Background Cardiovascular (CV) mortality in patients with rheumatoid arthritis (RA) is up to 50% higher than the general population. Whilst traditional CV risk factors such as smoking, diabetes and hypertension contribute to this increased mortality in RA, they do not fully explain the increase in risk. The British Society for Rheumatology, National Institute for Health and Clinical Excellence and European League Against Rheumatism (EULAR) recommend annual assessment of CV risk in RA patients. Furthermore, EULAR recommends multiplying such traditional CV risk scores by 1.5 for RA patients who meet two of three criteria consisting of (1) disease duration >10 years, (2) positive rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) serology, (3) presence of severe extra-articular manifestation, to account for the unexplained increased CV risk in RA.
Objectives This study assessed CV risk by QRISK2 score and used carotid ultrasound to determine cardiovascular risk and prevalence of subclinical atherosclerosis at the time of diagnosis of RA.
Methods Patients ≥18 years-old with early RA, defined by ACR/EULAR 2010 criteria and diagnosis of RA <6 months were recruited from The University Hospital of Wales, Cardiff. Exclusion criteria included definite other autoimmune or inflammatory rheumatic disease, ACR Classification of Functional Status stage IV, previous history of CV disease and diabetes mellitus. Demographic details were collected, blood pressure, body mass index, ESR, CRP and lipid profile were measured and QRISK2 was calculated. Carotid ultrasound was performed and mean carotid intima media thickness (CIMT) and presence of plaque were measured. The study was approved by Research Ethics Committee for Wales (11/WA/0326).
Results 40 patients, 10 males and 30 females with early RA were recruited. Mean age was 55.7±14.8 years. Rheumatoid factor and anti-CCP antibodies were positive in 62% and 80% of patients respectively. Mean BMI was 27.2±5.9. Twenty-nine percent were current smokers. Mean DAS28 was 3.8±1.3. According to the QRISK2, 54% of patients had >10% risk of CV disease over 10 years. Carotid ultrasound was conducted in 35 patients. Mean CIMT was 0.71±0.19 mm. 10 patients (29%) had carotid plaques. Fourteen patients (40%) had either plaque or CIMT >0.9mm, both considered markers of high CV risk. These patients were termed “ultrasound positive” patients. The sensitivity and specificity of the QRISK2 to predict US positive patients was 82% and 56% respectively. The positive predictive value of the QRISK2 was 63% and the negative predictive value of the QRISK2 was 88%. No patients met >1 criteria for EULAR adjustment of risk as all patients had early RA and none had severe extra-articular manifestations.
Conclusions Many patients with early RA have significant CV disease at the time of diagnosis. This suggests subclinical CV disease may be developing before patients become symptomatic. More than half of the patients with early RA fulfil current NICE guidelines for starting lipid-lowering therapy, although of these, over one-third had no subclinical disease on carotid ultrasound. There is scope to improve the sensitivity and specificity of the QRISK2 calculation in RA patients, perhaps with a biomarker.
Acknowledgements This work was funded by Arthritis Research UK, grant number 20760
Disclosure of Interest None declared
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