Sunday, February 14, 2010

Cardiovascular risk management in Rheumatology (The EULAR recommendations)
Bruno Oliveira, MD, Rheumatology, 09:32AM Feb 1, 2010

Cardiovascular (CV) events are responsible for a significant proportion of morbidity and mortality in patients with Rheumatic Diseases.
In addition to traditional risk factors (age, gender, smoking, blood pressure, LDL and HDL levels), inflammation caused by some autoimmune states has been recognized as an independent risk factor for CV events.

Rheumatologists and other health care providers need to incorporate the notion of Rheumatic diseases as a CV risk factor into their practice. To that effect, The EULAR has released a list of 10 evidenced-based recommendations for cardiovascular risk management in rheumatic diseases:

1. RA should be regarded as a condition associated with higher risk for CV disease. This may also apply to AS and PsA, although the evidence base is less.
The increased risk appears to be due to both an increased prevalence of traditional risk factors and the inflammatory burden.

Comment: According to some publications, the CV mortality attributed to RA is as significant as diabetes. Inflammatory markers (at baseline and after treatment) are also independently linked to increased CV mortality.
Inflammation has been hypothesized to drive endothelial damage in autoimmune diseases.

2. Adequate control of disease activity is necessary to lower the CV risk (best evidence for anti-tumour necrosis factor treatment and methotrexate treatment)

Comment: Early and aggressive treatment with methotrexate and TNF alfa blockers lowers the added mortality from RA. When patients do not respond, this beneficial effect is less evident. Methotrexate may cause hyperhomocysteinemia by reducing folic acid levels and hyperhomocysteinemia has been regarded as a CV risk factor as well.
Folic acid supplementation is highly recommended to prevent this undesirable side effect.

3. CV risk assessment using national guidelines is recommended for all patients with RA and should be considered annually for all patients with AS and PsA. Risk assessments should be repeated when antirheumatic treatment has been changed (in absence of national guidelines the SCORE function model is recommended)

Comment (Not from EULAR):The American Heart Association online risk factor calculator is a very fast and easy to use tool. Link:

4. Risk score models should be adapted for patients with RA by introducing a 1.5 multiplication factor. This multiplication factor should be used when the patient with RA meets two of the following three criteria: ‣Disease duration of more than 10 years ‣RF or anti-CCP positivity ‣Presence of certain extra-articular manifestations

Comment: To factor in the added mortality caused by RA, the EULAR recommends multiplying the risk

assessment result by 1.5.

5. Total cholesterol/HDL cholesterol ratio should be used when the SCORE model is used

Comment: DMARDs, TNF blockers and even corticosteroid favorably affect lipid profiles in early RA treatment. Nevertheless, long term corticosteroids negatively affect metabolic profiles.

6. Intervention should be carried out according to national guidelines.
Comment: Thresholds to start treatment for hypertension and hyperlipidemia are similar to recommendations for the general population.

(Not from EULAR): RA patients typically present with atypical chest pain during coronary events. Having a lower lower threshold for ordering investigational studies (stress test, troponins, EKG and heart cath) is also recommended.

7. Statins, ACE-inhibitors and/or angiotensin II blockers are preferred treatment options due to their potential anti-inflammatory effects

8. The role of cyclo-oxygenase-2 inhibitors and most non-steroidal anti-inflammatory drugs in CV risk is not well established and needs further investigation. Hence, we should be very cautious about prescribing them, especially for patients with a documented CV disease or in the presence of CV risk factors

Comment: Most Rheumatologists already have this mindset due to the potential for life-threatening GI bleeds with long term NSAIDs and cox-2 inhibitors use

9. Corticosteroids: use the lowest dose possible

Comment: This is advisable not only for CV risk reduction but to prevent the myriad of side effects that corticosteroids may cause

10. Recommend smoking cessation

Comment: In addition to lowering CV risk, stop smoking may also increase the chances of achieving remission in RA.

Do you think it is realistic for Rheumatologists to take care of Internal Medicine problems in daily practice? Are these recommendations better accomplished by working in collaboration with Primary Care Physicians? Would Generalists like our interference in these areas?

Free Full Text Link:
EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis 2010;69:325-331

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