Studies carried out more that a decade ago showed that patients with rheumatoid arthritis (RA), which affects about 1 percent of the general population, had an increased risk of premature death, largely as the result of coronary heart disease.
Two research groups recently reported that RA raises the risk of cardiovascular disease and heart attacks to a risk level equal to that of diabetes, a disorder long associated with an especially high risk of death from cardiovascular disease. In these studies, heart attack rates were about 2.3-fold higher in persons with RA than in the general population, even after correcting for traditional risk factors.
RA is an autoimmune disorder in which inflammatory factors damage the joints. It is now thought that the spread of these factors throughout the body can also cause inflammation of arteries—and, as we now recognize, inflamed arteries are an important component in the development of the atherosclerotic plaques that predispose to heart attacks.
Another reason why this inflammatory process in RA patients may be responsible for cardiovascular disease is the fact that the traditional risk factors for heart attacks—high cholesterol, high blood pressure, and smoking—are not prominent in RA patients. Instead, the risk for cardiovascular disease is greatest in those whose joint symptoms (and inflammation) are most severe.
What can be done to minimize cardiovascular disease in RA? Patients and physicians alike must keep in mind this increased risk of cardiovascular disease and choose medications with that in mind. For example, available evidence suggests that the disease-modifying anti-rheumatic drugs (DMARDs), such as sulphasalazine (Azulfidine), methotrexate (Rheumatrex, Trexall), and hydrochloroquine (Plaquenil), do in fact tend to protect against heart attacks, whereas glucocorticoids like prednisone may be harmful. Aspirin and other antiplatelet drugs also have not been generally recommended to prevent cardiovascular events in people with RA.
Even though the usual risk factors for coronary heart disease apparently take a back seat to inflammation, it seems reasonable to treat persons with RA like patients who have already had a heart attack; that is, by emphasizing smoking cessation, lowering blood pressure to less than 130/80 mm Hg, and using statins to reduce LDL cholesterol to around 70 mg/dL.
Another autoimmune disorder with a major inflammatory component, systemic lupus erythematosus (SLE), is less common than RA, but is also associated with a markedly higher rate of cardiovascular events. Both heart attacks and strokes are especially common among young women with SLE. High blood pressure, resulting from the damage SLE does to the kidneys, combines with the inflammation to enhance vascular disease.