Age, sex and traditional risk factors-such as hypertension, diabetes, smoking, and body mass-are more important predictors of heart attack in patients with rheumatoid arthritis than the use of certain medications that have been considered the link between the two and lipid-lowering medications may actually reduce this risk, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in San Francisco, Calif.
Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.
Disease-modifying antirheumatic drugs, or DMARDS as they are commonly called, are often the therapy of choice for patients with RA as they not only reduce inflammation and pain, but can slow the overall progression of the disease.
Although it is known that people with RA are at an increased risk for premature death due to heart attacks, little is known about the influence of RA disease activity, the use of DMARD and corticosteroid therapy, and the impact of traditional cardiovascular risk factors on the development of heart disease in people with RA. It is uncertain what effect reducing risk factors like high blood fat and cholesterol levels or high blood pressure has on heart disease risk in these patients.
Researchers in the United Kingdom, in two studies, recently looked to the United Kingdom General Practice Research Database, or GPRD, which contains the records of over seven million individuals-including patients with RA-to estimate the incidence of heart attack and assess whether DMARDS and corticosteroid therapy played a role in heart attack. They also evaluated the effectiveness of lipid-lowering medications and antihypertensive drugs in the prevention of heart attacks in patients diagnosed with RA.
The GPRD was used to identify 34,364 adults with RA and 103,089 controls - all of whom were matched according to age, sex, and primary care practice. The subjects were studied between 1987 and 2002, and the incidence of heart attack in those with RA was compared to that in the controls.
Researchers documented 2.96 heart attacks per 1,000 people each year in the control group and 6.49 per 1,000 people per year among patients with RA.
In the first study, researchers found that of the 966 cases of heart attack occurring in patients with RA, 73 percent of the cases, patients had taken a DMARD or prednisolone (a cortisone drug) at some point during the study period prior to the heart attack, and in 56 percent of the cases, patients had taken a DMARD or prednisolone in the two months immediately prior to the heart attack.
The chance of having a heart attack among patients with RA who had been prescribed a DMARD or prednisolone was reduced compared to the chance of heart attack in patients who had not been prescribed either of these. When analyzing DMARDS separately, researchers found that the use of hydroxycholoroquine, methotrexate, and sulphasalazine appeared to be protective against heart attack in these patients, while prednisolone was found to increase the risk but these effects were modest compared to traditional risk factors.
In the second study, researchers found that treatment with lipid-lowering medications were associated with a significant reduction in the incidence of heart attacks among the patients studied - dropping the incidence rate by 25 percent.
However, when researchers looked at the effect that traditional risk factors have on heart attacks, they found that although these factors were important, the effect of having RA itself was greater.
"This suggests that treating RA and traditional cardiovascular risk factors, such as high cholesterol, are both important in trying to reduce the number of heart attacks in our patients with RA," explains Christopher J. Edwards, BSc, FRCP, MD; consultant rheumatologist and honorary senior lecturer, Southampton General Hospital, department of rheumatology, Southampton, United Kingdom, and lead investigator in both studies. "We have known for a while that RA is associated with an increased risk of heart attacks. This work gives an insight into the relative importance of different risk factors in this process. The presence of RA appears to be the most important factor, followed by traditional cardiovascular risk factors and then prednisolone use. Importantly, the use of treatments to lower cholesterol may reduce this risk."
The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases.
Source: ACR
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