Stable Low Risk of Acute Coronary Syndrome in RA Save

A Nordic multinational collaborative study examined the risk of acute coronary syndrome (ACS) in rheumatoid arthritis and found a less than 2 fold increased risk of ACS patients initiating biologic disease-modifying antirheumatic drugs (bDMARDs) with little risk variation with short-term, intermediate-term and longer-term bDMARDs use.

The goal of this study was to compare the 1-year, 2-year and 5-year risk of of acute coronary syndrome (ACS) in patients with rheumatoid arthritis (RA) starting bDMARDs and to use a general population risk as the comparator. The drugs under study included the use of adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, abatacept, rituximab, tocilizumab, baricitinib and tofacitinib.

The study cohort included 24,083 patients (75% women, mean age 56 yrs)  from Denmark, Finland, Norway and Sweden (2008–2017) starting a bDMARD. There were 40,850 treatment courses over a maximum of 5 years follow-up. With up to 5 years of follow-up (141,257 person-years of observation) there were 780 ACS events (crude IR 5.5 per 1000 pyrs).  The same rate was seen in patients with one year of observation (215 ACS in 38,102 pyrs; crude IR of 5.6 per 1000 ptyrs).

The incidence of ACS in RA was 80% higher than that in the general population. For all bDMARDs the risk was similar as the hazard ratio were close to 1 using etanercept as reference. Hazard ratios were higher in patients starting their third or more bDMARD and followed up for 5 years and for those taking abatacept, infliximab and rituximab (HR 1.19 to 1.49). These findings probably relate to confounding factors, like (longer disease duration, comorbidities, disease severity and chronic inflammation), that may augment CV risks.

Overall, the short-term, intermediate-term and longer-term risks of ACS vary little across most bDMARDs.