Arthritis and Heart Attack

Atherosclerosis (hardening of arterial wall) is a chronic inflammatory response in the walls of arteries leading to their narrowing, occlusion or occasional rupture. Risk of cardiovascular death is more than twofold in patients of rheumatoid arthritis as compared to general population.
The prevalence, causes and prevention of cardiovascular risk in some rheumatic diseases are discussed in following paragraphs.

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  • Rheumatoid arthritis (RA)

    Standardized mortality ratio (SMR = the ratio of observed deaths to expected deaths) in patients with RA was 1.8 for patients with disease onset in 1970-1979 and 1.3 for those with disease onset after 1980. Although mortality rate has decreased due to better therapy it is still high as compared to general population. RA patients have 2-4 fold higher risk of developing myocardial infarction (heart attack). Another study showed that prevalence of diseased blood vessels supplying heart (CVD) is 13% in RA patients as opposed to 12% diabetics of same (50-75 yrs) age group. RA is thus an independent risk factor for heart attacks. Cardiovascular (CV) risk increases early in the course of RA due to initial inflammatory responses. CV disease develops prematurely and is often silent leading to an unfavorable outcome. Heart failure (usually asymptomatic), cerebrovascular accidents (‘stroke’- weakness of a part or complete half side of the body) and peripheral vascular disease are also more common. 44% RA patients show plaques in blood vessels supplying brain. Age, male sex and lower socioeconomic status are important predictors of mortality in RA cases. Dyslipidemia (raised cholesterol and other blood fats), diabetes, high blood pressure, abnormal body composition with normal BMI (body mass index) and impaired physical fitness may also contribute to higher CV risk. Decreased physical activity, cumulative disease activity (number of swollen and tender joints), rheumatoid factor positivity, nodules and involvement of organs other than joints are specific determinants of mortality in RA. Prolonged use of glucocorticoids aggravates various CV risk factors such as diabetes, hyperlipidemia and hypertension although small dose glucocorticoids for short periods may not be as harmful. Some painkillers (Cox-2 inhibitors – celecoxib and others) increase CV risk. Chloroquin has lipid lowering and other effects that are cardioprotective. Methotrexate and newer biologic drugs reduce CV mortality by controlling disease activity.

  • Ankylosing Spondylitis (AS)

    This disease is also associated with increased mortality (SMR 1.7) which increases with disease duration and severity. 30-50 % of AS patients die of atherosclerotic heart or brain disease. It seems that higher disease activity has unfavorable effect on atherogenic index (Total Cholesterol/HDL Cholesterol ratio). Myocardial infarction in these patients occurs at 60-64 years age. Non-atherosclerotic diseases such as defects in heart valves are also found in AS.

  • Psoriatic Arthritis (PsA)

    Patients of PsA too are at significantly higher risk of ischemic heart disease, cerebrovascular disease and peripheral vascular disease (SMR 1.6). Higher disease activity (with high ESR) and extent of damage seen on X-rays indicate mortality in PsA cases.

  • Gout

    Gout is a lifestyle disease and a component of metabolic syndrome along with hypertension, atherosclerosis, obesity, stress and diabetes. Patients with gout have an increased risk of death by all causes, particularly cardiovascular. Higher uric acid levels are associated with carotid plaque formation in men and are now recognized as an independent CV risk factor. Control of weight and avoidance of stress are extremely important in management of gout. Therapy must be continued throughout life with regular monitoring for uric acid as well as associated risk factors. There is no evidence as yet to recommend lowering serum urate levels to bring down CV mortality in these cases. Greater intake of Vitamin C may be protective against ischaemic heart disease in gout.

  • Systemic Lupus Erythematosus (SLE)

    CV risk is 50 times higher in SLE patients. Myocardial infarction (heart attack) is 9 times more frequent than general population due either to accelerated atherosclerosis or thrombotic complications. Hypercholesterolemia and SLE diagnosis late in life are associated with higher CV risk. Early menopause, kidney involvement and raised homocysteine levels are other possible factors. SLE patients have many other risk factors such as raised CRP levels, low HDL-Cholesterol levels, insulin resistance, anti-phospholipid antibodies and defective regeneration of inner lining of blood vessels. Glucocorticoids used in SLE management have adverse effect on blood pressure and glucose as well as lipids.

  • CV Risk Management

    CV risk in inflammatory arthritis is not well recognized and is under treated. Treatment of CV risk includes life style modification, weight management and control of known risks (smoking, hypertension, lipids). Hydroxychloroquin, though a weak antirheumatic drug, has many beneficial CV effects. Low dose aspirin and control of lipids are also important. Statins decrease CRP production and have other beneficial effects in rheumatic diseases. Effective anti-rheumatic therapy improves function of blood vessels. Rapid and aggressive disease control is of utmost importance in managing CV risk in RA.

    Current recommendations for management of CV risk are as follows:

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    • Consider inflammatory arthritis as a potential CV risk factor.
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    • Rapid control of disease activity with appropriate therapy lowers CV risk
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    • Risk assessment and monitoring should be carried out in all cases at regular intervals.
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    • Treat risk factors with standard therapy.
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    • Use painkillers and glucocorticoids with caution especially in patients with known CV risk.
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    • Quit smoking.
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