664306 research-article2016
TAB0010.1177/1759720X16664306Therapeutic Advances in Musculoskeletal DiseaseA Tournadre, S Mathieu
Therapeutic Advances in Musculoskeletal Disease
Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations
Review
Ther Adv Musculoskel Dis 2016, Vol. 8(5) 180–191 DOI: 10.1177/ 1759720X16664306 © The Author(s), 2016. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Anne Tournadre, Sylvain Mathieu and Martin Soubrier
Abstract: Patients with inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, have higher rates of cardiovascular mortality. While the increased cardiovascular risk is only explained to some extent, a lot of research is currently conducted to improve our understanding of its pathogenesis, risk stratification, and optimal cardiovascular risk management. This review sought to report epidemiological data pertaining to the cardiovascular disease burden in patients with inflammatory arthritis, underlying mechanisms accounting for excessive cardiovascular risk, along with recommendations regarding risk assessment and management in this patient population.
Keywords: cardiovascular risk, rheumatoid arthritis, spondyloarthritis
Introduction Rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) are inflammatory rheumatic diseases that have in common an increased cardiovascular (CV) mortality due to accelerated atherosclerosis. The full mechanisms resulting in CV risk excess are still to be clarified. Although standard CV risk factors may account for the majority of CV risks, they do not fully explain the CV risk excess observed in rheumatic diseases. Inflammation that both promotes atherogenesis and exacerbates established CV risk factors may partly explain this increased risk. Moreover, the treatments of rheumatic disease may potentially impact CV risk. Although CV risk management is key in order to decrease CV mortality, CV risk assessment in rheumatic diseases proves complex, and the prediction of CV mortality remains problematic. In this review, we sought to report epidemiological data regarding CV mortality and morbidity in both RA and spondyloarthritis (SpA). We then discussed the potential mechanisms resulting in increased CV risk, comprising standard risk factors and inflammation, along with their impact on lipid profiles. Lastly, the management of CV risk in rheumatic diseases was addressed, including CV risk assessment, along with the impact of rheumatic medications.
Literature search A thorough search of literature published between January 1966 and December 2015 was undertaken using the Medline database. For this search, the following Mesh terms were used: ‘arthritis, rheumatoid’, ‘spondylarthropathies’, ‘arthritis, psoriatic’, ‘spondylitis, ankylosing’, ‘mortality’, ‘cardiovascular diseases’, ‘atherosclerosis’, ‘lipids’, ‘hypertension’, ‘smoking’, and ‘therapeutics’.
Correspondence to: Martin Soubrier, MD, PhD Rheumatology Department, CHU Gabriel Montpied, 58 Rue Montalembert, F-63000 Clermont-Ferrand, France [email protected] Anne Tournadre, MD, PhD Sylvain Mathieu, MD, PhD Rheumatology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
Epidemiology of cardiovascular diseases in inflammatory arthritis Rheumatoid arthritis One-half of all deaths in RA are due to CV diseases [Aviña-Zubieta et al. 2008]. The CV mortality is increased by 50% and the risk of CV disease by 48% in the RA population compared with the general population [Aviña-Zubieta et al. 2012]. Increased mortality concerns both heart disease (68%) and cerebrovascular events (41%), affecting equally females and males [AviñaZubieta et al. 2008, 2012]. The highest CV mortality is observed in patients with long disease duration [Naz et al. 2008], rheumatoid factor or anti-CCP autoantibodies [Humphreys et al. 2014], and extra-articular manifestations [Gabriel et al. 2003]. RA itself is an independent CV risk factor that carries as much weight as diabetes
180 http://tab.sagepub.com
A Tournadre, S Mathieu et al. mellitus [Peters et al. 2009]. In the Danish nationwide study, the overall incidence rate ratio of myocardial infarction (MI) in RA was estimated at 1.7 [95% confidence interval (CI) 1.5–1.9], which is similar to that observed in diabetes mellitus [Lindhardsen et al. 2011]. Particularly, the risk was shown to be markedly raised in women 10%, documented CV disease), high CV risk (SCORE >5% and 1% and
TAB0010.1177/1759720X16664306Therapeutic Advances in Musculoskeletal DiseaseA Tournadre, S Mathieu
Therapeutic Advances in Musculoskeletal Disease
Managing cardiovascular risk in patients with inflammatory arthritis: practical considerations
Review
Ther Adv Musculoskel Dis 2016, Vol. 8(5) 180–191 DOI: 10.1177/ 1759720X16664306 © The Author(s), 2016. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Anne Tournadre, Sylvain Mathieu and Martin Soubrier
Abstract: Patients with inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, have higher rates of cardiovascular mortality. While the increased cardiovascular risk is only explained to some extent, a lot of research is currently conducted to improve our understanding of its pathogenesis, risk stratification, and optimal cardiovascular risk management. This review sought to report epidemiological data pertaining to the cardiovascular disease burden in patients with inflammatory arthritis, underlying mechanisms accounting for excessive cardiovascular risk, along with recommendations regarding risk assessment and management in this patient population.
