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"Cardiovascular manifestations in rheumatoid arthritis can be complex, raising concerns for adequate patient management and provider-dependent roles.”
Patients with rheumatoid arthritis (RA) who received regular cardiology follow-up appointments exhibited fewer cardiac-related adverse events when compared with patients who did not receive cardiology care. Co-management should be a consideration in this patient population, according to results from a study published in Springer.1
“RA is a systemic autoimmune disease with important cardiovascular (CV) implications,” investigators sated. “CV disease represents over half of RA patient deaths and causes significant morbidity. CV manifestations in RA can be complex, raising concerns for adequate patient management and provider-dependent roles.”
The retrospective study investigated 399 patients diagnosed with both RA and coronary artery disease (CAD), identified and filtered via the EPIC Database search engine between January 2014 and December 2020. Adult patients (aged 18 years or older) who met diagnostic criteria for both RA and CAD, as well as those followed by College Station, Round Rock, and Temple TX BSW Health Rheumatologists were included in the study. Adverse events and hospitalizations were the primary outcomes, with secondary outcomes focusing on CV and non-CV hospitalizations. Other data collected included the number of clinical visits, cardiology follow-up, time to cardiology visit after RA diagnosis, disease duration versus CV diagnosis, treatment, outcomes, and the number of CV events prior to first cardiology visit.
Of the patients included in the study, most (68.2%, n = 272) were female and 127 (31.8%) were male, with a median age of 73 years. Most patients (77.8%) experienced at least 1 adverse event prior to care and averaged 8.35 visits during the follow-up period.
Patients without cardiology follow-up appointments reported significantly higher rates of hospitalizations (RR 1.63 95% CI 1.12, 2.38) as well as higher rates of adverse events, including myocardial infarction (MI) (RR 4.82 95% CI 1.94, 11.98), heart failure (HF) (OR 15.81 95% CI 3.54, 70.52), and stroke (RR 2.55 95% CI 1.29, 5.03). Additionally, patients without cardiology care had increases in both CV death (4 deaths compared with none in the cardiology follow cohort) and all-cause mortality (HR 1.03 95% CI 0.63, 1.67).
Identifying RA-specific medications was not a focus of the study, thus limiting the results. Investigators believe it is important to understand the impact of certain drugs as they relate to CVD risk, such as glucocorticoids and disease-modifying antirheumatic drugs (DMARDs), including tumor necrosis factor (TNF)-alpha inhibitors. Future studies may be beneficial to recognize associations between medications and cardiovascular outcomes. Further, the population studied exhibited a high degree of heterogeneity. Methods to implement expert advice and evidence-based approaches to optimize care within this patient population to improve cardiovascular outcomes are needed. Although analysis of adverse events for both CV and non-CV hospitalizations was attempted, the data was too sparse for statistical analyses of subtypes. Lastly, generalizability may be hindered as most patients were White and all patients resided in Central Texas.
“Given the increased risk of morbidity and mortality related to CV disease and the silent nature of CAD, intervention via cardiology co-management should be an early consideration in the management of RA patients,” investigators concluded. “Further studies are warranted to identify additional interventions for CV disease risk reduction in this select patient population. The findings of this study may potentially provide a blueprint to guide medical management and optimize outcomes in patients with both medical conditions. Early screening, risk stratification of coronary disease, and appropriate treatment algorithms are important to decrease morbidity and mortality.”
Guerra JD, De Santiago AB, Reed S, et al. Cardiology co-management of rheumatoid arthritis patients with coronary artery disease as an intervention reduces hospitalization rates and adverse event occurrence [published online ahead of print, 2022 Aug 16]. Clin Rheumatol. 2022;1-10. doi:10.1007/s10067-022-06335-4