electronic and grey literature databases, trial registries, medical clearing houses, and professional rheumatology organisations. Findings were synthesised narratively. A total of 12 studies were included. Strategies reported in this review used various system-based interventions to support delivery of CVD risk assessments in patients with RA, operationalised in different ways, adopting two approaches: (a) multidisciplinary collaboration, and (b) education. Various composite measures were cited in use, with and without adjustment for RA. Results from this review demonstrate that although several strategies to support CVD risk assessments in patients with RA are cited in the literature, there is limited evidence to suggest a standardised model has been applied to routine care. Furthermore, extensive evidence to map how health care professionals conduct CVD risk assessments in practice is lacking. Research needs to be undertaken to establish the extent to which healthcare professionals are CVD risk assessing their patients with RA in routine care. Key Points • A limited number of system-based interventions are in use to support the delivery of CVD risk assessments in patients with RA. • Multidisciplinary team collaboration, and education are used to operationalise interventions to support Health Care Professionals in conducting CVD risk assessments in practice. • The extent to which Health Care Professionals are CVD risk assessing their patients with RA needs to be established.
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Affiliation(s)
- Louise Murphy
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland.
- Department of Rheumatology, Cork University Hospital, Wilton, Cork, Ireland.
| | - Mohamad M Saab
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Nicola Cornally
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - Patrick Cotter
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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Kitas GD, Dimitroulas T. Cardiovascular comorbidity in rheumatic and musculoskeletal diseases: Where we are and how can we move forward? Int J Rheum Dis 2021; 24:473-476. [PMID: 33817989 DOI: 10.1111/1756-185x.14112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK.,School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Theodoros Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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3
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Fragoulis GE, Panayotidis I, Nikiphorou E. Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment. Curr Vasc Pharmacol 2020; 18:431-446. [PMID: 31258091 DOI: 10.2174/1570161117666190619143842] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Ismini Panayotidis
- Faculty of Medical Sciences, Medical School, University College London, London, United Kingdom
| | - Elena Nikiphorou
- Department of Inflammation Biology, King's College London, London, UK and Department of Rheumatology, King's College Hospital, London, United Kingdom
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Provan SA, Lillegraven S, Sexton J, Angel K, Austad C, Haavardsholm EA, Kvien TK, Uhlig T. Trends in all-cause and cardiovascular mortality in patients with incident rheumatoid arthritis: a 20-year follow-up matched case-cohort study. Rheumatology (Oxford) 2020; 59:505-512. [PMID: 31504942 DOI: 10.1093/rheumatology/kez371] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/10/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To examine all-cause and cardiovascular disease (CVD) mortality in consecutive cohorts of patients with incident RA, compared with population comparators. METHODS The Oslo RA register inclusion criteria were diagnosis of RA (1987 ACR criteria) and residency in Oslo. Patients with disease onset 1994-2008 and 10 matched comparators for each case were linked to the Norwegian Cause of Death Registry. Hazard ratios for all-cause and CVD mortality were calculated for 5, 10, 15 and 20 years of observation using stratified cox-regression models. Mortality trends were estimated by multivariate cox-regression. RESULTS 443, 479 and 469 cases with disease incidence in the periods 94-98, 99-03 and 04-08 were matched to 4430, 4790 and 4690 comparators, respectively. For cases diagnosed between 1994 and 2003, the all-cause mortality of cases diverged significantly from comparators after 10 years of disease duration [hazard ratio (95% CI) 94-98 cohort 1.42 (1.15-1.75): 99-03 cohort 1.37 (1.08-1.73)]. CVD related mortality was significantly increased after 5 years for the 94-98 cohort [hazard ratio (95% CI) 1.86 (1.16-2.98) and after 10 years for the 99-03 cohort 1.80 (1.20-2.70)]. Increased mortality was not observed in the 04-08 cohort where cases had significantly lower 10-year all-cause and CVD mortality compared with earlier cohorts. CONCLUSION All-cause and CVD mortality were significantly increased in RA patients diagnosed from 1994 to 2003, compared with matched comparators, but not in patients diagnosed after 2004. This may indicate that modern treatment strategies have a positive impact on mortality in patients with RA.
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Affiliation(s)
- Sella A Provan
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Siri Lillegraven
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Joe Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Kristin Angel
- Department of Cardiology, Akershus University Hospital, Lørenskog, Oslo, Norway
| | - Cathrine Austad
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Cardiology, Akershus University Hospital, Lørenskog, Oslo, Norway
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol 2020; 16:361-379. [PMID: 32494054 DOI: 10.1038/s41584-020-0428-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Patients with rheumatoid arthritis (RA) are at high risk of developing cardiovascular disease (CVD). Inflammation has a pivotal role in the pathogenesis of CVD. RA is an inflammatory joint disease and, compared with the general population, patients with RA have approximately double the risk of atherosclerotic CVD, stroke, heart failure and atrial fibrillation. Although this high risk of CVD has been known for decades, patients with RA receive poorer primary and secondary CVD preventive care than other high-risk patients, and an unmet need exists for improved CVD preventive measures for patients with RA. This Review summarizes the evidence for atherosclerotic CVD in patients with RA and provides a contemporary analysis of what is known and what needs to be further clarified about recommendations for CVD prevention in patients with RA compared with the general population. The management of traditional CVD risk factors, including blood pressure, lipids, diabetes mellitus and lifestyle-related risk factors, as well as the effects of inflammation and the use of antirheumatic medication on CVD risk and risk management in patients with RA are discussed. The main aim is to provide a roadmap of atherosclerotic CVD risk management and prevention for patients with RA.
