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Women with RA, psoriasis at increased CV risk
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Recently published findings revealed that women with rheumatoid arthritis and psoriasis have an increased risk for major adverse cardiac events compared with the general population.
“This is the first study to determine whether patients with rheumatoid arthritis (RA), psoriasis and psoriatic arthritis (PsA) have an increased risk of major cardiovascular events after controlling for traditional cardiovascular risk factors, such as hypertension and diabetes,” Roxanne Cooksey, PhD, of the Swansea University Medical School in Wales, told Healio Rheumatology.
To analyze the incidence of major adverse cardiac events among patients with RA, psoriasis and PsA, the researchers reviewed data from the Secure Anonymized Information Linkage database, which includes more than 1 billion anonymous records, including Welsh general practice, hospital and mortality information. Focusing on data collected from 1999 to 2013, the Cooksey and colleagues examined information from 8,650 patients with RA, 2,128 patients with PsA and 24,630 patients with psoriasis; they then compared those patients with 1,187,706 control individuals without any diagnosis of RA, PsA or psoriasis.
The primary outcome measures were major cardiac events, specifically myocardial infarction, cerebrovascular accident and associated deaths. The researchers adjusted for traditional cardiovascular risk factors — which they defined as age at diagnosis, age at study start, sex, BMI, smoking status, hypertension, diabetes, previous cardiovascular disease and family history of cardiovascular disease — as well as potential confounders, including the use of NSAIDs, disease-modifying antirheumatic drugs, oral corticosteroids and topical steroids.
According to the researchers, traditional cardiovascular risk factors were higher among patients with PA, PsA and psoriasis, compared with patients in the control group. However, after adjusting for the above risk factors, additional risk was only significantly increased among female patients with RA (HR = 1.3; 95% CI, 1-1.7) and psoriasis (HR = 1.2; 95% CI, 1-1.4)
“We found that there is an increased risk of cardiovascular events for all patients with psoriasis and for women with rheumatoid arthritis,” Cooksey said. “Conversely, there was not an increased risk of cardiovascular events among patients with psoriatic arthritis or men with rheumatoid arthritis. In addition to traditional cardiovascular risk factors, systemic inflammation as measured by erythrocyte sedimentation rate contributes to the increased risk in rheumatoid arthritis.”
However, Cooksey noted that this was not the case for patients with psoriasis, for whom there appear to be additional, unidentified risk factors for major adverse cardiovascular events.
“The clinical significance of this research is that cardiovascular risk strategies need to be disease specific for inflammatory conditions and psoriasis,” she said. “Furthermore, further study is warranted to investigate further risk factors to explain the increased cardiovascular events in individuals with psoriasis.” – by Jason Laday
Disclosure: The researchers report funding from Pfizer.
Perspective
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Iris Zink, MSN, RN, ANP-BC, RN-BC
In their recent study, Cooksey and colleagues examined the relationship between cardiovascular risk factors and rheumatoid arthritis, psoriatic arthritis and psoriasis; the researchers concluded that although there is known increased cardiovascular disease risk among female patients with RA and psoriasis, the study failed to show increased risk among psoriatic arthritis patients.
In a recent study by Eder and colleagues in the Journal of Rheumatology, researchers demonstrated that there is, in fact, a statistical increase in CVD risk in a majority of patients with PsA and psoriasis using the Framingham Risk Score, which directly contradicts the results from Cooksey and colleagues. For this specific study, a limitation revolves around the sample size: 24, 630 patients with psoriasis, 8,650 patients with RA, and 2,128 patients with PsA in the Cooksey study compared with 2,254 overall in the Eder study. Whether this sample size is statistically significant remains up for debate.
Many of us remember a time when our waiting rooms were full of patients using walkers and wheelchairs who were often dependent on oxygen due to the comorbidities associated with progressive joint disease. In the era of biologic medications, we have been able to slow the progression of joint destruction. Where we are falling short, however, is in the identification and treatment of the comorbidities of the inflammatory arthritides that more often contribute to the patient’s eventual mortality.
The study from Cooksey and colleagues revealed unanswered questions about possible mediators of inflammation and yet, as health care providers, it is our job to practice vigilance and surveillance of potential mortality risk in our patients. We must look at all of our patients who have systemic inflammation as having an increased risk of CVD and treat them appropriately.
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