—Rheumatoid arthritis (RA) patients have nearly double the myocardial infarction (MI) risk of patients with noninflammatory rheumatic disorders. What’s more, the increased risk is due to RA-specific factors and to the effects of corticosteroid use, according to Frederick Wolfe, MD, and Kaleb Michaud, PhD, of the National Data Bank for Rheumatic Diseases in Wichita, Kansas. Their findings appear in the September issue of Arthritis & Rheumatism.1
Cohort study included >20,000 patients
The new cohort study comprised 17,738 patients with RA and 3001 patients with noninflammatory rheumatic disorders but who had suffered a heart attack. Participants were assessed at 6-month intervals between 1999 and July 2006. The investigators found that the risk of first MI in RA versus that in noninflammatory rheumatic disorders was 1.9 (P = .005).
MI risk was predicted by age, sex, education level, hypertension, smoking, exercise, prior MI, diabetes, number of comorbid conditions, use of low-dose aspirin and antilipemic agents, RA severity and treatment variables, and corticosteroid use among RA patients. MI predictors were balanced in RA and noninflammatory rheumatic disorders except for obesity, the study showed. Lifetime smoking was 24% more common among RA patients than their counterparts with noninflammatory rheumatic diseases.
Corticosteroid connection
Moreover, the increased risk for MI in RA compared with that in noninflammatory rheumatic disorders lessened when corticosteroid users were excluded. Use of corticosteroids was associated with future development of diabetes and hypertension. Corticosteroids are often reserved for people with severe RA, which is in turn associated with heart risks, the researchers explained.
“The risk associated with corticosteroids is partially a severity risk and partially a treatment risk. Study data support the hypothesis that RA activity causes MI and that corticosteroids are primarily a marker of RA activity. However, corticosteroids increase the risk of diabetes and hypertension, and contribute to the overall risk of MI.”The researchers did not find any cardioprotective effect associated with the use of TNF-blockers.
Translating research into practice
Daniel H. Solomon, MD, MPH, an associate physician at Brigham and Women's Hospital in Boston, has published a great deal on how RA and its treatments affect the heart.
Looking at the weight of the available evidence “we should work to manage traditional risk factors such as hypertension, elevated lipids, [and] tobacco use, but we should also work on inflammation,” Dr. Solomon told MSKreport.com. He noted that the effect of TNF-blockers on MI risk in patients with RA is still under investigation.
“We have a poster at [the upcoming American College of Rheumatology meeting] suggesting a significant decrease in cardiovascular risk among patients on TNF-[blockers] compared with nonbiologic, nonmethotrxate disease-modifying antirheumatic drugs. But until we have trial data, the jury will be out,” Dr. Solomon said.
Reference 1. Wolfe F, Michaud K. The risk of myocardial infarction and pharmacologic and nonpharmacologic myocardial infarction predictors in rheumatoid arthritis: A control and nested case control analysis. Arthritis Rheum. 2008;58:2612-2621.
And here I thought you were talking about the MI AI vortex.