Cardiovascular Disease Prevention Remains Lackluster in Patients With Rheumatoid Arthritis and Diabetes Mellitus

While prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with rheumatoid arthritis (RA) is advocated by recent recommendations, ASCVD prevention in patients with RA was underwhelming, according to an international audit.

In patients with rheumatoid arthritis with diabetes mellitus (RA-DM), the use of cardiovascular disease (CVD) medication and prevalence of atherosclerotic cardiovascular disease (ASCVD) were higher than patients with rheumatoid arthritis without diabetes mellitus (RAwoDM), according to a study published in BMJ.1 However, CVD prevention programs are lacking in this patient population.

“Prevention of ASCVD in patients with RA is advocated both by the European League Against Rheumatism (EULAR) and other recent recommendations,” stated investigators. “Despite these efforts, ASCVD prevention in patients with RA was noted to be incomplete across the world in our international audit, Survey of Cardiovascular Disease Risk Factors in Patients with Rheumatoid Arthritis (SURF-RA).”

Both RA and DM are historically associated with increased risk of ASCVD. Surveys like SURF-RA can be used to improve quality of care and treatment strategies.

Investigators analyzed the prevalence of CVD among RA-DM and RAwoDM groups utilizing data from already established clinical cohorts in the SURF-RA survey, which included patient records from 53 centers in 19 countries on 3 continents. Centers were divided into Western Europe, Eastern Europe, North America, and Asia. Patients were separated into 2 groups: those with ASCVD and those without ASCVD. They then compared both risk factors and preventative treatment between the RA-DM cohort and the RAwoDM cohort.

RA variables, such as rheumatoid factor and anti-citrullinated protein antibody positivity, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), antirheumatic medication, and Disease Activity Score were recorded. CVDs, such as coronary heart disease and stroke, as well as self-reported CVD risk factors, such as smoking, hypertension, waist circumference, and physical activity, were also entered into the database. Finally, lipids, glucose, glycosylated haemoglobin A1c (HbA1c), and lipid-lowering agents were analyzed.

The goal of antihypertensive treatment was <140/90mm Hg for RAwoDM and <140/80mm Hg for RA-DM. The low-density lipoprotein cholesterol (LDL-c) goal was set to ≤2.5 mmol/L for those in the high-risk group and ≤1.8 mmol/L for patients with ASCVD.

CVD risk factors and management between patients with and without DM were analyzed separately from those with and without ASCVD.

A total of 10543 patients with RA, 1381 (13%) in the RA-DM cohort, were reviewed. Of the study population, 1434 had an established ASCVD diagnosis and 9109 patients did not. In the RA-DM group, 26.7% had an ASCVD diagnosis, compared with only 11.6% in the RAwoDM group. Coronary heart disease (CHD), stroke, heart failure, and peripheral artery disease were more prevalent in patients with RA and DM. Hypertension, hyperlipidaemia, and the use of antihypertensive agents were more common in that cohort as well.

Among patients with ASCVD, the majority were not able to achieve the lipid goal (<1.8mmol/L), however attainment was significantly higher in those with RA and DM when compared with the RAwoDM group, regardless of ASCVD diagnosis.

Interestingly, LDL-c, high-density lipoprotein cholesterol (HDL-c) and cholesterol levels were generally lower in the DM group. The RA-DM cohort without ASCVD and receiving preventative lipid-lowering treatment had significantly lower LDL-c when compared with RAwoDM.

ASCVD prevention was notably better in patients with RA and DM group when compared with the RAwoDM group, exemplified by the higher number of patients in this group achieving their lipid goals, regardless of ASCVD status.

The SURF-RA survey was limited by the variations in the recorded prevalence of ASCVD risk factors among 3 continents, including primary care records, rheumatology outpatient clinics, and cardiology outpatient clinics. Data extracted from pre-existing registries added to the differences across regions. The importance of increasing awareness of this field was highlighted by the rates of missing data on CVD risk factors, thus indicating that the screening and recording of these variables are lacking. Additionally, medication adherence was not evaluated. Lastly, investigators utilized European recommendations in achieving treatment targets throughout all countries and continents surveyed, and there were a disproportionate amount of patients recruited from North America and Western Europe. However, these audits are important tools for improving clinical outcomes in this patient population.

“Despite the knowledge of the increased risk of ASCVD in patients with RA, their CVD risk factors often remain underdiagnosed, and they receive poorer CVD prevention than general population,” concluded investigators. “We found that patients with RA with DM more often used lipid-lowering and antihypertensive medications compared with their counterparts without DM, regardless of if they had ASCVD or not. This may reflect the well-developed CVD preventive programs in patients with DM.”


Semb AG, Rollefstad S, Ikdahl E, et al. Diabetes mellitus and cardiovascular risk management in patients with rheumatoid arthritis: an international audit. RMD Open. 2021;7(2):e001724. doi:10.1136/rmdopen-2021-001724