Assessing Cardiovascular Risks: The Responsibility of the Rheumatologist Save

In 2016, the European League Against Rheumatism (EULAR) posted recommendations for the management of cardiovascular (CV) risks in patients with rheumatoid arthritis (RA) and other inflammatory joint diseases (IJD)1. Three overarching principles emerged, but one caught my attention: “the rheumatologist is responsible for CV disease risk management.” It leaves no room for interpretation.

Rheumatologists need to be actively involved in managing comorbidities especially when CV disease is involved. The recommendations further noted rheumatologists should assess and mitigate CV risk using a standardized scoring system, monitor patients’ lipids, and control disease activity. My initial thoughts when reading these recommendations were while they were good recommendations, implementing them may be impractical in the current practice environment. Visits are truncated to 15-20 min, diseases are complex, and there are so many other issues rheumatologists need to address with their patients:  disease activity, medication side effects, test results, prior authorizations and denials, vaccinations, osteoporosis monitoring, and contraception. How will rheumatologists incorporate CV monitoring and risk mitigation in a short visit when other issues are more pressing? Burnout is high; are the guidelines asking too much from my colleagues? 

I contemplated this issue over the last year, polling rheumatologists if they routinely assess CV risk and how they do it. The vast majority state they do not address this issue but rely heavily on primary care providers to do the task.

So why did the guidelines place the burden of CV risk monitoring on the rheumatologist? 

The answer lies in the fact that CV disease is the leading cause of death in our patients with immune mediated inflammatory disease (IMID).  Additionally, rheumatologists see these patients and obtain labs more frequently than their other doctors, and many primary care providers are nervous when managing complex patients whose symptoms may mimic other diseases.  The rationale for assuming an active role makes sense, but how would we incorporate CV risk monitoring and mitigation into a busy practice? Fortunately, most of what we do for patients to help arthritis and inflammation will also reduce CV risk (e.g., control disease activity, weight loss, exercise, smoking cessation, and diet). Patients with multiple risk factors (e.g, diabetes, hypertension, hyperlipidemia, obesity, tobacco use, on chronic steroids, or older age) may benefit from additional CV assessments. Triaging these patients to a separate, dedicated visit or referring them to a cardiologist may be more appropriate if time management is an issue during a routine visit. 

We all want the best care for our patients but are limited by time constraints. Sharing the care of the patient will help to reduce that burden. The more recently published 2021 EULAR recommendations2 on CV risk assessment for patients with gout, vasculitis, systemic sclerosis, myositis, mixed connective tissue disease, Sjogren’s syndrome, lupus, and anti-phospholipid syndrome are less jarring than the 2016 recommendations for RA and IJD. While the emphasis remains on the rheumatologists’ responsibility for CV risk assessment and management; the committee recommended doing this “in collaboration with primary care providers, internists or cardiologists and other healthcare providers.” 

After careful consideration, I concluded rheumatologists are responsible for addressing CV risk and comorbidities. We should promote awareness about CV disease and treat patients according to best practices to mitigate risks while enlisting help from other specialties.

References:

1. Ann Rheum Dis. 2017 Jan;76(1):17-28. doi: 10.1136 
2. Annals of the Rheumatic Diseases 2022;81:768-779.