Current therapies, guidelines inadequate to manage CV events in rheumatic diseases
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Although patients with rheumatic diseases are at increased risk for cardiovascular events, risk stratification tools and available guidelines to aid rheumatologists in managing these events are lacking, according to data presented at the virtual ACR State-of-the-Art Clinical Symposium.
“Almost all of our diseases are associated with rates of ischemic events compared with otherwise similar background population,” Jon Giles, MD, MPH, associate professor of medicine in the division of rheumatology at the Columbia University College of Physicians & Surgeons, said in his presentation. “One of the key features is that cardiovascular disease can often be seen at younger ages than expected” in patients with rheumatic diseases.
These events have been studied most in rheumatoid arthritis (RA), while less is known about the spondyloarthropathies and systemic lupus erythematosus (SLE). It is clear, however, that cardiovascular disease and events are a significant driver of morbidity and mortality in patients across the rheumatology spectrum. “Often, cardiovascular disease is the primary cause of death,” he said.
Despite this prevalence, Giles highlighted one key challenge for rheumatologists in the U.S. attempting to manage these events. “I wish I could say that there are evidence-based guidelines, but they are not evidence-based,” he said.
The situation is much the same in Europe. “The strength of evidence [in EULAR guidelines] is not strong,” he said.
In light of these hurdles, Giles aimed to discuss risk management and implications for cardiovascular disease screening in the rheumatology patient.
Patients with rheumatic diseases are at particular risk for subclinical atherosclerosis, according to Giles. Plaques tend to have more inflammation and are more likely to rupture. Compared with plaques seen in the general population, “the plaques themselves are different in rheumatic diseases,” he said.
Chronically elevated circulating inflammatory cytokines and other aspects of systemic immunoactivation put individuals at risk for ischemic events, Giles reported. Because many patients with rheumatic diseases marked by these factors, they are at an increased risk. Of course, traditional cardiovascular risk factors also contribute and may have a synergistic effect with inflammatory risk factors. Accelerated atherogenesis may occur, as may destabilization of plaques.
But for rheumatologists hoping to gain understanding of atherosclerotic risk in their patients, Giles warned that standard atherosclerotic cardiovascular disease (ASCVD) risk stratification tools often underperform, particularly in patients with RA.
That said, Giles stressed three factors that may predispose patients with rheumatic diseases to unpredicted events, including age older than 55 years, rheumatoid factor and persistently elevated ESR.
A solution, then, is technology. “Secondary screening with imaging may be appropriate for patients with certain characteristics,” Giles said.
Therapeutic options also may be considered, according to Giles. “Statins for plaque stabilization are underutilized,” he said. “Observational data support a role for treatment with specific immunomodulators as a strategy for CVD event reduction in RA.”
Regarding other treatments, while data are primarily available for methotrexate and TNF inhibitors, an emerging body of data may support other cytokine inhibitors to mitigate cardiovascular outcomes.
But challenges remain, particularly regarding whether ASCVD and cardiovascular events are declining in the treat-to-target era of rheumatology. “We have not quite answered this,” Giles said. – by Rob Volansky
Reference:
Giles J. Screening and Management of Cardiovascular Disease in Rheumatic Diseases. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium. May 16-17, 2020 (virtual meeting).
Disclosures: Giles reports consulting for AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech and UCB; and receiving grant support from Pfizer.
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Giles J. Screening and Management of Cardiovascular Disease in Rheumatic Diseases. Presented at: American College of Rheumatology State-of-the-Art Clinical Symposium. May 16-17, 2020 (virtual meeting).
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