Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE

Abstract

The excess risk of cardiovascular disease (CVD) associated with inflammatory rheumatic diseases has long been recognized. Patients with established rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) have higher mortality compared with the general population. Over 50% of premature deaths in RA are attributable to CVD. Excess mortality in SLE follows a bimodal pattern, with the early peak predominantly a consequence of active lupus or its complications, and the later peak largely attributable to atherosclerosis. Patients with RA or SLE are also at increased risk of nonfatal ischemic heart disease. The management and outcome of myocardial infarction and congestive heart failure in patients with RA or SLE differs from that in the general population. Traditional CVD risk factors (TRF) include increasing age, male gender, smoking, hypertension, hypercholesterolemia and diabetes. Whereas some TRFs are elevated in patients with RA or SLE, several are not, and others exhibit paradoxical relationships. Risk scores developed for the general population based on TRFs are likely, therefore, to underestimate CVD risk in RA and SLE. Until additional research and disease-specific risk prediction tools are available, current evidence supports aggressive treatment of disease activity, and careful screening for and management of TRFs.

Key Points

  • Fatal and nonfatal cardiovascular disease (CVD) is increased in patients with RA or SLE, compared with the general population

  • CVD, including heart failure, might be under-recognized and under-treated in patients with RA or SLE

  • The increase in CVD is due, in part, to both the cumulative burden of inflammation and the increased prevalence—or altered properties—of traditional cardiovascular risk factors

  • Inflammation and traditional cardiovascular risk factors interact to promote atherosclerosis in RA and SLE

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Figure 1: Comparison of the cumulative incidence of congestive heart failure in RA and non-RA cohorts, according to the number of years since the index date, adjusting for the competing risk of death.
Figure 2: Hypothetical distribution of cardiovascular risk factors in patients with SLE or RA in comparison with the general population.
Figure 3: Cardiovascular event-free probability to 3 years among nondiabetic controls, patients with T2DM, and nondiabetic patients with RA.
Figure 4: Explanations for the link between inflammatory rheumatic disease and CVD mortality.

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Acknowledgements

We thank Dr. Nicola Goodson for the concept behind Figure 4.

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Correspondence to Deborah P. M. Symmons.

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Symmons, D., Gabriel, S. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol 7, 399–408 (2011). https://doi.org/10.1038/nrrheum.2011.75

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