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The increased risk of acute coronary syndromes and subsequent death is not the result of other cardiovascular risk factors.
Patients with rheumatoid arthritis are at higher risk for acute coronary syndromes, such as angina and myocardial infarction, than the general population and are at higher risk for death after these syndromes, Swedish researchers found.
The increased risk of acute coronary syndromes and subsequent death in patients with rheumatoid arthritis is not the result of other cardiovascular risk factors, such as high blood pressure and diabetes mellitus.
Patients with rheumatoid arthritis are treated with medications aimed at secondary prevention of acute coronary syndromes with a frequency similar to that in the general population.
Studies have shown that patients with rheumatoid arthritis are at high risk for cardiovascular disease and present with ST elevation myocardial infarction and sudden cardiac death with alarming frequency. Further research has revealed an increase in short-term mortality in patients with rheumatoid arthritis not otherwise explained by comorbidities.
Ãngla Mantel and fellow researchers sought to determine whether patients with rheumatoid arthritis were at higher risk for recurrent acute coronary syndrome and long-term mortality after acute coronary syndromes and whether they received appropriate cardioprotective secondary pharmacologic treatment after acute coronary syndromes. They presented their findings in a recent Annals of the Rheumatic Diseases article.
The authors performed a cohort study consisting of 1135 patients with prevalent rheumatoid arthritis and 3184 comparator subjects in whom acute coronary syndrome developed and who did not have rheumatoid arthritis. Final follow-up was at 4 years.
• Of the patients with rheumatoid arthritis, 79.6% were still alive at 90 days after an acute coronary syndrome.
• Of non–rheumatoid arthritis patients, 86.1% were alive at 90 days after an acute coronary syndrome.
• At 365 days after an acute coronary syndrome, 70.7% and 79.6% of rheumatoid arthritis and non–rheumatoid arthritis patients, respectively, were still alive.
• The rate of recurrent acute coronary syndrome was 30% higher in patients who had rheumatoid arthritis than in those who did not (hazard ratio [HR] at 1-year, 1.35; 95% confidence interval [CI], 1.09-1.68; at final follow-up, 1.34; 95% CI, 1.12-1.60). When propensity adjustment was performed, the HRs remained significant (1 year, 1.28, 95% CI, 1.03 to 1.60); complete follow-up, 1.25 (95% CI, 1.05 to 1.50).
• Mortality after acute coronary syndrome for patients with and without rheumatoid arthritis was 30% and 20%, respectively (relative risk, 1.6; HR, 1.59; 95% CI, 1.39-1.82).
• At final follow-up, mortality after acute coronary syndrome for patients with and without rheumatoid arthritis was 45% and 30%, respectively (HR, 1.73; 95% CI, 1.55 to 1.93).
• In both groups, 80% of deaths were attributed to ischemic heart disease or related complications, such as sudden cardiac arrest, arrhythmias, heart failure, and conduction abnormalities.
• After propensity adjustment, the HRs remained significant (HR at 1 year, 1.38; 95% CI, 1.20 to 1.59; final follow-up, 1.50; 95% CI, 1.34 to 1.68).
• After acute coronary syndromes, prescriptions for statins were filled by 3% to 7% fewer patients who had rheumatoid arthritis than those who did not across all time intervals.
• In the first 90 days, the percentages of post–acute coronary syndrome patients with and without rheumatoid arthritis receiving 2 or more secondary preventative drugs were 89% and 93%, respectively (p=0.0009).
• There was no difference between groups as to secondary preventative drugs after 90 days.
• Patients who did not have rheumatoid arthritis were less likely to be receiving 3 or more secondary preventative drugs at all time intervals than patients who had rheumatoid arthritis.
Implications for physicians
• Physicians should recognize the increased risk of acute coronary syndromes and death related to heart disease in patients with rheumatoid arthritis.
• Steps should be taken to screen patients who have rheumatoid arthritis and when cardiac risk factors are present, initiate appropriate secondary preventative drug therapy as well as pertinent lifestyle modifications.
• Initiation of drug therapy after acute coronary syndromes should take into account rheumatoid arthritis as a comorbidity and interactions with antirheumatic drugs but, when appropriate, should not be delayed.
Funding was provided by the Swedish Research Council, the Swedish Foundation for Strategic Research, the Stockholm County Council, the Heart Lung Foundation, the Swedish Cancer Society, and the Karolinska Institutet (Strategic Research Area Epidemiology).
Mantel Ã, Holmqvist M, Jernberg T, et al. “Long-term outcomes and secondary prevention after acute coronary events in patients with rheumatoid arthritis.” Ann Rheum Dis. 2017 Aug 20. pii: annrheumdis-2017-211608. doi: 10.1136/annrheumdis-2017-211608. [Epub ahead of print]