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Early diagnosis, treatment and cardiovascular screening and management has led to a decrease in cardiovascular-related mortality in rheumatoid arthritis patients.
There’s some good news for patients with rheumatoid arthritis. There’s no longer a difference between the cardiovascular mortality rate of the general population and those with rheumatoid arthritis, according to a study presented by Elena Myasoedova, MD, at the 2015 ACR/ARHP annual meeting in San Francisco, Calif on Nov. 11.
Dr. Myasoedova, of the Mayo Clinic in Rochester, Minn., co-authored a study retroactively looking at cardiovascular morbidity and mortality from 1980-2007. She and colleagues assessed data from almost three decades, from 813 patients with rheumatoid arthritis and 813 without. During the most recent period, 2000-2007, they found that the 10 year mortality rate from all cardiovascular causes in the rheumatoid arthritis patients was 2.8%, versus 3.2% for the general population. That included 1.2% of those with rheumatoid arthritis who died from coronary heart disease, versus 1.3% for the general population cohort. In the two prior decades, these figures were not comparable.
They found that in 1990-1999, the 10-year overall cardiovascular mortality rate for rheumatoid arthritis patients was 7.9%, versus 6% for the general population, and for coronary heart disease, it was 4.7% for the rheumatoid arthritis patients, compared to 2.5% of the general population.
“While the exact causes of improvement in cardiovascular mortality in patients more recently diagnosed with rheumatoid arthritis, as compared to those diagnosed previously are uncertain, it is likely that early diagnosis and early aggressive anti-rheumatic treatment, as well as vigilant cardiovascular screening and management, could have played a role and are beneficial,” she said in an interview.
Dr. Myasoedova said the data suggests that treating physicians should be encouraged to follow current guidelines for rheumatoid arthritis disease control and cardiovascular risk management in these patients, with a goal of continued outcome improvement. Her group is currently investigating the reasons for the recent improvement in cardiovascular deaths in rheumatoid arthritis patients.
Those with newer diagnoses of incident rheumatoid arthritis should be glad they’re living with the disease now, rather than prior to 2000. Research presented by Diane Lacaille, MD, at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., on Nov. 9, showed that those with new cases of rheumatoid arthritis from 2001-2006 had no greater mortality rate than the general population, something that couldn’t be said for those with disease onset from 1996-2000.
The retrospective cohort study used administrative health data from British Columbia. The study included 24,914 subjects dived into two rheumatoid arthritis groups and one control group. The rheumatoid arthritis patients must have had at least two visits more than two months apart for rheumatoid arthritis from 1996-2006, with no history of the disease before 1990. The rheumatoid arthritis groups were dived by those meeting the criteria from 1996-2000 (earlier group), and in 2001-2006 (later group). The control group included people of similar age and gender.
The all-cause mortality rate for the earlier group was 32.68 per 1,000 patient years, and for the later group it was 18.29. The all-cause mortality rate for the control group for the earlier range was 19.9, and 17.88 for the later range. When they looked specifically at mortality from cardiovascular disease, the rate was 12.3 for the earlier rheumatoid arthritis group compared to 7.4 for the similar control group. The later rheumatoid arthritis cohort had a mortality rate of 5.66, compared to 5.85 for the corresponding control group.
Why the change in mortality rate? Dr. Lacaille, of the University of British Columbia, Vancouver, hypothesized in an interview that the improvement in mortality is due to improved treatment of rheumatoid arthritis, and a better success at controlling inflammation. She said that prior research has showed greater inflammation, disease activity and severity were associated with greater risk of mortality.
“With the major shift in the last one to two decades in the approach to rheumatoid arthritis treatment towards early and aggressive treatment, and treat-to-target to eradicate inflammation, one would expect that mortality would have improved. This is what we found,” she said.
She cautions against concluding from her study that the mortality gap no longer exists. “We can say from our study that mortality is better for people who develop rheumatoid arthritis in recent years than it was for people who got rheumatoid arthritis earlier,” she said.
In the study, the researchers didn’t observe an increased risk of mortality in the most recent cohort, but she said that follow-up was only five years. “We know that the risk of mortality increases with increasing rheumatoid arthritis duration. So it is possible that with longer follow-up, there will still be a mortality gap. This needs to be studied further,” she said.
Based on the study, Dr. Lacaille said that treating rheumatoid arthritis patients with a contemporary approach can improve long term outcomes, including mortality. “Definitely, physicians should keep treating rheumatoid arthritis early and aggressively. Our study provides evidence supporting this treatment strategy. Whatever changes we have done in recent years, it’s working, we should keep it up,” she said.
"Decreased Cardiovascular Mortality in Patients with Incident Rheumatoid Arthritis (RA) in Recent Years: Dawn of a New Era in Cardiovascular Disease in RA?," Elena Myasoedova, MD, ACR 2015. Nov. 11, 2015.
"Improvement in Mortality in RA Compared to the General Population - Closing the Mortality Gap," Diane Lacaille, MD. ACR 2015. Nov. 9, 2015.