A Heart In Danger

The use of NSAIDs is not contraindicated, but such therapy should be individualized keeping in mind the potential risks and benefits. The precise nature and magnitude of the cardiovascular risk imparted by traditional NSAIDs and COX-2 inhibitors is a subject of controversy and requires further study.

Research and Debate Will Refine Treatment

This aggressive approach is particularly important in SLE and RA patients in whom preclinical ASCVD is detected. The relative merits of the various non-invasive tests to detect preclinical ischemia or atherosclerosis and thereby identify high-risk individuals are beyond the scope of this commentary, and the economic implications of systematic non-invasive testing in SLE and RA patients must be considered before adopting a public policy of widespread screening.

Ongoing research may identify subsets of SLE and RA patients who are at heightened risk of premature atherosclerosis based on clinical identifiers. For the present, close adherence to guidelines for primary prevention of ASCVD and a lower threshold for more aggressive interventions are warranted in our SLE and RA.

Further, now that it is clear that chronic inflammation is a driving force for premature atherosclerosis, we also must be more aggressive in managing lupus and RA disease activity. We may find that the standard practice of using immunosuppressive therapy only for clinical flares does not inhibit chronic low-level inflammation that promotes atherosclerosis.

Dr. Salmon is senior scientist of the program in autoimmunity and inflammation at Hospital for Special Surgery and professor of medicine at Weill Medical College of Cornell University in New York City.

References

1. Bulkley BH, Roberts WC. The heart in SLE and the changes induced in it by corticosteroid therapy. A study of 36 necropsy cases. Am J Med. 1975;53:243-264.
2. Urowitz MB, Bookman AA, Koehler BE, Gordon DA, Smythe HA, Ogryzlo MA. The bimodal mortality pattern of SLE. Am J Med. 1976;60:221-225.
3. Aranow C, Ginzler EM. Epidemiology of cardiovascular disease in systemic lupus erythematosus. Lupus. 2000;9:166-169.
4. Manzi S, Meilahn EN, Rairie J, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: Comparison with the Framingham study. Amer J Epidemiol. 1997;145:408-415.
5. Esdaile JM, Abrahamowicz M, Grodzicky T, et al. Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus. Arthritis Rheum. 2001;44:2331-2337.
6. Ross R. Atherosclerosis-an inflammatory disease. N Engl J Med. 1999;340:115-126.
7. Libby P. Inflammation in atherosclerosis. Nature. 2002; 420:868-874.
8. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352:1685-1695.
9. Hulthe J, Wikstrand J, Emanuelsson H, et.al. Atherosclerotic changes in the carotid artery bulb as measured by B-mode ultrasound are associated with the extent of coronary atherosclerosis. Stroke. 1997;28:1189-1194.
10. Belcaro G, Nicolaides AN, Laurora G, et al. Ultrasound morphology classification of the arterial wall and cardiovascular events in a 6-year follow-up study. Arterioscler Thromb Vasc Biol. 1996;16:851-856.
11. Roman MJ, Shanker B-A, Davis A, et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. New Engl J Med. 2003;349:2399-2406.
12. Wolfe F, Mitchell DM, Sibley JT, et al. The mortality of rheumatoid arthritis. Arthritis Rheum. 1994;37:481-494.
13. Goodson NJ, Wiles NJ, Lunt M, Barrett EM, Silman AJ, Symmons DP. Mortality in early inflammatory polyarthritis: cardiovascular mortality is increased in seropositive patients. Arthritis Rheum. 2002;46:2010-2019.
14. Solomon DH, Karlson EW, Rimm EB, et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation. 2003;107:1303-1307.
15. del Rincón I, Williams K, Stern MP, Freeman Gl, Escalante A. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis Rheum. 2001;44:2737-2745.
16. Choi HK, Hernán MA, Seeger JD, Robins JM, Wolfe F. Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. Lancet. 2002;359:1173-1177.
17. Roman M, Moeller E, Davis A, et al. Preclinical carotid atherosclerosis in patients with rheumatoid arthritis: prevalence and associated factors. Ann Intern Med. 2006;144:249-256.
18. Maradit-Kremers H, Nicola PJ, Crowson CS, Ballman KV, Gabriel SE. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2005;52:722-732.
19. Al-Herz A, Ensworth S, Shojania K, Esdaile JM. Cardiovascular risk factor screening in systemic lupus erythematosus. J Rheumatol. 2003 30:493-496.
20. Costenbader KH, Wright E, Liang MH, Karlson EW. Cardiac risk factor awareness and management in patients with systemic lupus erythematosus. Athritis Rheum. 2004;51:983-988.
21. Smith SC, Becker D, Clark LT, et al. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation. 2002;106:3143-3421.
22. Grundy SM, Cleeman JI, Merz CN, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004; 110:227-239.
23. Smith SC Jr, Allen J, Blair SN, et al. MD AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update. Circulation. 2006;113:2363-2372.