Measuring CVD Risk

October 3, 2016
Rheumatology Network Staff

Polish researchers writing in the journal Reumatologia outline algorithms used to assess cardiovascular disease risk in rheumatoid arthritis, PsA and AS patients.

Polish researchers writing in the journal Reumatologiasay there is a need for a new algorithm to assess cardiovascular disease in rheumatoid arthritis patients.

But this is easier said than done, they write. Rhematologists, cardiologists and general practitioners need to agree on screening methods and perhaps on a rheumatoid arthritis specific calculator.

Cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients is complex. A clear link exists between inflammation, lipid metabolism and cardiovascular disease.

What is poorly understood is the connection between treatments for RA and CVD, the authors write. Some studies, including QUEST-RA, show that methotrexate and sulfasalazine are associated with a reduced prevalence of cardiovascular events. And, the debate on whether disease-modifying anti-rheumatic drugs (DMARDs) and biologics contribute to or lessen CVD risk, remains controversial, wrote Krzysztof Bonek and Piotr Gluszko, of the National Institute of Geriatrics, Rheumatology and Rehabilitation in Poland. The article appears in the July 18 issue of the journal.

“It is necessary to consider the new guidelines presented in the USA in 2013 by the American College of Cardiology/American Heart Association (ACC/AHA). Their CV risk estimation method is based on a new Poled Cohort Equation formula,” the authors wrote.

The authors of the study highlight and evaluate some of the most commonly used CVD-risk calculators. 

CVD Risk Calculators

  • The authors highlighted a more recent cardiovascular risk calculator, “the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA),” which is based on the CORRONA registry, a cohort of 23,605 patients with rheumatoid arthritis. But it has some limitations:  a relatively short follow-up time of 10 years and its lack of extensive imaging diagnostics.
  • The Reynolds Risk Score is a risk calculator based on traditional risk factors and a myocardial ischemia patient family history; and, high sensitivity C-reactive protein (hs-CRP) levels in women.
  • The Framingham Heart Score (FRS) was published in 1998 owing to large studies. There are two variants: The first is based on a 30-year risk and the second is used to evaluate the 10-year risk of the end event.
  • The PROCAM calculator was developed as a follow- up to the Prospective Munster Heart Study (PROCAM) in Germany. The PROCAM calculator is used to assess the 10-year risk of heart attack (fatal and non-fatal) and sudden death.
  • A new calculator, ATACC-RA, is in development. It uses a mathematical model based on nearly 8 years of observation of a cohort of 3,176 patients in the primary prevention of cardiovascular events.

The List:  CVD Risk Assessment

The European League Against Rheumatism (EULAR) recently highlighted key factors physicians should consider in evaluating patients with rheumatoid arthritis, ankylosing spondylitis (AS) and psoriatic arthritis (PsA) for CVD risk. “They also pointed out the need to create a new RA-focused cardiovascular risk calculator, stating that the current methods of cardiovascular risk assessment are maladjusted,” the authors wrote.

The EULAR group stated that:

  • Reducing disease activity in this group of patients can reduce CVD risk.
  • RA and AS patients have a higher CVD risk due to both traditional risk factors and active inflammation.
  • Assess CVD risk every five years.
  • Many medical societies recommend the use of the Systematic Coronary Risk Evaluation (SCORE) equation, but rheumatoid arthritis has not been included in the algorithm itself.
  • Apply the ratio of total cholesterol (TC) and high-density lipoprotein (HDL) levels. Test lipid parameters in remission or during stable disease activity. 

  • The final risk calculator score should be the risk score multiplied by a coefficient of 1.5, but only if RA is not a parameter taken into account. “As SCORE and Framingham Risk Score (FRS) were created for the general population, the EULAR experts recommend multiplying cardiovascular risk in RA patients by 1.5 if patients have two out of three factors: anti-CCP or RF positivity or RA progression over 10 years or presence of extra-articular symptoms. This coefficient, based on assessment of risk of death of patients with RA compared with the general population risk, is widely criticized, pointing to the ineffectiveness of the above modification to cardiovascular risk assessment,” the authors wrote.
  • NSAIDs in patients with CVD should be prescribed in RA and PsA patients with caution, but they can be used as first line treatment in AS unless contraindications coexist.
  • Use the lowest possible dose of corticosteroids. Strive to reduce corticosteroid intake after achieving low disease activity.
  • Emphasize healthy diet, regular physical activity and smoking cessation.

  • Use carotid ultrasound to search for atherosclerotic plaques.

 

References:

Bonek K, Głuszko P. “Cardiovascular risk assessment in rheumatoid arthritis – controversies and the new approach.” Reumatologia/Rheumatology r. 2016;3:128-135. DOI:10.5114/reum.2016.61214.