PARIS, France—Cardiovascular disease (CVD) remains the most common cause of death for patients with rheumatoid arthritis (RA), and CVD mortality has not decreased despite improvements in RA management, according to data reported at the 2006 EULAR meeting.1  Data reported in the Journal of Rheumatology  by Martin Soubrier, MD, and colleagues at Hopital G. Montpied in Paris suggest that this situation is so serious that RA should be considered an independent cardiovascular risk factor (like diabetes mellitus), and should trigger interventions to lower the low density lipoprotein cholesterol (LDL-C) in many RA patients who are not currently receiving such treatment.2

"As the lipid profile changes with disease activity, serial lipid determinations should be performed." — Martin Soubrier, MD
"Our conclusion is that cholesterol-lowering therapy is insufficiently prescribed in our patients with RA. As the lipid profile changes with disease activity, serial lipid determinations should be performed. Our results highlight the need for all physicians to screen appropriately for cardiovascular risk factors and to treat all rheumatoid patients with abnormal lipid values," Dr. Soubrier writes.

Should RA Be Considered an Independent CVD Risk Factor?

The French researchers used guidelines from the ATPIII (the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults) to determine which patients in a cross-sectional study of 145 patients with RA would be candidates for lipid-lowering treatment. The treatment goals for LDL-cholesterol in this prospective study were set according to the number of risk factors.

Risk factors that increased the risk of CVD were defined as

● Age (male >45 years of age or female >55 years of age)
● Family history of premature coronary heart disease (definite myocardial infarction [MI]) or sudden cardiac death before 55 years of age in father or other male first-degree relative, or before 65 years of age in mother or other female first-degree relative)
● Current cigarette smoking
● Hypertension
● High-density lipoprotein (HDL) cholesterol <40 mg/dL.

According to the ATPIII guidelines, target LDL-cholesterol levels should be <160 mg/L for subjects with 0-1 of these risk factors, <130 mg/L for those with two or more risk factors, and <100 mg/L for those with multiple risk factors and a CHD risk >20% per 10 years, with CHD, or with a CHD risk equivalent such as other clinical atherosclerotic diseases or diabetes mellitus.

70% of RA Patients May Be Candidates for Lipid-Lowering Treatment

By these criteria, 27 of the 122 patients who were not taking LDL-cholesterol–lowering drugs and had no history of MI, 22% needed LDL-cholesterol–lowering therapy but were not receiving it.

"If RA is considered an additional risk factor, 35 patients (29%) should have been receiving primary prevention. If RA is considered a strong risk factor for cardiovascular disease, similar to diabetes mellitus, 86 patients (70%) should have been receiving primary prevention," Dr. Soubrier writes. "Despite an inordinately high risk of cardiovascular events in RA, assessment of cardiovascular risks was uncommon in our practice, and cholesterol-lowering treatment was insufficiently prescribed."

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References

1. Bergström UGB, L. Jacobsson L, Turesson C. Cardiovascular morbidity and mortality remains increased in patients with rheumatoid arthritis. Studies from a defined catchment area in 1995-2002 compared to 1978-1985. Presented at: 2006 EULAR Meeting; June 21–24, 2006; Amsterdam, The Netherlands. Abstract OP0137.
2. Soubrier M, Zerkak D, Dougados M. Indications for lowering LDL cholesterol in rheumatoid arthritis: an unrecognized problem. J Rheumatol. 2006 July 15