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• Parental and propositus cardiovascular disease in individuals with rheumatoid arthritis
  Bruce M Rothschild
  Published on: 20 July 2006

• Published on: 20 July 2006

  Parental and propositus cardiovascular disease in individuals with rheumatoid arthritis

  • Bruce M Rothschild, Professor of Medicine, Rheumatology

  Dear Editor,

  The article by Björnådal et al.[1] addresses an issue which has become increasingly recognized in the past decade.[2-4] They took a somewhat unique approach, examining cause of parental death. The authors[1] are to be congratulated for excluding individuals with alternative (to rheumatoid arthritis) discharge diagnoses, recognizing the 'lumping' character of the current ACR criteria[5] and partially ob...

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  Dear Editor,

  The article by Björnådal et al.[1] addresses an issue which has become increasingly recognized in the past decade.[2-4] They took a somewhat unique approach, examining cause of parental death. The authors[1] are to be congratulated for excluding individuals with alternative (to rheumatoid arthritis) discharge diagnoses, recognizing the 'lumping' character of the current ACR criteria[5] and partially obviating the lumping problem.[6]

  As I personally record familial evidence of cardiac disease rather than mortality, this article by Björnådal et al.[1] would stimulate a modification of my approach - should their work be extrapolatable to clinical outpatient practice. However, it is not clear that the group studied by Björnådal et al.[1] is representative of general rheumatologic practice. Perhaps it is representative of those individuals who required hospitalization for their disease or for a concurrent, incidental disorder.

  Several additional caveats must also be considered. We do not know what biases were created by excluding individuals with absence of full parental information, which accounted for 25% of discharged rheumatoid patients in their study. This is similar to the 25% missing observations that Björnådal et al.[1] cited as problematic for interpretation of the work of Maradit-Kremers et al.[7] It would be intriguing to learn if missing data would reveal differential characteristics of rheumatoid patients incurring cardiovascular deaths. It also would be of interest to learn of the criteria for adjucation of deaths as cardiovascular, given the notoriety of death certificates.

  Cardiovascular mortality is of concern in rheumatoid arthritis and perhaps even paradoxical, given the anti-thrombotic / cardioprotective effects attributed to some COX-1 agents,[8,9] although steroid use may be the pertinent factor? It would have been of great interest to examine differential NSAID, steroid, and of course aspirin use between the groups. Does aspirin make a difference, and do steroids modify/compromise any related benefit?

  Most good research elicits more questions than it answers. The study by Björnådal et al.[1] raises a number of intriguing questions, which I hope will be answered by further analysis of their data base.

  References

  1 Björnådal L, Brandt L, Klareskog L, Askling J. Impact of parental history on patients’ cardiovascular mortality in rheumatoid arthritis. Ann Rheum Dis 2006;65:741-5.

  2 Callahan LF, Pincus T. Mortality in the rheumatic diseases. Arthritis Care Res 1995;8:229-41.

  3 Björnådal L, Baecklund E, Yin L, Granath F, Klareskog L, Ekbom A. Decreasing mortality in patients with rheumatoid arthritis: Results from a large population based cohort in Sweden, 1964-95. J Rheumatol 2002;29:906 -12.

  4 Solomon DH, Karlson EW, Rimm EB, Cannuscio CC, Mandl LA, Manson JE et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthrritis. Circulation 2003;107:1303-7.

  5 Arnett FC, Edworth SM, Bloch DA. The American Rheumatism Association revised criteria for the calssification of rheumatoid arthr4itis. Arthritis Rheum 1988;31:315-24.

  6 Rothschild BM. Two faces of “rheumatoid arthritis”: Type A versus type B disease. J Clin Rheumatol 1997;3:334-8.

  7 Maradit-Kremers H, Crowson CS, Nicola PJ, Ballman KV, Roger VL, Jacobsen SJ, et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: A population-based cohort study. Arthritis Rheum 2005;52:402-11.

  8 Watson DJ, Rhodes T, Cai B, Guess HA. Lower risk of thromboembolic cardiovascular events with naproxen among patients with rheumatoid arthritis. Arch Intern Med 2002;162:1105-10

  9 Rahme E, Pilote L, Lelorier J. Association between naproxen use and protection against myocardial infarction. Arch Intern Med 2002;162:1111-5.

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  Conflict of Interest:
  None declared.

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