New tools help rheumatologists take on CVD risk management
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New and emerging risk stratification tools can assist rheumatologists who are increasingly “taking on the challenge” of cardiovascular risk management in patients, according to a speaker at the 2020 Congress of Clinical Rheumatology-East.
“How to communicate risk, and how to both risk stratify and, perhaps, even to intervene, is honestly going to be the next wave for rheumatology, I think,” Jeffrey Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, told attendees on the live stream. “It’s going to be the next wave to consider regarding how we optimize care for our patients and reduce the burden of this morbidity.”
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Existing tools to assess general cardiovascular disease risk include the ASCVD calculator, the Framingham risk score, the QRISK3 algorithm and the SCORE Risk Chart from the European Society of Cardiology. In addition, the age-adjusted ESR/CRP calculator for rheumatoid arthritis and the EULAR multiplier can provide risk stratification that is more specific to rheumatology.
However, according to Curtis, these tools suffer for being too time consuming and cumbersome to use in everyday practice.
“It may be possible that if you or I have to go to an app to look something up, you’re actually not going to do it,” Curtis said. “You’re busy, you’re seeing 20-, 30-plus patients in a day, and there are only so many minutes in the day to do this.
“On the other hand, if you are handed a risk estimate or risk calculator like my DEXA machine hands me the FRAX score, I now talk about that a whole lot more with my patients and it is much more accessible because it’s on my DEXA report,” Curtis added. “So, what if you could have this in your EHR, in a lab report or through other mechanisms?”
This, according to Curtis, was the goal when he and colleagues analyzed 30,751 Medicare patients from administrative data from 2006 to 2016, and compared the multi-biomarker disease activity (MBDA) score with four other cardiovascular outcome prediction models.
According to the results, which Curtis presented at the American College of Rheumatology 2019 Annual Meeting, MBDA was superior to the other four models in predicting incidence of the primary outcome events. In addition, when the MBDA cardiovascular score was converted to a 3-year percentage risk for a cardiovascular event, a moderate to high risk for such an event was observed in 80% of the cohort.
“I’ve done some work looking at the 12 biomarkers in the Vectra score that some people use to measure RA disease activity, and we had done some work suggesting that that is in fact associated with cardiovascular risk,” Curtis said. “So, we looked at some traditional risk factors, plus the score, and then each of the 12 biomarkers — CRP and the other 11 — and then we used that to both derive and validate a cardiovascular risk score, and to predict that over three years.”
In practice, the MBDA-based CVD score would require a physician to list a couple of risk factors, most of which could be extracted from the EHR automatically, and it would generate predicted risk, he added.
“So, if you have this at your fingertips, I would encourage and maybe challenge you to think, ‘Is this useful?’” Curtis said. “Some might say sure, and others would say they don’t want to be responsible for this, especially if it obligated you to do more work. On the other hand, if your patient is on the fence about whether to start the new RA treatment that you are recommending, this might actually be pretty important to educate them or even motivate them to change treatments if they have high disease activity. You could then start a conversation about the beneficial effects on the heart if you could reduce that.”
According to Curtis, the responsibility of managing cardiovascular risk is increasingly falling on rheumatologists, who may see patients with RA more often than a cardiologist. In addition, many patients with RA “have no notion” that their disease carries a cardiovascular risk, or that their medications may have a potential effect on the heart.
In one intervention study published in 2016 in BMJ, 10 rheumatology clinics in Denmark randomized patients newly diagnosed with RA to receive cardiovascular risk management or standard of care, Curtis said.
Meanwhile, another study out of Denmark, URICORI, is currently recruiting patients with gout with the goal of analyzing the effectiveness of a 1-year, intervention of modifiable risk factors for cardiovascular disease administered in a rheumatology practice, compared with conventional treatment.
According to Curtis, both studies reflect how cardiovascular disease risk is being managed from a rheumatologist’s office.
“The intervention is being done by rheumatology offices — not necessarily by the doctors, but by support staff or nurses,” Curtis said. “So, again, I think we are starting to see, more and more, where rheumatology is taking on the challenge of optimizing these risk factors.”
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Curtis J. Cardiovascular Risk in Rheumatic Diseases: Do Medications Help or Hurt? Presented at: Congress of Clinical Rheumatology-East annual symposium; September 10-13, 2020 (virtual meeting).
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