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Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis

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.

Key points

  • Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD) compared with the general population.

  • The improvement of CVD risk prevention in patients with RA is an unmet need.

  • CVD risk calculators developed for use in the general population inaccurately predict CVD in patients with RA, but the addition of RA-specific risk factors does not improve CVD risk prediction

  • The use of ultrasonography of the carotid arteries improves CVD risk classification in patients with RA by identifying atherosclerotic plaques.

  • CVD risk prevention in patients with RA closely follows the recommendations for the general population; however, clinicians should be aware of some specific drug–drug interactions in this patient population.

  • Inflammation and antirheumatic medication use in patients with RA does not affect the doses of statins or antihypertensive medications required for attainment of recommended lipid or blood pressure goals.

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Fig. 1: Imaging modalities in cardiovascular disease risk evaluation.
Fig. 2: Model for cardiovascular disease risk evaluation in a rheumatology clinic.
Fig. 3: Cardiovascular disease risk management in patients with rheumatoid arthritis.
Fig. 4: The interaction between lipids and inflammation in rheumatoid arthritis.

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Acknowledgements

The work of the authors has been supported by grants from the South Eastern Regional Health Authorities of Norway (2013064 to A.G.S. and 2016063 to S.R.).

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Glossary

Diastolic dysfunction

A stiffening of the ventricles that restricts the ability of the heart to fill with blood between beats.

Heart failure with preserved ejection fraction

A form of heart failure in which the ejection fraction — the percentage of the volume of blood ejected from the left ventricle with each heartbeat divided by the volume of blood when the left ventricle is maximally filled — is normal, defined as greater than 50%.

Atrial fibrillation

An irregular, rapid heart rate that occurs when the atria beat out of rhythm with the ventricles, which can cause symptoms including heart palpitations, fatigue and shortness of breath.

Coronary angiography

Radiography performed with contrast agent in the coronary arteries.

Coronary artery stenosis

Narrowing of the arteries that supply blood to the heart muscle.

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Semb, A.G., Ikdahl, E., Wibetoe, G. et al. Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol 16, 361–379 (2020). https://doi.org/10.1038/s41584-020-0428-y

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