Patients often express hesitancy about using multiple medications at the same time, which makes treatment difficult, says Joan M. Bathon, MD, director, Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York.
“A patient may feel they don’t need cholesterol-lowering medication or may say that the cholesterol meds make their muscles feel worse,” Dr. Troum says.
As patients are commonly told to lose weight, change their diet, and exercise more—be it to help their joints or decrease the risk of heart dangers—there are the usual barriers to accomplishing those, Dr. Bathon says. “They’re no different from other patients [in that way],” she says.
When to Refer to a Cardiologist
Although it may have been common in the past to wait for a heart problem to emerge before referring a patient to a cardiologist, the emphasis now is on quicker preventive care, says cardiologist Guy Mayeda, MD, Good Samaritan Hospital, Los Angeles. He’s seen many patients who have damage to the heart or blood vessels but are not yet symptomatic. “The sooner they get referred to a cardiologist, the better the patient can improve with a collaborative effect,” he says. In that kind of patient, the cardiologist will recommend the rheumatologist prescribe aggressive therapy to get the inflammation under control, he adds. The cardiologist may also see early signs of such problems as a pericardial effusion, in which fluid accumulates around the heart and compresses it, leading to possible death if untreated, Dr. Mayeda says.
Although many clinicians preach the value of preventive care, what actually happens in practice can depend on one’s setting, says Dr. Bathon, who has done research related to heart problems in rheumatic disease. In one scenario, the rheumatologist may take an interest in treating cholesterol or related heart issues. However, with everyone tight on time and with guidelines about cholesterol levels ever in flux, this does not happen that often.
A second option is referring patients to a cardiologist simply because their disease puts them at a higher risk. “That works well in academic centers, but many cardiologists are unaware of the risk,” Dr. Bathon says.
In his area, Dr. Troum has seen the primary care physician (PCP) serve as the quarterback to decide which other specialists a patient may see. Dr. Troum will advise that a patient with RA or a related disease see a cardiologist, but then the PCP ultimately makes the call.
