Rheumatoid arthritis presents with many different symptoms, which often vary from person to person. Among these is a generally higher risk of serious heart problems compared to a person of the same age and health living without rheumatoid arthritis. While it has been known that patients with RA are at higher risk for heart failure or complications, recent improvements in the treatment of rheumatoid arthritis may be the cause of a decrease in cardiovascular events following the turn of the 21st century.
A recent meta-analysis of cardiovascular events and risk levels in rheumatoid arthritis patients confirms that overall risk has decreased since the year 2000. The meta-analysis was conducted by Dr. Elisabeth Filhol and Dr. Cécile Gaujoux-Viala, along with their respective colleagues, and presented at the annual meeting of the European Congress of Rheumatology in 2017. Filhol is a rheumatologist in training at Nîmes University Hospital in France. Gaujoux-Viala serves as head of the department of rheumatology at Nîmes University Hospital.
A meta-analysis combines data from multiple studies surveying the same subject area, analyzing trends and patterns in order to gain a better understanding of the progress or ineffectiveness of medicine over time. In order to gather research data, Filhol and Gaujoux-Viala utilized data from 28 different observational studies, some falling before the year 2000 and some after. The literature was drawn from PubMed and the Cochrane Library, both public domain resource databases.
The team set up a control group in order to measure their respective risk levels with individuals who experienced cardiovascular events but did not have rheumatoid arthritis. The study measured a value called attributable risk or excess risk, which is the difference in risk between patients with a condition and those without. In this case, patients with rheumatoid arthritis have an excess risk of experiencing cardiovascular problems, including stroke, myocardial infarction (MI), congestive heart failure (CHF), and cardiovascular mortality (CVM).
Heart Conditions Linked to Rheumatoid Arthritis
A stroke occurs when blood vessels that carry oxygen and other nutrients to the brain becomes obstructed. Inflammation caused by rheumatoid arthritis can lead to a higher risk of blockage, and when the brain does not receive blood, part of it can die very quickly. Individuals without rheumatoid arthritis have a slight advantage over those who do, as regular exercise is a critical way of reducing risk of stroke. Age may also play a part, as both rheumatoid arthritis and strokes tend to occur later in life.
A myocardial infarction—commonly known as a heart attack—is similar to a stroke in that a blockage prevents blood from reaching a critical organ, in this case, the heart. When oxygen is prevented from reaching the heart muscles, they can die. The name myocardial infarction translates literally to “death of heart muscle.” As with a stroke, rheumatoid arthritis can prevent individuals from getting the exercise and can contribute to other risk factors that increase the likelihood of having a heart attack.
Congestive heart failure is a condition in which the heart is unable to properly function in its role as a pump that circulates blood throughout the body. Rheumatoid arthritis can cause bone and tissue damage that may make it more difficult the body to maintain strong and healthy muscles. As with the previous two conditions, aerobic exercise is critical to maintaining a healthy heart, and rheumatoid arthritis can in some ways complicate a person’s ability to exercise and maintain the heart.
Any heart related condition can lead to death, and the meta-analysis conducted by Filhol and Gaujoux-Viala also compared RA patients and healthy individuals to each other’s risk of cardiovascular mortality. Heart disease is prevalent as it is in the United States, but rheumatoid arthritis patients stand especially at risk of dying of a heart disease. Research suggests that half of all deaths in rheumatoid arthritis patients are the result of heart disease, while it is estimated that one in every three deaths in the US is due to heart disease.
Explanations for Decrease in Cardiovascular Events
Filhol suggested that the most straightforward explanation might have something to do with the decrease in cardiovascular patients following the turn of the century. She claims that “it may simply be due to better management of cardiovascular risk in patients with RA.” Given the knowledge that heart disease is such a risk for patients with rheumatoid arthritis, doctors and physicians have certainly taken preventative measures in treating RA.
The second explanation came from Gaujoux-Viala, who suggested that the explanation could lie in better treatments, resulting in less interference from the disease itself. Regarding the decrease in cardiovascular events, she stated: “knowing that systemic inflammation is the cornerstone of both RA and atherosclerosis, it may also be related to better control of chronic systemic inflammation as the result of new therapeutic strategies.”
These new therapeutic strategies include tight control, treat to target, methotrexate optimization, and the use of biologic disease-modifying antirheumatic drugs (DMARDs). Each of these strategies has become a standard in the treatment of rheumatoid arthritis within the last twenty years, and it may be both this and an increased awareness of cardiovascular risk that have led to safer outcomes for patients with rheumatoid arthritis.
Tight control is an umbrella term for treatments that are closely monitored from the onset of the disease. This allows doctors to quickly adjust treatments and determine whether the treatment is effective or not. In standard care, patients will often experience long stretches of time in which symptoms are not improving, medicine is proving ineffective, or side effects are occurring unchecked. In these cases, the longer the root of the issue is ignored, the more severe the progression of the disease can be.
Now that doctors are using biologics and DMARDs in conjunction with traditional therapies, it is more important than ever to monitor developing complications or symptomatic fluctuation. Setting treatment goals is a good way for doctors to quickly determine how a patient is responding to treatment, and can ensure that once a patient strikes the optimal dosage, they stay there and do not incur unwanted side effects from additional dosage.
Recently, doctors have taken to aggressively swapping medications until something sticks and a patient has a response to medicine that drastically reduces or eliminates symptoms. By shaving off the time that most physicians spend waiting for a treatment to take, this treat to target method offers the best possible outcome with the least long-term side effects. However, aggressively treating rheumatoid arthritis can be a demanding process for those who feel that they are able to cope with their symptoms well, or who have low to moderate symptoms.
Results of the Meta-Analysis
Before the year 2000, studies indicated that rheumatoid arthritis patients were at a significantly higher risk of having cardiovascular events than those who did not have RA. The most significant decrease in risk following the turn of the century was a decrease in risk of myocardial infarctions. As fewer and fewer patients experienced heart attacks, risk of cardiovascular deaths decreased as well.
The risk of having a stroke remained approximately the same in patients both with and without rheumatoid arthritis. Since stroke occurs in the brain and not in the heart, improvements in preventing cardiovascular events may have greater outcomes for heart-related disease. Regardless, the meta-analysis reveals clearly that risks for heart disease has decreased in rheumatoid arthritis patients, even if they remain at a higher risk of experiencing a cardiovascular event than those who do not have rheumatoid arthritis.