Update on Cardiovascular Disease Risk in Patients with Rheumatic Diseases

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Key points

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    Cardiovascular disease (CVD) risk calculators underestimate CVD risk in rheumatoid arthritis (RA) and should be multiplied by 1.5 to reflect the greater than 1.5 times higher risk of CVD among adults with RA, even with no traditional CVD risk factors, although risk increases substantially with the number of CVD risk factors.

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    Current CVD risk factors, particularly total and low-density lipoprotein (LDL)-C, likely underestimate the extent of subclinical atherosclerosis.

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    LDL or high-density

What explains the excess cardiovascular disease risk in rheumatoid arthritis?

Active RA is characterized by systemic inflammation that is credited with much of the excess risk of CVD and mortality in RA. The contribution of inflammation to atherosclerosis, endothelial dysfunction, plaque vulnerability, and atherothrombotic events has been previously reviewed.24 In RA, CVD risk reduction has been reported using several antiinflammatory disease-modifying antirheumatic drugs (DMARDs), including hydroxychloroquine25 and methotrexate,26 and possibly for tumor necrosis factor

Can Lipoprotein Particle Concentrations Explain the Lipid Paradox in Rheumatoid Arthritis?

The lipid paradox in RA describes the seemingly paradoxic association of low levels of TC and LDL-C with increased CVD risk.19 However, recent large studies show a J-shaped association of LDL-C with CVD in RA30, 31 that is similar to non-RA controls.31 Indeed, the lipid paradox of high CVD risk with normal or low LDL-C is well known in adults with the metabolic syndrome, diabetes, or obesity. These conditions are characterized by increased levels of inflammation; triglycerides; and small,

Summary

The risk of CVD and death is increased greater than or equal to 1.5-fold among adults with RA, most of whom are postmenopausal women. CVD risk scores underestimate their CVD risk due to an accelerated burden of subclinical atherosclerosis before diagnosis and changes in postdiagnosis risk factor levels (decreased lipids, possibly smoking). Current recommendations include multiplying risk scores by 1.5, considering subclinical disease burden, and use of statins and antihypertensive medications.

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    This article is an update of an article previously published in Geriatric Clinics, Volume 33, Issue 1, February 2017.

    Disclosure Statement: Dr R.H. Mackey and Dr. L.H. Kuller have no disclosures. Dr L.W. Moreland serves on data safety monitoring boards for Boeringher-Ingelheim, and Pfizer.

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