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Jelsness-Jørgensen LP, Grøvle L, Julsrud Haugen A. Association between vitamin D and fatigue in patients with rheumatoid arthritis: a cross-sectional study. BMJ Open 2020; 10:e034935. [PMID: 32034029 PMCID: PMC7044854 DOI: 10.1136/bmjopen-2019-034935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES In rheumatoid arthritis (RA), fatigue is an important complaint with a significant impact on quality of life. Vitamin D has modulatory effects on cells of the immune system and may potentially affect RA disease activity and thereby RA-related fatigue. The purpose of this study was to explore associations between fatigue and vitamin D status in patients with RA. DESIGN Hypothesis-generating cross-sectional study. SETTING Scheduled follow-up visits at a hospital-based general rheumatology clinic. PARTICIPANTS Patients (n=169) with established RA. PRIMARY OUTCOME MEASURES AND ANLYSES Fatigue, assessed by the Chalder fatigue questionnaire, and serum concentrations of 25-hydroxyvitamin D (25(OH)D), assessed by liquid chromatography-tandem mass spectrometry. Associations were analysed by correlation, and multivariate linear regression with adjustments for age, sex, body mass index, RA disease activity as measured by the Disease Activity Score 28-joint count C reactive protein (DAS28-CRP), psychological distress, pain and sleep. Fatigue was also compared across four groups based on the levels of serum 25(OH)D with cut points at 30, 50 and 75 nmol/L using one-way analysis of variance. RESULTS Two-thirds of the patients (116/169, 69%) were classified with low RA disease activity, that is, a DAS28-CRP score below 3.2. Their mean (SD) serum 25(OH)D concentration was 56.3 (21.2) nmol/L, with 77 (45.6%) having values below 50 nmol/L and 12 patients (7.1%) below 30 nmol/L. The correlation between fatigue and serum concentrations of 25(OH)D was weak and not statistically significant, r = -0.14 (95% CI: -0.29 to 0.03, p=0.08). In the multivariate model, fatigue was significantly associated with RA disease activity, psychological distress and pain, but not with serum 25(OH)D. Fatigue did not differ across groups with varying levels of serum 25(OH)D. CONCLUSION This cross-sectional study found no evidence of association between vitamin D and fatigue in patients with RA.
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Affiliation(s)
- Lars Petter Jelsness-Jørgensen
- Internal Medicine, Sykehuset Ostfold HF, Sarpsborg, Norway
- Health Sciences, Østfold University College, Fredrikstad, Norway
| | - Lars Grøvle
- Rheumatology, Sykehuset Ostfold HF, Sarpsborg, Norway
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Persell SD, Lee JY, Lipiszko D, Peprah YA, Ruderman EM, Schachter M, Majka DS. Outreach to Promote Management of Cardiovascular Risk in Primary Care Among Patients With Rheumatoid Arthritis Seen in Rheumatology Practice. ACR Open Rheumatol 2020; 2:131-137. [PMID: 31989787 PMCID: PMC7077787 DOI: 10.1002/acr2.11116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/06/2019] [Indexed: 12/28/2022] Open
Abstract
Objective Rheumatoid arthritis (RA) confers a 1.5‐ to 2.0‐fold increased risk of cardiovascular disease (CVD). A prior multifaceted quality improvement approach to improving CVD preventive care increased CVD risk factor assessments, but there was no significant effect on the management of risk factors. We tested the impact of adding a proactive outreach strategy promoting primary care treatment of CVD risk factors among patients with RA through their rheumatology practice. Methods Through electronic health record searches, we identified patients with RA who were potential candidates for hypertension treatment initiation or intensification, statin therapy, or a smoking‐cessation intervention. A nonclinician care manager contacted patients by phone and mail on behalf of the rheumatologists, provided information about the identified risk factor(s), recommend follow‐up with primary care physicians (PCPs), sent correspondence to PCPs, and followed up with patients to see what actions had been taken. We measured preventive cardiology quality indicators and compared preintervention and intervention time periods using interrupted time series methods. Results During the 6‐month intervention period, the proportion of patients prescribed at least moderate‐intensity statin treatment for primary prevention rose from 18.4% to 23.8%. The rate of increase was 1.06% greater per month than during the preceding period (P < 0.001). Rates of increase in hypertension diagnosis and control improved more rapidly during this phase (P < 0.001 for each) and reversed preceding negative trends. Conclusion Implementing proactive nonclinician outreach to encourage primary care–based treatment of CVD risk factors was associated with increases in statin prescribing and in hypertension diagnosis and control. Smoking was not affected.
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Affiliation(s)
- Stephen D Persell
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ji Young Lee
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dawid Lipiszko
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Yaw A Peprah
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Eric M Ruderman
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Mathieu S, Couderc M, Tournadre A, Soubrier M. Cardiovascular profile in osteoarthritis: a meta-analysis of cardiovascular events and risk factors. Joint Bone Spine 2019; 86:679-684. [DOI: 10.1016/j.jbspin.2019.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/24/2019] [Indexed: 02/08/2023]
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Ljung L, Holmqvist M. Addressing the hardest endpoint. Rheumatology (Oxford) 2019; 59:462-463. [DOI: 10.1093/rheumatology/kez514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/24/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lotta Ljung
- Clinical Epidemiology Section, Department of Medicine, Karolinska Institutet, Solna, Stockholm
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Marie Holmqvist
- Clinical Epidemiology Section, Department of Medicine, Karolinska Institutet, Solna, Stockholm
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