Clin Rheumatol DOI 10.1007/s10067-014-2522-5
ORIGINAL ARTICLE
The role of rheumatologists vis-à-vis assessment of traditional cardiovascular risk factors in rheumatoid arthritis Yael Luck & Murray Baron & Sonia Bardakjian & Laeora Berkson & Maura Buchignani & Sabrina Fallavolita & Frédérique Giac & Geneviève Gyger & Solène Tatibouet & Marie Hudson
Received: 17 October 2013 / Revised: 20 January 2014 / Accepted: 29 January 2014 # Clinical Rheumatology 2014
Abstract This study was designed to estimate the burden of care that would be placed on rheumatologists to undertake cardiovascular (CV) risk assessment of traditional CV risk factors in their patients. This cross-sectional study was set in a rheumatology ambulatory clinic of a tertiary care, university hospital. Consecutive rheumatoid arthritis (RA) patients were recruited over 6 weeks and matched 1:1 on age and sex to patients with non-inflammatory problems who presented to the same clinic. CV risk was calculated using the Framingham Risk Score. We recruited 68 RA patients and 64 controls. The distribution of CV risk factors in RA patients and controls was similar. Ten-year Framingham CV risk scores based on traditional risk factors were moderate and similar in RA patients and controls (13.7 and 14.3 %, respectively). Nevertheless, the proportion of RA patients with a history of coronary artery disease was more than twice that of controls (13 versus 5 %, respectively). Approximately 20 % of RA patients and controls did not have a primary care physician. In rheumatology practice, the problem of elevated CV risk due to traditional risk factors is not unique to RA patients. The burden for rheumatologists of undertaking CV risk assessment in their clinic could be considerable. Rheumatologists should manage inflammatory disease and health services should be improved Y. Luck : M. Baron : L. Berkson : S. Fallavolita : G. Gyger : M. Hudson Faculty of Medicine, McGill University, Montréal, Québec, Canada M. Baron : L. Berkson : M. Buchignani : S. Fallavolita : G. Gyger : M. Hudson Division of Rheumatology, Jewish General Hospital, Montréal, Québec, Canada M. Baron : S. Bardakjian : F. Giac : S. Tatibouet : M. Hudson (*) Lady Davis Institute for Medical Research, Jewish General Hospital, Room A-725, 3755 Cote Ste Catherine Road, Montreal, Québec H3T 1E2, Canada e-mail: [email protected]
to ensure the optimal management of traditional CV risk factors for all rheumatology patients. Keywords Cardiovascular disease . Rheumatoid arthritis . Screening Rheumatoid arthritis (RA) is a chronic autoimmune disease characterised by inflammatory arthritis, joint destruction and disability. It affects 0.5–1 % of the population, with a female to male ratio of 2:1 and a peak age of onset of 50 years of age [1]. RA is associated with high morbidity, including physical and work-related disability, and increased mortality, predominantly due to accelerated coronary artery and cerebrovascular disease [2]. Indeed, cardiovascular (CV) events occur approximately a decade earlier in RA than in the general population [3], suggesting that RA, similarly to diabetes mellitus, is a possible risk factor for premature CV disease [4, 5]. The increased CV risk in RA appears to be due to both the inflammatory burden and traditional risk factors [2, 6]. Thus, in addition to achieving adequate control of disease activity, it has been recommended that rheumatologists undertake CV risk assessment and management in RA patients according to national guidelines [7]. Aspirin, statins, ACE inhibitors and angiotensin II blockers have proven efficacy to treat CV risk factors. In addition, they are also known to have a favourable effect on platelet function, inflammatory markers and endothelial function in RA. Hence, these agents have been recommended as preferred treatment options in RA, when indicated [7]. Finally, patients should be counselled concerning smoking cessation using best evidence methods. However, there is considerable debate among rheumatologists over these recommendations [8]. Among the points at issue is that some believe that rheumatologists do not have the time or the expertise to undertake CV risk assessment and management among their RA patients. Rather, rheumatologists
Clin Rheumatol
should be responsible for managing inflammatory disease and traditional CV risk assessment and management should be the responsibility of primary care physicians (PCP). Others argue that this is problematic, however, because many patients may not have a PCP or, among those who do, PCP may not be aware of the increased CV risk in RA and the preferred treatment options [9]. In part, this particular debate revolves around the magnitude of the task for rheumatologists to undertake the additional responsibility of assessing CV risk in their RA patients. However, little data is available on how many RA patients in routine clinical practice are at increased CV risk. This study was undertaken to estimate the magnitude of the task for rheumatologists to undertake CV risk assessment in RA patients. We aimed to measure how many RA patients in routine rheumatology clinical practice would be at increased CV risk using the Framingham Risk Score.
