In this issue of the Annals of the Rheumatic Diseases, Munro and colleagues¹ report a comparative study of intramuscular gold and hydroxychloroquine in rheumatoid arthritis (RA). They demonstrate a beneficial effect of hydroxychloroquine on lipid profiles compared with gold and suggest that hydroxychloroquine might be considered for RA patients at adverse cardiovascular risk.

Should rheumatologists be interested in their patients’ cardiovascular and lipid status? The answer to this question is an unqualified ‘yes’. Several studies suggest that cardiovascular diseases account for about half of all deaths in RA.2 Cardiovascular deaths are more pronounced in the younger age group (<55 years), and may contribute to the substantial reduction in life expectancy, with estimates of standardised mortality ratios ranging from 1.1 to 3.3

We previously suggested that cardiovascular disease in RA may result from accelerated atherosclerosis caused by clinical or subclinical vasculitis.4 The main determinants of cardiovascular risk in the general population, however, are the concentrations of serum low density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol. In men who are middle aged or over, a ratio of total to HDL cholesterol over 5 associates with increased risk of a first myocardial infarction.5 Oxidative modification of LDL may also be important and it is of interest that oxidised LDL has been noted in RA synovial biopsy specimens.6 Products of LDL oxidation may be recognised …