1
|
Rohrich DC, van de Wetering EHM, Rennings AJ, Arts EE, Meek IL, den Broeder AA, Fransen J, Popa CD. Younger age and female gender are determinants of underestimated cardiovascular risk in rheumatoid arthritis patients: a prospective cohort study. Arthritis Res Ther 2021; 23:2. [PMID: 33397472 PMCID: PMC7784252 DOI: 10.1186/s13075-020-02384-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background Rheumatoid arthritis (RA) patients have an increased cardiovascular (CV) risk. Here, we aimed to investigate whether gender and age are contributing to the misclassification of CV risk in RA patients. Methods Prospectively collected data on cardiovascular risk factors and incident events from the Nijmegen inception cohort were analyzed, with up to 10 years follow-up. Original as well as the EULAR-modified (M)_SCORE algorithms were used to calculate CV risk. Patients were stratified in deciles according to predicted risk; the Hosmer-Lemeshow test was used to check concordance between observed and predicted risk, in subgroups of gender and age. Results There were 863 RA patients included with 128 incident CV events. When using SCORE in the whole group, there was evidence of a discrepancy between the predicted and observed CV risk (H-L test p < 0.003), mainly present in the female subgroup (H-L test p < 0.001). Interestingly, 36% of females who developed an event belonged to the low CV risk group, whereas this was just 10% in RA males. When analyzing the subgroups based on age, a discrepancy was present only in the youngest patients (H-L test p < 0.001 in patients < 55 years) consisting of an underestimation of CV risk (5.3% predicted vs. 8.0% observed). Similar results were obtained when the M_SCORE was applied. Conclusion CV risk is especially underestimated in female and younger RA patients. This suggests that modifying the weight for the female gender and/or younger age in currently used CV risk algorithms might improve their predictive value in RA, contributing to better CV risk management.
Collapse
Affiliation(s)
- Daphne C Rohrich
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands
| | - Eline H M van de Wetering
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Alexander J Rennings
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Elke E Arts
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Inger L Meek
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands
| | - Jaap Fransen
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands
| | - Calin D Popa
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal nr. 3, 6574 NA, Ubbergen, The Netherlands. .,Department of Rheumatology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, 6500 HB, Nijmegen, The Netherlands.
| |
Collapse
|
2
|
Wibetoe G, Sexton J, Ikdahl E, Rollefstad S, Kitas GD, van Riel P, Gabriel S, Kvien TK, Douglas K, Sandoo A, Arts EE, Wållberg-Jonsson S, Dahlqvist SR, Karpouzas G, Dessein PH, Tsang L, El-Gabalawy H, Hitchon CA, Pascual-Ramos V, Contreas-Yañes I, Sfikakis PP, González-Gay MA, Colunga-Pedraz IJ, Galarza-Delgado DA, Azpiri-Lopez JR, Crowson CS, Semb AG. Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models. Arthritis Res Ther 2020; 22:90. [PMID: 32326974 PMCID: PMC7178602 DOI: 10.1186/s13075-020-02178-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/31/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. METHODS RA patients aged 30-70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusion criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. RESULTS A total of 1974 patients were included in the main analyses, and 144 events were observed during follow-up, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15-32% of patients. C-statistics ranged 0.68-0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. CONCLUSIONS The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive.
Collapse
Affiliation(s)
- Grunde Wibetoe
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway.
| | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Eirik Ikdahl
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
| | - Silvia Rollefstad
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
| | - George D Kitas
- School of Sport, Exercise and Rehabilitation, University of Birmingham, Birmingham, UK
- Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Piet van Riel
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sherine Gabriel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karen Douglas
- Dudley Group NHS Foundation Trust, West Midlands, UK
| | - Aamer Sandoo
- Dudley Group NHS Foundation Trust, West Midlands, UK
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Elke E Arts
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | | | - George Karpouzas
- Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Patrick H Dessein
- Vrije Universiteit Brussel, Brussels, Belgium
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Linda Tsang
- Rheumatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | | | - Virginia Pascual-Ramos
- Instituto Nactional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Irazu Contreas-Yañes
- Instituto Nactional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | - Petros P Sfikakis
- First Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miguel A González-Gay
- Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, Santander, Spain
| | | | | | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anne Grete Semb
- Preventive Cardio-Rheuma clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vindern, N-01319, Oslo, Norway
| |
Collapse
|
3
|
Kievit W, Maurits JSF, Arts EE, van Riel PLCM, Fransen J, Popa CD. Cost-Effectiveness of Cardiovascular Screening in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:175-182. [PMID: 27159060 DOI: 10.1002/acr.22929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 03/29/2016] [Accepted: 04/26/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Early detection and preemptive treatment of patients at risk is of great importance in reducing the excess risk of cardiovascular (CV) disease in rheumatoid arthritis (RA). However, it is unclear how much screening is cost-effective in RA. The objective is to assess whether CV screening in RA proves to be cost-effective from a medical perspective, using different scenarios based on different guidelines. METHODS A Markov chain model was used with a time horizon of 10 years. Parameter values were mainly obtained from literature and from RA patients screened for CV diseases at the Radboud University Medical Centre, Nijmegen, The Netherlands. The primary outcome was incremental cost-effectiveness expressed as costs per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analysis was performed and described in willingness-to-pay curves; several scenarios were built. RESULTS In the base case scenario, in 82% of the simulations, screening proved to be dominant compared to no screening. The mean QALY gain was 0.09 (95% percentile -0.07, 0.27), and the mean cost savings were €-1,057 (95% percentile -€2,825, €333). Different scenarios showed small differences in cost-effectiveness; the probability that screening is dominant remained high with the lowest probability being 50% for a very conservative scenario. CONCLUSION Screening for CV events in RA patients was estimated to be cost-effective with high chances of being less expensive and more effective. These results support endorsement of screening for CV risk in patients with RA.
Collapse
Affiliation(s)
- Wietske Kievit
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jake S F Maurits
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Elke E Arts
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Piet L C M van Riel
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, and Bernhoven Hospital, Uden, The Netherlands
| | - Jaap Fransen
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Calin D Popa
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, and Bernhoven Hospital, Uden, The Netherlands
| |
Collapse
|