Methods Study design We designed a cross-sectional study of consecutive RA patients and control subjects presenting to a tertiary care, academic, ambulatory rheumatology clinic (Jewish General Hospital, Montreal, Canada). Study subjects
scored on a scale ranging from 0 to 10) [10] and a rheumatologist completed a global assessment of disease activity using a numerical rating scale ranging from 0 to 10. Blood pressure, height and weight were measured by a research assistant on all study subjects. Fasting lipid profiles and blood glucose, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies were measured in a clinical laboratory using commercial assays. CV risk was calculated u s i n g t h e F r a m i n g h a m R i s k S c o r e ( h t tp : / /w w w. framinghamheartstudy.org/risk/hrdcoronary.html ), which measures 10-year risk of major CV events (fatal and nonfatal) based on the following: age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, diabetes and smoking status. As recommended by the EULAR guidelines, to account for the increased CV risk in RA, the CV risk estimate of those study subjects was multiplied by 1.5 if at least two of the following criteria were present: disease duration of more than 10 years, RF and/or anti-CCP positivity, and the presence of severe extraarticular manifestations. Primary outcome measure The primary outcome was the proportion of RA patients at moderate or high CV risk according to the Framingham Risk Score and who did not have regular access to a PCP to identify this excess risk.
RA patients were eligible for the study if they (1) had a diagnosis of RA confirmed by a rheumatologist, (2) were ≥18 years of age, (3) were fluent in either English or French and (4) were on a disease-modifying anti-rheumatic drug or a biologic agent. Controls were recruited from the same clinic and sampled to be of similar age and sex as the RA patients. Controls were eligible if they had a diagnosis of noninflammatory arthritis (e.g. osteoarthritis) or soft tissue musculoskeletal problem (e.g. tendonitis, bursitis) confirmed by a rheumatologist. Research ethics approval for this study was obtained from the ethics review board of the Jewish General Hospital, Montreal, Canada, and all study subjects signed an informed, written consent to participate.
Statistical analysis
Study measures
Over a 6-week period, 68 RA and 64 control patients were recruited, found to be eligible, agreed to participate and completed the study protocol. Baseline characteristics were similar in RA subjects and controls: mean age 60±14 versus 59± 15 years, 74 versus 73 % female, and 66 versus 77 % White, respectively (Table 1). Approximately 20 % of RA patients and controls did not have a PCP. RA patients had a median disease duration of 6.7±7.5 years, a mean physician global assessment of 1.8±2.4 (on a scale of 0–10), and a RADAI score of 3.4±2.3 (on a scale of 0–10). The majority were
Detailed clinical histories, physical measures and lab tests were collected using standardised case report forms. Sociodemographic characteristics, smoking status, medical history (including co-morbidities and family history), current medications, accessibility to a PCP and function (measured using the Health Assessment Questionnaire) were collected by patient self-reports. In addition, RA subjects also completed the Rheumatoid Arthritis Disease Activity Index (RADAI;
Descriptive statistics were used to summarise the characteristics of the RA and control subjects. Logistic regression was performed to determine the relationship between RA and CAD, adjusted for ethnicity (White versus non-White), hypertension, hypercholesterolemia and current smoking. pvalues
ORIGINAL ARTICLE
The role of rheumatologists vis-à-vis assessment of traditional cardiovascular risk factors in rheumatoid arthritis Yael Luck & Murray Baron & Sonia Bardakjian & Laeora Berkson & Maura Buchignani & Sabrina Fallavolita & Frédérique Giac & Geneviève Gyger & Solène Tatibouet & Marie Hudson
Received: 17 October 2013 / Revised: 20 January 2014 / Accepted: 29 January 2014 # Clinical Rheumatology 2014