Keywords: cardiovascular risk, rheumatoid arthritis, spondyloarthritis
Introduction Rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) are inflammatory rheumatic diseases that have in common an increased cardiovascular (CV) mortality due to accelerated atherosclerosis. The full mechanisms resulting in CV risk excess are still to be clarified. Although standard CV risk factors may account for the majority of CV risks, they do not fully explain the CV risk excess observed in rheumatic diseases. Inflammation that both promotes atherogenesis and exacerbates established CV risk factors may partly explain this increased risk. Moreover, the treatments of rheumatic disease may potentially impact CV risk. Although CV risk management is key in order to decrease CV mortality, CV risk assessment in rheumatic diseases proves complex, and the prediction of CV mortality remains problematic. In this review, we sought to report epidemiological data regarding CV mortality and morbidity in both RA and spondyloarthritis (SpA). We then discussed the potential mechanisms resulting in increased CV risk, comprising standard risk factors and inflammation, along with their impact on lipid profiles. Lastly, the management of CV risk in rheumatic diseases was addressed, including CV risk assessment, along with the impact of rheumatic medications.
Literature search A thorough search of literature published between January 1966 and December 2015 was undertaken using the Medline database. For this search, the following Mesh terms were used: ‘arthritis, rheumatoid’, ‘spondylarthropathies’, ‘arthritis, psoriatic’, ‘spondylitis, ankylosing’, ‘mortality’, ‘cardiovascular diseases’, ‘atherosclerosis’, ‘lipids’, ‘hypertension’, ‘smoking’, and ‘therapeutics’.
Correspondence to: Martin Soubrier, MD, PhD Rheumatology Department, CHU Gabriel Montpied, 58 Rue Montalembert, F-63000 Clermont-Ferrand, France [email protected] Anne Tournadre, MD, PhD Sylvain Mathieu, MD, PhD Rheumatology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
Epidemiology of cardiovascular diseases in inflammatory arthritis Rheumatoid arthritis One-half of all deaths in RA are due to CV diseases [Aviña-Zubieta et al. 2008]. The CV mortality is increased by 50% and the risk of CV disease by 48% in the RA population compared with the general population [Aviña-Zubieta et al. 2012]. Increased mortality concerns both heart disease (68%) and cerebrovascular events (41%), affecting equally females and males [AviñaZubieta et al. 2008, 2012]. The highest CV mortality is observed in patients with long disease duration [Naz et al. 2008], rheumatoid factor or anti-CCP autoantibodies [Humphreys et al. 2014], and extra-articular manifestations [Gabriel et al. 2003]. RA itself is an independent CV risk factor that carries as much weight as diabetes
180 http://tab.sagepub.com
A Tournadre, S Mathieu et al. mellitus [Peters et al. 2009]. In the Danish nationwide study, the overall incidence rate ratio of myocardial infarction (MI) in RA was estimated at 1.7 [95% confidence interval (CI) 1.5–1.9], which is similar to that observed in diabetes mellitus [Lindhardsen et al. 2011]. Particularly, the risk was shown to be markedly raised in women 10%, documented CV disease), high CV risk (SCORE >5% and 1% and
