Skip to comments.RA, Others Join Diabetes as Major CVD Risk Factors: Consensus on management reached.
Posted on 07/21/2009 1:02:32 AM PDT by neverdem
COPENHAGEN Rheumatoid arthritis and two other rheumatic diseases are as strong as diabetes as risk factors for cardiovascular disease, prompting a European League Against Rheumatism task force to issue the group's first consensus recommendations for managing cardiovascular risk in patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
In our view, rheumatoid arthritis [RA], ankylosing spondylitis [AS], and psoriatic arthritis [PsA] should be seen as new, independent cardiovascular risk factors, Dr. Michael T. Nurmohamed said at the annual European Congress of Rheumatology. Very importantly, the risk is comparable to type 2 diabetes, added Dr. Nurmohamed, a rheumatologist at the Free University Medical Center in Amsterdam.
Cardiovascular risk management is absolutely necessary in patients with RA, AS, or PsA, and should involve assessing and treating conventional cardiovascular disease (CVD) risk factors as well as suppressing the underlying inflammatory process by treatment with disease-modifying antirheumatic drugs (DMARDs). Most important is to decrease the inflammatory burden as much as possible, through the use of biologic and/or synthetic DMARDs, he said in an interview. The extent to which antirheumatic treatment decreases the risk is not known.
Just as cardiovascular disease is now the most feared outcome of diabetes, it may be time to expand the definition of the clinical impact of RA, AS, and PsA to include the extra CVD burden they trigger, Dr. Nurmohamed said.
The extra risk from RA and the other disorders is substantial. When a clinician uses the European SCORE (Systemic Coronary Risk Evaluation) formula to calculate an RA patient's 10-year risk for cardiovascular disease death, the number should be increased by 50% to get the patient's actual risk when at least two of the following three criteria are present: disease duration of more than 10 years, positivity for rheumatoid factor or anti-cyclic citrullinated peptide antibody, or extra-articular manifestations.
Dr. Nurmohamed based his recommendation on findings from an analysis done with his associates that found a greater than twofold increased risk for CVD in patients with RA, compared with people without RA. The higher level of conventional risk factors among the RA patients in the study explained roughly half of the doubled risk. The other half of the increased risk was directly attributable to RA, he said.
In the same way, a person's Framingham risk score for having a cardiovascular event should also be boosted by about 50% if RA, AS, or PsA is present, he said.
Major evidence for the impact of rheumatoid diseases on cardiovascular risk came in data on findingsfrom 294 patients with RA, 194 patients with type 2 diabetes, and 258 controls, all aged 50-75 yearsthat Dr. Nurmohamed and his associates first reported last year. In an analysis that controlled for age, sex, and cardiovascular risk factors, patients with RA had a 2.7-fold increased risk for cardiovascular disease events, compared with controls, and patients with type 2 diabetes had a 2-fold increased risk (Ann. Rheum. Dis. 2008 Aug. 12 [doi:10.1136/ard.2008.094151]).
These and other findings prompted Dr. Nurmohamed to convene an 18-member task force for the European League Against Rheumatism (EULAR) that included rheumatologists, cardiologists, internists, and epidemiologists from nine European countries. The panel wrote nine evidence- and expert-opinion-based recommendations for the management of cardiovascular risk in these patients.
The key recommendation is that patients with RA, AS, or PsA should be considered at high risk for developing CVD because of both an increased prevalence of traditional CVD risk factors and their inflammatory burden.
The increased CVD risk in patients with inflammatory arthritis is now well recognized; everyone is aware that something should be done. But the extent to which the new guidelines are already routinely followed in Europe by rheumatologists and other physicians who manage these patients is variable. In some countries, CVD risk management in patients with rheumatoid diseases is uncommon.
Dr. Nurmohamed itemized the other eight recommendations:
▸ Adequate control of rheumatoid disease activity is necessary to lower a patient's CVD risk.
▸ A CVD risk assessment following evidence-based EULAR guidelines is recommended annually for all RA patients, and should be considered for all patients with AS and PsA. Risk assessment should be repeated when antirheumatic treatment changes. The risk assessment should be initiated by the patient's rheumatologist; the assessment may be done by the rheumatologist, a cardiologist, or a primary care physician with an interest in CVD, Dr. Nurmohamed said.
▸ CVD risk score models should be multiplied by 1.5 when an RA patient has at least two of the following three criteria: disease duration of more than 10 years, positivity for rheumatoid factor or anti-cyclic citrullinated peptide antibody, and extra-articular manifestations.
▸ The total cholesterol:HDL cholesterol ratio should be used in the formula for estimating CVD risk.
▸ Interventions with lipid-lowering drugs and with antihypertensive medications should follow national guidelines.
▸ Statins, ACE inhibitors, and angiotensin receptor blockers are the preferred treatment agents because of their pleiotropic effects.
▸ The role of cyclooxygenase-2 selective inhibitors (coxibs) and most NSAIDs in most CVD is not well established and needs further investigation; therefore, these agents should be prescribed with caution.
▸ When corticosteroids are prescribed, they should be at the lowest dose possible.
Dr. Nurmohamed reported having no financial conflicts of interest.
Just as cardiovascular disease is now the most feared outcome of diabetes ...
Agreed. I do not fear a heart attack. Blindness-now that’s a life-changer.
Mine is also at 5.0. I’ve recently started riding a bicycle
to work. 6 miles each way mostly flat (If Mike Gallagher is reading this, no I don’t wear gaye-looking skin tight riding apparel).
Yep - guess we don’t think like doctors.
I was working out regularly for several years with weights. It helped keep my blood sugar down. I also slowly cut down on the carbs, but I went too far. Now I find it hard to eat high carb food - I’m lucky to get 90-100 grams a day, on my last doctor’s visit she chewed me out for having meter readings to low. I’m working to get my numbers up again - so I can workout again.
This is what is so silly about all these studies and statistics. The death rate is 100% and the number one risk factor for death and most diseases is age. Until they stop this nonsense about worrying what is killing people in their 80s and 90s and also start reporting risk reductions in terms of absolute rather than relative risk, none of these studies mean a thing.
Not to scare all the folks with type 2 diabetes, but it is quite possible that lowering blood sugar values is treating the symptom rather than the disease. The studies reporting reduced risk of complications and mortality due to some intervention that lowered blood sugar are really poor. The date has been massaged to say what they want it to say, and they still report differences in terms of relative risk vs absolute risk. Yes, I am including the famous studies you hear about that are used to justify various treatments.