Abstract This study was designed to estimate the burden of care that would be placed on rheumatologists to undertake cardiovascular (CV) risk assessment of traditional CV risk factors in their patients. This cross-sectional study was set in a rheumatology ambulatory clinic of a tertiary care, university hospital. Consecutive rheumatoid arthritis (RA) patients were recruited over 6 weeks and matched 1:1 on age and sex to patients with non-inflammatory problems who presented to the same clinic. CV risk was calculated using the Framingham Risk Score. We recruited 68 RA patients and 64 controls. The distribution of CV risk factors in RA patients and controls was similar. Ten-year Framingham CV risk scores based on traditional risk factors were moderate and similar in RA patients and controls (13.7 and 14.3 %, respectively). Nevertheless, the proportion of RA patients with a history of coronary artery disease was more than twice that of controls (13 versus 5 %, respectively). Approximately 20 % of RA patients and controls did not have a primary care physician. In rheumatology practice, the problem of elevated CV risk due to traditional risk factors is not unique to RA patients. The burden for rheumatologists of undertaking CV risk assessment in their clinic could be considerable. Rheumatologists should manage inflammatory disease and health services should be improved Y. Luck : M. Baron : L. Berkson : S. Fallavolita : G. Gyger : M. Hudson Faculty of Medicine, McGill University, Montréal, Québec, Canada M. Baron : L. Berkson : M. Buchignani : S. Fallavolita : G. Gyger : M. Hudson Division of Rheumatology, Jewish General Hospital, Montréal, Québec, Canada M. Baron : S. Bardakjian : F. Giac : S. Tatibouet : M. Hudson (*) Lady Davis Institute for Medical Research, Jewish General Hospital, Room A-725, 3755 Cote Ste Catherine Road, Montreal, Québec H3T 1E2, Canada e-mail: [email protected]
to ensure the optimal management of traditional CV risk factors for all rheumatology patients. Keywords Cardiovascular disease . Rheumatoid arthritis . Screening Rheumatoid arthritis (RA) is a chronic autoimmune disease characterised by inflammatory arthritis, joint destruction and disability. It affects 0.5–1 % of the population, with a female to male ratio of 2:1 and a peak age of onset of 50 years of age [1]. RA is associated with high morbidity, including physical and work-related disability, and increased mortality, predominantly due to accelerated coronary artery and cerebrovascular disease [2]. Indeed, cardiovascular (CV) events occur approximately a decade earlier in RA than in the general population [3], suggesting that RA, similarly to diabetes mellitus, is a possible risk factor for premature CV disease [4, 5]. The increased CV risk in RA appears to be due to both the inflammatory burden and traditional risk factors [2, 6]. Thus, in addition to achieving adequate control of disease activity, it has been recommended that rheumatologists undertake CV risk assessment and management in RA patients according to national guidelines [7]. Aspirin, statins, ACE inhibitors and angiotensin II blockers have proven efficacy to treat CV risk factors. In addition, they are also known to have a favourable effect on platelet function, inflammatory markers and endothelial function in RA. Hence, these agents have been recommended as preferred treatment options in RA, when indicated [7]. Finally, patients should be counselled concerning smoking cessation using best evidence methods. However, there is considerable debate among rheumatologists over these recommendations [8]. Among the points at issue is that some believe that rheumatologists do not have the time or the expertise to undertake CV risk assessment and management among their RA patients. Rather, rheumatologists
Clin Rheumatol
should be responsible for managing inflammatory disease and traditional CV risk assessment and management should be the responsibility of primary care physicians (PCP). Others argue that this is problematic, however, because many patients may not have a PCP or, among those who do, PCP may not be aware of the increased CV risk in RA and the preferred treatment options [9]. In part, this particular debate revolves around the magnitude of the task for rheumatologists to undertake the additional responsibility of assessing CV risk in their RA patients. However, little data is available on how many RA patients in routine clinical practice are at increased CV risk. This study was undertaken to estimate the magnitude of the task for rheumatologists to undertake CV risk assessment in RA patients. We aimed to measure how many RA patients in routine rheumatology clinical practice would be at increased CV risk using the Framingham Risk Score.
