Turesson C et al. (2007) Severe extra-articular disease manifestations are associated with an increased risk of first ever cardiovascular events in patients with rheumatoid arthritis. Ann Rheum Dis 66: 70–75

The excess cardiovascular disease (CVD) risk seen in patients with rheumatoid arthritis (RA) correlates with RA-related rather than traditional risk factors and, therefore, might be exacerbated in patients with severe, extra-articular manifestations of RA. Turesson and colleagues at the Mayo Clinic have confirmed this hypothesis in their retrospective study of a well-characterized population of patients with RA.

The authors reviewed medical records from 81 patients with severe, extra-articular RA (mean disease duration 9.5 years) and 184 age-matched control patients with RA but without extra-articular disease. Rheumatoid-factor-positive patients had an elevated CVD risk, but patients with severe, extra-articular disease had the highest risk of incident CVD and coronary artery disease (hazard ratios 3.78 and 3.16, respectively). Both associations were independent of age, sex, smoking status, rheumatoid factor, or the presence of erosive disease. The authors suggest that CVD in patients with RA is particularly associated with systemic, extra-articular disease, rather than being associated with disease severity; the onset of extra-articular disease preceded CVD events in 77% of cases (26 of 34 patients). They suggest that pathogenetic mechanisms involved in extra-articular RA initiate or accelerate vascular pathology (perhaps via systemic endothelial activation and clonal expansion of immunosenescent T cells), which contributes to increased atherosclerosis.

Patients with RA who have no history of vascular disease, but who have severe, extra-articular disease or are rheumatoid-factor-positive, should be considered for cardioprotective therapies such as statins and low-dose aspirin.