Patients with RA in the Setting of Cardiovascular Disease

WASHINGTON, D.C.—At ACR Convergence 2024, Christina Charles-Schoeman, MD, MS, professor of medicine and chief, Division of Rheumatology, University of California Los Angeles Medical Center, Santa Monica, Calif., gave a practical talk on the management of rheumatoid arthritis (RA) in the setting of cardiovascular disease (CVD).

Background

CVD is the leading cause of death in people with RA. Patients with RA have twice the risk of myocardial infarction, a 50% increased risk of stroke and double the risk of developing congestive heart failure.^1-3

These stats are bleak, but there’s a lot that we as rheumatologists can do to protect our patients. Multiple factors propagate atherosclerosis, and these can be separated into three main buckets: 1) RA and inflammation; 2) traditional CV risk factors; and 3) RA medications.

RA & Inflammation

Dr. Charles-Schoeman

When it comes to decreasing CV risks in patients with RA, getting the RA under control is an obvious place to start. “If you control the RA, you can reduce the risk of CVD,” noted Dr. Charles-Schoeman.

She pointed to prospective observational data that showed the incidence rate of first verified myocardial infarction was significantly lower in patients who responded to tumor necrosis factor (TNF) inhibitors than those who were non-responders.⁴

Traditional CV Risk Factors

Controlling traditional CV risk factors, such as hypertension, diabetes and smoking, also plays a crucial role in decreasing CV risks in our patients with RA. Up to 70% of CVD events in patients with RA can be attributed to CVD risk factors and RA characteristics combined.⁵

Dr. Charles-Schoeman first spoke to the benefits of controlling blood pressure. In the NHANES III Linked Mortality study, uncontrolled hypertension increased the risk of all-cause and CV disease mortality in U.S. adults. And interestingly, treatment for hypertension did not save lives—treatment with control of blood pressure did.⁶ “What matters is if the blood pressure is controlled,” she emphasized, “not if they’re taking meds or not. Patients taking pills without blood pressure at goal actually did the worst.”

So the next time your patient has high blood pressure at their clinic visit, don’t be reassured by seeing anti-hypertensives on the medication list. Adjustment of those medications to get blood pressure to goal is really where the money is.

Next, she turned toward smoking cessation, citing a “two-for-one” stat that could be the final push needed to inspire some patients to quit smoking. “This is one of my favorite studies to talk about smoking cessation with my patients,” she said. “Smoking cessation not only decreased CV events, but also reduced RA disease activity.”⁷