Methods Study design We designed a cross-sectional study of consecutive RA patients and control subjects presenting to a tertiary care, academic, ambulatory rheumatology clinic (Jewish General Hospital, Montreal, Canada). Study subjects
scored on a scale ranging from 0 to 10) [10] and a rheumatologist completed a global assessment of disease activity using a numerical rating scale ranging from 0 to 10. Blood pressure, height and weight were measured by a research assistant on all study subjects. Fasting lipid profiles and blood glucose, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies were measured in a clinical laboratory using commercial assays. CV risk was calculated u s i n g t h e F r a m i n g h a m R i s k S c o r e ( h t tp : / /w w w. framinghamheartstudy.org/risk/hrdcoronary.html ), which measures 10-year risk of major CV events (fatal and nonfatal) based on the following: age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, diabetes and smoking status. As recommended by the EULAR guidelines, to account for the increased CV risk in RA, the CV risk estimate of those study subjects was multiplied by 1.5 if at least two of the following criteria were present: disease duration of more than 10 years, RF and/or anti-CCP positivity, and the presence of severe extraarticular manifestations. Primary outcome measure The primary outcome was the proportion of RA patients at moderate or high CV risk according to the Framingham Risk Score and who did not have regular access to a PCP to identify this excess risk.
RA patients were eligible for the study if they (1) had a diagnosis of RA confirmed by a rheumatologist, (2) were ≥18 years of age, (3) were fluent in either English or French and (4) were on a disease-modifying anti-rheumatic drug or a biologic agent. Controls were recruited from the same clinic and sampled to be of similar age and sex as the RA patients. Controls were eligible if they had a diagnosis of noninflammatory arthritis (e.g. osteoarthritis) or soft tissue musculoskeletal problem (e.g. tendonitis, bursitis) confirmed by a rheumatologist. Research ethics approval for this study was obtained from the ethics review board of the Jewish General Hospital, Montreal, Canada, and all study subjects signed an informed, written consent to participate.
Statistical analysis
Study measures
Over a 6-week period, 68 RA and 64 control patients were recruited, found to be eligible, agreed to participate and completed the study protocol. Baseline characteristics were similar in RA subjects and controls: mean age 60±14 versus 59± 15 years, 74 versus 73 % female, and 66 versus 77 % White, respectively (Table 1). Approximately 20 % of RA patients and controls did not have a PCP. RA patients had a median disease duration of 6.7±7.5 years, a mean physician global assessment of 1.8±2.4 (on a scale of 0–10), and a RADAI score of 3.4±2.3 (on a scale of 0–10). The majority were
Detailed clinical histories, physical measures and lab tests were collected using standardised case report forms. Sociodemographic characteristics, smoking status, medical history (including co-morbidities and family history), current medications, accessibility to a PCP and function (measured using the Health Assessment Questionnaire) were collected by patient self-reports. In addition, RA subjects also completed the Rheumatoid Arthritis Disease Activity Index (RADAI;
Descriptive statistics were used to summarise the characteristics of the RA and control subjects. Logistic regression was performed to determine the relationship between RA and CAD, adjusted for ethnicity (White versus non-White), hypertension, hypercholesterolemia and current smoking. pvalues
