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Cardiovascular co-morbidity in early rheumatoid arthritis

https://doi.org/10.1016/j.berh.2008.11.007Get rights and content

Rheumatoid arthritis (RA) is associated with increased morbidity and mortality due to cardiovascular disease (CVD), mostly accelerated atherosclerotic CVD, and there is evidence that this occurs early in the inflammatory disease process. Both traditional and novel CVD risk factors as well as the effects of the RA disease process and its treatment interact and contribute to the development of CVD in RA. In this review we discuss the evidence for co-morbid CVD complicating early RA. This includes examining studies of mortality outcome and CVD events in cohorts of early RA patients as well as studies using surrogate markers for atherosclerotic CVD in RA. The evidence for shared risk factors for RA and CVD is presented. Screening and modification of CVD risk factors should be an integral part of care for any patient diagnosed with RA. Novel methods to diagnose CVD in high-risk asymptomatic RA patients need to be evaluated.

Section snippets

Cardiovascular disease co-morbidity in established RA

Rheumatoid arthritis is associated with heart disease. Pericardial disease, including pericarditis and pericardial effusions, have long been identified as extra-articular manifestations of RA and were first described by Charcot in 1881 [5]. The true prevalence of pericardial disease in association with RA is difficult to determine as it often remains clinically silent. Echocardiographic studies in established cohorts of RA patients have reported prevalence rates of pericardial disease between 1

What is early RA?

The definition of early RA is not always easy as the 1987 ACR classification criteria were derived from study of patients with established disease [48] and have not been found to be discriminatory at symptom onset [49]. For patients presenting with recent-onset inflammatory polyarthritis (IP) or undifferentiated inflammatory arthritis, it has been suggested that the patient should not be immediately classified but observed [50]. Experience in early arthritis clinics, such as the Leiden early

What is the evidence for CVD events or CVD risk factors prior to RA?

Retrospectively exploring medical records back to aged 18 years of all 603 patients in the Rochester RA incidence cohort revealed that in the 2-year period prior to fulfilling the diagnostic ACR criteria for RA, these participants were significantly more likely to have been hospitalized for an acute MI or to have experienced an unrecognized MI compared to non-RA subjects [14]. The previously discussed study examining co-morbidities in patients with early RA also revealed that for many patients

Conclusion

In summary, there is well-established evidence for CVD mortality and morbidity in patients with RA. However, the more recent evidence that CVD morbidity and mortality occurs early in the disease process, and the suggestion that pathogenic processes for atherosclerosis may be in place even before a diagnosis of RA, represents a new development in our understanding of CVD co-morbidity. Further research is required to explore CVD in early RA, particularly to elucidate the relative contributions of

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

H.J. is in receipt of an Arthritis Research Campaign (ARC) Educational Research Fellowship (number: 17883), and the Dudley Group of Hospitals NHS Trust Department of Rheumatology is in receipt of an infrastructure support grant from the ARC (number: 17682).

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