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Rheumatoid Arthritis and Coronary Artery Disease

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Updated July 11, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

People with rheumatoid arthritis (RA), a chronic inflammatory condition affecting the joints and sometimes other parts of the body, have an increased risk of developing coronary artery disease (CAD). Anyone living with RA needs to take every precaution to reduce their overall cardiac risk, both by addressing all the "traditional" cardiac risk factors, and by working with their doctor to choose the best therapy for their RA.

Why Is CAD More Common In People With RA?

CAD is itself in some degree an inflammatory syndrome. The process of atherosclerosis includes the deposition of excess inflammatory cells within the walls of the affected arteries. And elevations in blood C-reactive protein (CRP) levels - a marker for the presence of inflammation - is associated with a significantly increased risk of CAD. So, the thinking goes, the widespread inflammation that is commonly seen in RA seems to accelerate atherosclerosis, and to make CAD more likely.

In addition, treating RA with high-dose steroids (formerly a very common practice) may also accelerate atherosclerosis.

Is CAD "Different" In People With RA?

For the most part CAD in people with RA behaves much like CAD in anyone else, with one exception: People with RA seem less likely to experience the symptom of angina (chest discomfort) with exertion than people without RA. Because their CAD is somewhat less likely to announce itself by producing angina, the diagnosis of CAD may be delayed in people with RA.

However, in every other way their CAD is like just CAD in anyone else, and just as dangerous. The chief risk is that an atherosclerotic plaque may suddenly rupture, creating acute coronary syndrome (ACS), manifested by unstable angina, heart attack, or sudden death. In fact, the increased incidence of CAD largely explains why people with RA can experience premature death.

Diagnosing and Treating CAD In People With RA

Neither the diagnosis nor the treatment of CAD is any different in people with RA than in anyone else. However, because the risk of premature CAD is higher in people with RA, and because exertional angina is less likely to occur (and thus is less likely to provide a clue that CAD is present), doctors need to be particularly vigilant about the possibility of CAD in their patients with RA. Many experts recommend that yearly medical evaluations be done in people with RA once they turn 50 years of age, looking for signs or symptoms of possible CAD. If the medical history or physical examination has changed, or if the ECG shows changes suggestive of CAD, a cardiac stress test should be strongly considered.

Preventing CAD In People With RA

There are two general approaches to preventing CAD in people with RA, and both approaches should be used.

The first approach is to aggressively manage all the "standard" risk factors for CAD, including not smoking, maintaining a good body weight, eating a heart-healthy diet, and managing blood lipid levels. Most experts recommend prescribing statins in people with RA, both for their lipid lowering and their anti-inflammatory effects. And while exercise may be a particular challenge in people with severe RA, exercising frequently, as tolerated, remains an important step in lowering the risk of CAD. Your doctor should be able to help you devise an exercise regimen which is suitable to your condition.

The second approach to preventing CAD involves the treatment of RA itself. In the past, the prolonged use of high-dose steroids was pretty common in treating severe RA. But steroids used in this way have several negative side effects - including the acceleration of CAD. Today, doctors usually try to minimize their use of steroids in RA, sticking to the minimum effective dose, for the shortest time possible.

Instead, doctors today tend to use DMARDs therapy (disease-modifying anti-rheumatic drugs, employing drugs such as methotrexate). DMARDs attempts to modify the immune system itself - that is, to slow or stop the immune processes that are causing the RA. The good news is that the DMARDs approach also appears to reduce the risk of developing CAD. A recent review of available data, for instance, concluded that using methotrexate in the treatment of RA significantly lowers the risk subsequent cardiac events caused by CAD.

Summary

An increased risk of CAD is an unfortunate consequence of RA. This risk can be reduced by aggressively controlling all the "traditional" cardiac risk factors, by minimizing the use of steroids, and by applying the DMARDs approach to treating RA.

Sources:

Maradit-Kremers H, Crowson CS, Nicola PJ, et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum 2005; 52:402.

Westlake SL, Colebatch AN, Baird J, et al. The effect of methotrexate on cardiovascular dsease in patients with rheumatoid arthritis: a systematic literature review. Rheumatology (Oxford) 2010; 49:295.

Peters MJ, Symmons DP, McCarey D, et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann Rheum Dis 2010; 69:325.

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