Cardiovascular Risk Management in Patients With Arthritis

Results from a meta-analysis of population-based studies recently published in Annals of the Rheumatic Diseases found several major types of arthritis to be associated with a higher risk of incident myocardial infarction (MI). The elevated MI risk was partially accounted for by a higher prevalence of conventional cardiovascular (CV) risk factors in the populations with arthritis.

A research team led by Orit Schieir of the Division of Epidemiology at the University of Toronto Dalla Lana School of Public Health carried out the meta-analysis using methodology delineated by Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-Analysis of Observational Studies in Epidemiology guidelines.

Using the MEDLINE, EMBASE and CINAHL databases, the investigators searched for population-based cohort or case-control studies that reported an association between incident MI or acute coronary syndrome (ACS) and 5 major forms of arthritis: rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), gout or osteoarthritis (OA). Further qualifications included publication dates between January 1980 and January 2015, French or English language, and adjustment for at least age and sex. Of 4,285 articles identified by the search strategy, 25 were ultimately deemed eligible for inclusion in the meta-analysis.

Upon data synthesis and analysis, an average 50% increase in risk was seen for all 5 types of arthritis in aggregate based on 23 studies with adjustment for age and sex only. Analysis of 13 studies with adjustment for at least one traditional risk factor (body mass index, physical activity, hyperlipidemia, diabetes or high blood pressure) showed a 30% increase in risk for all 5 arthritis types in aggregate. 

Subgroup analyses by type of arthritis showed that in studies adjusted by age and sex, a significantly higher risk of incident MI was evident in RA (pooled relative risk [RR]: 1.69, 95% confidence interval [CI] 1.50-1.90), gout (pooled RR: 1.47, 95% CI 1.24-1.73), PsA (pooled RR: 1.41, 95% CI 1.17-1.69), and OA (pooled RR: 1.31, 95% CI 1.01-1.71). 

Patients with AS “tended towards increased risk” (pooled RR: 1.24, 95% CI 0.93-1.65).

In studies with adjustments for at least one traditional risk factor, the increased risk of MI was attenuated but still persistent in RA, gout and PsA. Only two studies with adjustments for traditional risk factors were found for OA and AS. Their results were not pooled because the evidence was sparse, and the relevant studies had an inconsistent direction or magnitude of results.

The authors wrote that their results suggest that lowering the risk of MI in patients with arthritis requires that physicians provide better management of conventional CV risk factors. “This is important for patients with inflammatory arthritis as clinicians may focus on controlling inflammation as a sole means of reducing risk,” the authors wrote.

Summary and Clinical Applicability

“Results showed that MI risk was consistently increased in multiple types of arthritis, and was partially explained by a higher prevalence of traditional [risk factors] in all types of arthritis under study,” stated the investigators in their conclusions. 

“Study findings support more integrated CV prevention strategies for arthritis populations that target both reducing inflammation and enhancing management of traditional CV [risk factors].”

Study Limitations

• Few relevant studies were identified in PsA, AS and OA. 
• Only studies published in French or English were included.
• The majority of studies did not account for known differences in baseline risks and characteristics of arthritis or heart disease by age and sex.
• Over a third of studies did not adjust for conventional risk factors.

Reference 

Schieir O, Tosevski C, Glazier RH, Hogg-Johnson S, Badley EM. Incident myocardial infarction associated with major types of arthritis in the general population: a systematic review and meta-analysis [published online February 20, 2017]. Ann Rheum Dis. doi:10.1136/annrheumdis-2016-210275

This article originally appeared on Rheumatology Advisor