Patients with rheumatoid arthritis (RA) (and other inflammatory joint diseases (IJD)) have an increased cardiovascular (CV) risk that, for RA, is comparable to that of diabetes. Therefore, screening, identification of CV risk factors and cardiovascular risk management (CV-RM) was recommended by the EULAR task force in 2009. Our recommendation in 2009 regarding the multiplication factor of 1.5 was derived mainly from relevant Standardized Mortality Ratios and was, to a large extent, empiric because information from large-scale prospective cohort studies was lacking. Our research agenda of 2009 determined that the multiplication factor of 1.5 should be revisited as better evidence became available potentially leading to a distinct approach to devising numerical adjustment factors. For instance, the QRISK2-2013, risk score based on routinely collected data from GPs across the UK, now includes RA as a risk factor with a hazard ratio of approximately 1.4. Furthermore, several RA-specific risk model are presently developed.
Research Objectives 1) To review the presently available RA-specific cardiovascular risk prediction models and give evidence based advice about the most appropriate model(s), as well as on adjusting risk models for the general population so that they that can be used in patients IJD.
2a) To assess the value of imaging techniques for either improvement of CV risk prediction models, and b) give advice whether routine screening with echocardiography is necessary or routine screening before biologic therapy is initiated.
3) To give recommendations about lipid assessment, lipid lowering treatment and treatment targets, with specific attention for tocilizumab and rituximab and the possible interaction between statins and efficacy of rituximab.
4) To give recommendations about life style modifications.
5) To conduct a systematic literature update to a) determine the cardiovascular risk in AS and PsA and b) describe whether or not there is enough evidence to adapt the existing cardiovascular risk models for a more precise cardiovascular risk estimation in AS and PsA.
6) To update the previous recommendation about NSAID/COXIB use in patients IJD as well as other drugs such as corticosteroids, vitamin D and aspirin.
Preliminary results 1) Validated RA-specific CV-risk models have not yet been published, hence the adjustment of existing risk models is still recommended
2) There are some suggestions that (imaging) biomarkers might improve risk prediction models. However, there are some practical constraints for implementation. Echocardiographic screening before initiation of biologic treatment is not recommended.
3) Statins are at least equally effective in RA patients when compared to non-RA controls. Statins do not influence rituximab efficicacy.
4) Exercise should be part of RA management, both to lower CV risk and improve disease outcomes.
5) There is now more evidence-base for an increased CV-risk in patients with AS and PsA that is comparable to RA, hence from this point of view CV-RM should be similar. Systemic inflammation enhances CV risk and adequate control of disease activity is necessary to reduce this CV risk. Cumulative disease activity counts more than disease duration per se.
6) Current evidence does not support a strong association between NSAIDs and CVD in patients with RA. The use of aspirin for the primary prevention of cardiovascular events in patients with IJD is not recommended.
Conclusions The present update confirms and further extends the evidence that the CV-risk in IJD is increased. This underscores the need for CV-RM in these patients. As these updated recommendations are now based on a pan-European consensus it is expected that they will facilitate CV-RM in daily clinical practice.
Disclosure of Interest None declared
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