Cardiovascular risk underestimated in women, younger patients with rheumatoid arthritis
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Cardiovascular disease incidence among women and patients younger than 55 years with rheumatoid arthritis is higher than their typical “low risk” classification would suggest, according to data published in Arthritis Research & Therapy.
“Current algorithms developed to predict CVD, such as the Systematic Coronary Risk Evaluation score (SCORE), underestimate the risk in RA patients, especially in those patients originally classified as having low or intermediate risk,” Daphne C. Rohrich, MSc, of Sint Maartenskliniek, in Ubbergen, Netherlands, and colleagues wrote. “It is well known that older age leads to higher CV risk in the general population. Likewise, males are at greater risk compared to females.”
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“However, the results of a recent meta-analysis suggested that compared to the general population, younger RA patients bear the greatest relative risk of developing CV events, whereas older RA patients seem to have similar relative risks when compared to age-matched counterparts,” they added. “Furthermore, women with RA seem to be at a greater CV risk than those without RA. Early menopause seems to be a predictor for RA, and in addition, early menopause in women with RA may lead to a higher CVD risk. Therefore, one can suggest that gender and age are likely to have a distinct impact on CVD risk in RA patients than in the general population.”
To examine whether gender and age contribute to the misclassification of cardiovascular risk among patients with RA, Rohrich and colleagues prospectively collected data from the Nijmegen inception cohort. This cohort included patients diagnosed with RA at the Radboud University Nijmegen Medical Center, in the Netherlands, since 1985, as well as those from Sint Maartenskliniek Nijmegen since 1990. The researchers analyzed data on cardiovascular risk factors and incident events, with a follow-up period of up to 10 years. In all, 863 patients with RA, with 128 incident cardiovascular events, were included in the study.
Rohrich and colleagues used both the original and the EULAR-modified (M)_SCORE algorithms to calculate cardiovascular risk. The researchers stratified patients into deciles according to predicted risk, using the Hosmer-Lemeshow test to verify concordance between observed and predicted risk, in subgroups based on gender and age.
According to the researchers, there was evidence of a discrepancy between the predicted and observed cardiovascular risks (H-L test P < .003), primarily among women (H-L test P < .001), when using the SCORE algorithms for all patients. More than a third — 36% — of women with a cardiovascular event belonged to the low cardiovascular risk group, compared with just 10% among men with RA. Regarding age, researchers found a discrepancy only in those younger than 55 years (H-L test P < .001), with an overall underestimation of cardiovascular risk — 5.3% predicted compared with 8% observed.
The M_SCORE algorithm produced similar results.
“The results of our study suggest that the incidence of CVD among women and young RA patients initially assigned to the low-risk category is higher than predicted using current algorithms,” Rohrich and colleagues wrote. “Consequently, the CV risk in these subgroups seems underestimated.”
“Whether modifying the weight for the female gender and/or younger age in the risk algorithms would result in better CV risk predictions in RA remains a subject to be investigated in future studies,” they added. “Alternatively, other strategies (eg, biomarkers, cIMT, or CAC measurements) aiming at the same goal could be envisaged in order to improve CV risk management in patients with RA and/or other chronic inflammatory conditions.”
Perspective
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Laura P. Kimble, PhD, RN, FNP-C, CNE, FAHA, FAAN
The findings of this study underscore the problem with using cardiovascular risk estimation algorithms in the rheumatoid arthritis population. In the study cohort from the Netherlands, the investigators found that the Systematic Coronary Risk Evaluation score (SCORE) algorithm systematically underestimated risk for incident cardiovascular events in young (< 55 years of age) patients with RA, particularly young females. Among those females who developed cardiovascular events such as myocardial infarction or peripheral artery disease, 36% had been classified as low risk for CVD (< 10% risk).
An acute cardiovascular event has major implications for health and well-being of young women. Until more precise algorithms for cardiovascular risk in the RA population are developed, rheumatology clinicians should assure consistent, comprehensive cardiovascular risk assessment and risk reduction.
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David A. McLain, MD, MACR, FACP, FRCP
Rheumatology has many challenges. We deal with complex patients that have a number of “data fields” to check and manage. Our medications must be selected, precerted, monitored for effect and reactions, and adjusted. The patient’s underlying disease must be diagnosed, continually evaluated and scored for CDAI or other disease activity indices, MIPS has to be reviewed and updated, the PDMP has to be checked if controlled substances are prescribed and a urine drug screen checked. Additionally, patient smoking needs to be addressed and counselled, the DXA has to up to date and addressed, and any new problems that may reflect a medication or disease association – or even just another of the patient’s comorbidities – need to be documented.
Therefore, to engage rheumatologists into also addressing lipid levels and cardiovascular risk is difficult. Many of our diseases have elevated cardiovascular risk. Patients with chronic inflammatory rheumatic conditions, such as systemic lupus erythematosus, rheumatoid arthritis, spondyloarthritis and juvenile idiopathic arthritis are at increased risk of developing premature cardiovascular disease; one study even showed increased carotid intima-media thickness in patients with scleroderma.
Hyperuricemia, a central feature of gout, is known to be associated with increased risk of cardiovascular disease, although causality has not been proved; it has also been associated with endothelial dysfunction, which may contribute to the risk of heart disease in these patients.
For the rheumatologist, screening and treating cardiovascular risk factors should be within our scope of practice. All these factors add up to comprehensive care for the rheumatic disease patient.
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