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Extended report
Response to biological treatment and subsequent risk of coronary events in rheumatoid arthritis
  1. Lotta Ljung1,2,
  2. Solbritt Rantapää-Dahlqvist2,
  3. Lennart T H Jacobsson3,
  4. Johan Askling1,4,
  5. for the ARTIS Study Group
  1. 1Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
  2. 2Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
  3. 3Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
  4. 4Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
  1. Correspondence to Dr Lotta Ljung, Department of Rheumatology, University Hospital, Umeå SE-901 87, Sweden; lotta.ljung{at}


Objectives Whether the increased risk of comorbidities, such as cardiovascular disease, in rheumatoid arthritis (RA) can be reverted by particular antirheumatic therapies, or response to these, is unclear but of critical clinical importance. We wanted to investigate whether response to tumour necrosis factor inhibitors (TNFi) translates into a reduced risk for acute coronary syndrome (ACS).

Methods A cohort of patients with RA initiating a first TNFi 2001–2012 was identified in the Swedish Biologics Register. The association between European League Against Rheumatism (EULAR) response after 3–8 months of treatment (assessed using the first, the best and the measurement closest to 5 months, respectively), and the risk of incident ACS during the subsequent year was analysed in Cox regression models. Adjustments included cardiovascular risk factors, joint surgery, RA duration, education and work disability.

Results During 6592 person-years among TNFi initiators (n=6864, mean age 55 years, 77% women), 47 ACS occurred. The adjusted HRs (95% CI), which were similar to the crude HRs, of the 1-year risk of ACS among EULAR good responders compared with non-responders were 0.5 (0.2 to 1.4), 0.4 (0.2 to 0.9) and 0.5 (0.2 to 1.2), for the first, the best and the evaluation closest to 5 months, respectively. EULAR moderate responders had equal risk to that of EULAR non-responders, who, compared with the general population referents (n=34 229), had a more than twice the risk of ACS. For good responders, there was no statistically significant difference in risk versus the general population.

Conclusions Optimised RA disease control has the potential to revert otherwise increased risks for ACS in RA.

  • Rheumatoid Arthritis
  • DMARDs (biologic)
  • Cardiovascular Disease

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  • Handling editor Tore K Kvien

  • Collaborators The Anti-Rheumatic Therapy in Sweden (ARTIS) Study Group conducts scientific analyses using data from the Swedish Biologics Register. It also safeguards the quality and handling of the nationwide data collected. The following are the members of the ARTIS Study Group: Johan Askling, Lars Klareskog and Ronald van Vollenhoven (Karolinska Institutet, Stockholm, Sweden); Eva Baecklund (Uppsala University, Uppsala, Sweden); Alf Kastbom (Linköping University, Linköping, Sweden); Lennart Jacobsson (Sahlgrenska Academy, Gothenburg, Sweden); Carl Turesson and Elisabeth Lindqvist (Lund University, Malmö and Lund, Sweden); Solbritt Rantapää-Dahlqvist and Helena Forsblad-d'Elia (Umeå University, Umeå, Sweden); Nils Feltelius (Chairman of the Medical Products Agency, Sweden) and Sofia Ernestam (Register Holder, Swedish Rheumatology Quality Register, Sweden).

  • Contributors All authors have made substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content and final approval of the version to be published.

  • Funding This study was supported by grants from the Swedish Research Council (K2013-52X-20307-07-3 and K2008-52X-20611-01-3), the Swedish Rheumatism Association, King Gustav V's 80-Year Foundation, the Västerbotten and Stockholm County Councils, the Swedish Heart-Lung Foundation, the Swedish Foundation for Strategic Research and the Swedish public-private COMBINE research consortium ( The ARTIS Study Group conducts scientific analyses using data from the Swedish Biologics Register ARTIS run by the Swedish Society for Rheumatology. ARTIS has entered into agreements with Abbvie, BMS, MSD, Pfizer, Roche and UCB.

  • Competing interests None declared.

  • Ethics approval The Stockholm Ethics Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.