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Could cardiovascular disease risk stratification and management in rheumatoid arthritis be enhanced?
  1. Patrick H Dessein1,
  2. Anne G Semb2
  1. 1Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  2. 2Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  1. Correspondence to Professor Patrick Dessein, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, PO Box 1012, Melville 2109, Johannesburg, South Africa; dessein{at}telkomsa.net

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The markedly enhanced risk of atherosclerotic cardiovascular disease (CVD) in rheumatoid arthritis (RA) is well documented.1 ,2 This prompted a European League Against Rheumatism (EULAR) task force to make a commendable effort in producing recommendations for cardiovascular risk management in patients with inflammatory arthritis.3 These included the application of the systematic coronary risk evaluation score (SCORE), a multiple major traditional risk factor assessment equation. In addition, the EULAR task force recommended applying a multiplier of 1.5 in patients with RA that met 2 of 3 criteria consisting of (1) a disease duration >10 years, (2) rheumatoid factor or anticyclic citrullinated peptide positivity and (3) the presence of extra-articular manifestation, thereby creating the modified (m) SCORE.

Risk factor assessment algorithms, including the SCORE and the Framingham risk equation, are recommended worldwide as part of CVD risk management in the population at large.4 ,5 These equations allow for stratifying subjects into low, intermediate, high and very high risk groups. With regard to CVD risk management, lifestyle factors should be addressed in all individuals. The use of cardiovascular drugs, particularly antihypertensive and lipid-lowering agents should be considered in those at high or very high risk as these interventions markedly reduce CVD event rates in such persons. Patients with established CVD, diabetes and chronic kidney disease are at high or very high risk and hence, risk factor equation application is not indicated.

Nonetheless, approximately a third of CVD events are not attributable to major CVD risk factors.6 Congruent with this, although multiple risk factor equations are useful in determining the overall CVD risk among different populations, they often underestimate the actual risk in individual subjects. This is particularly evident in those who are at moderate risk according to major risk factor assessment equations.4 ,5 Consequently, based on …

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