RA: Cardiovascular Risk Stratification and Potential Predictors of Risk Save

Early cardiovascular disease assessment and management is critical at diagnosis in patients with Rheumatoid Arthritis (RA). Patients with RA have a known increased risk of developing cardiovascular disease (CVD) due to a higher incidence of traditional cardiovascular (CV) risks such as hypertension and/or hyperlipidemia but also due to the systemic inflammation characteristic to RA. In fact, a RA patient’s risk of developing CVD is comparable to the risk of a patient with diabetes mellitus (DM). 

Patients with early RA have underdiagnosed and severely undertreated risk factors of CVD.

Abstract #0287, the CARRÉ study, investigated the incidence of cardiovascular events in RA patients with follow up of more than 20 years. The study revealed that 35% of RA patients developed a CV event compared to 37% of patients with DM and 26% of the general population. The incidence rate of CV events in RA patients was 3.1 per 100 patient years, with 3.9 years at risk compared to 3.9 per 100 patient years in those with DM with 1.4 years at risk and 1.9 per 100 patient years in the general population with 18.8 years at risk. Interestingly, the rate of CV events in RA patients has remained the same despite seemingly better control of inflammation.

Abstract #0285 showed that 43% of newly diagnosed Dutch patients with RA had an intermediate or high calculated 10-year CV morbidity risk and that 76% had an intermediate or high mortality risk within one year post diagnosis. Patients in this study had a mean age of 57 years, 74% were female, 72% had history of hypertension, and 57% had history of hyperlipidemia.

Abstract #0271 showed that patients aged 40-75 years old with a diagnosis of RA have a higher prevalence of subclinical atherosclerosis in the first 5 years of diagnosis compared to age-matched controls. The authors suggest obtaining a carotid ultrasound at the time of RA diagnosis and monitoring carotid US periodically thereafter per each patient’s individual risk based on the results of this study.

The above abstracts highlight that the assessment of CV risk is essential in clinical practice. The following abstracts below discussed potential predictors or markers that may aid in CVD risk stratification: 

• Abstract #0295 showed that historical weight loss may serve as a marker of adverse metabolic health and aid in CVD risk stratification in RA. Specifically, weight loss greater than  10% since age 30 was associated with 50% greater CVD risk independent of baseline BMI category (HR 1.50), a 2-fold increase in fatal CVD risk (HR 2.0), increased MI risk (HR 1.57), and increased HF risk (HR 1.58). 
• Abstract #0276 showed that RA patients had higher pulse pressures (SBP – DBP) than controls and that pulse pressure was the only independent risk factor for subclinical atherosclerosis. 
• Abstract #0268 showed that autoantibodies confer risk of incident CVD in US veterans with RA. Particularly, it showed that higher concentrations of RF (HR 1.15) and IgM anti-malondialdehyde acetaldehyde (anti-MAA) (HR 1.2) were associated with risk of MACE while higher concentrations of anti-citrullinated peptide antibody (ACPA) and IgM+IgG anti-MAA were associated with risk of CVD-death. Accordingly, autoantibodies may directly contribute to excess CVD risk in RA. 
• Abstract #0170 showed that epicardial adipose tissue volume (EATv) as measured on computed tomography angiography predicts new plaque formation in RA patients with less than 10 years of disease (OR 5.8), 1 cardiac risk factor (OR 3.4), statin treatment less than 1 year (OR 3.3), and in patients without calcification at baseline (OR 2.7). 

Thus, history of weight loss more than 10% since age 30 yo, higher pulse pressures, higher concentrations of autoantibodies (RF, anti-MAA, and ACPA), and higher EATv may potentially serve as predictors and/or biomarkers for CVD development in RA once further validated. The important take away from these abstracts is that early CV risk stratification and management is essential upon diagnosis of RA.