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Acute coronary syndrome incidence has declined but remains significantly higher in patients with rheumatoid arthritis.
The incidence of acute coronary syndrome declined from 1997 to 2012 in persons who have rheumatoid arthritis and in those who do not, but even with these declines, the risk is 40% higher in patients who have the disease.
In this study, the 40% increase in acute coronary syndrome risk in patients with rheumatoid arthritis was restricted to those who had Disease Activity Scores in 28 joints (DAS28) greater than 3.2 and those who were rheumatoid factor positive.
Marie Holmqvist and colleagues in Sweden pointed out that although disease activity in rheumatoid arthritis has been linked to cardiovascular risk, whether good management of rheumatoid arthritis leads to reductions in acute coronary syndrome risk is unknown.
The authors conducted the study to determine whether advances in rheumatoid arthritis management and vigilance for cardiovascular risk factors have led to a decrease in risk of acute coronary syndrome. They presented their findings in a recent Annals of the Rheumatic Diseases article.
The authors conducted a nationwide population-based cohort study that examined patients with newly diagnosed rheumatoid arthritis. Ultimately, 15,744 patients with rheumatoid arthritis and 70,899 comparator subjects without rheumatoid arthritis were included in the analysis.
• In 103,835 person-years of follow-up, a first episode of acute coronary syndrome developed in 772 subjects with rheumatoid arthritis (4.9%); over 466,930 person years of follow-up, acute coronary syndrome developed in 2418 comparator subjects (3.4%).
• Of patients who had rheumatoid arthritis, 1685 (10.7%) died during follow-up, compared with 7336 (10.4%) of patients who did not.
• Excess incidence of acute coronary syndrome increased from 1 in 1000 person-years during the first year after rheumatoid arthritis diagnosis to between 2 and 3 in 1000 person-years over the next 10 years.
• Rheumatoid arthritis was associated with a 40% higher risk of acute coronary syndrome (hazard ratio, 1.41; 95% confidence interval, 1.29-1.54). This risk was confined to patients with DAS28 higher than 3.2.
• Overall risk during all calendar periods remained similar (p=0.9).
Implications for physicians
• Acute coronary syndrome incidence has been declining both in the general population and in persons with rheumatoid arthritis.
• In spite of declines in acute coronary syndrome incidence, patients with rheumatoid arthritis and DAS28 greater than 3.2 are at 40% higher risk of acute coronary syndrome compared with the general public.
• Patients with rheumatoid arthritis appear to have benefited as much from better treatment for cardiovascular risk factors as the general population. However, better treatment for rheumatoid arthritis does not appear to have closed the gap between those who have it and those who do not with regard to the development of acute coronary syndrome.
• Physicians should remain vigilant with patients who have rheumatoid arthritis and maximize treatment aimed at lower disease activity and mitigation of cardiovascular risk.
Funding was provided for this project by the Swedish research Council, the Swedish Foundation for Strategic research, Stockholm County Council (ALF), Heart Lung Foundation, and the Karolinska Institutet (Strategic research Area Epidemiology).
Holmqvist M, Ljung L, Askling J. “Acute coronary syndrome in new-onset rheumatoid arthritis: a population-based nationwide cohort study of time trends in risks and excess risks.” Ann Rheum Dis. 2017 Oct;76(10):1642-1647. doi: 10.1136/annrheumdis-2016-211066. Epub 2017 Jul 14.