The Link Between Rheumatoid Arthritis and Heart Disease

People with rheumatoid arthritis (RA) have twice the risk for cardiovascular disease (CVD) than the general population—with the CVD risk even higher than that of people with type 2 diabetes.

The causal relationship between cardiovascular disease and rheumatoid arthritis is complex and appears to be related to several factors, including traditional cardiovascular risk factors (hypertension, obesity, smoking, diabetes, high cholesterol) as well as the severity of the RA.

For many years, researchers have been studying the association and whether enough attention is paid to cardiovascular risk factors in people with inflammatory types of arthritis. Research now points to rheumatoid arthritis itself being an independent risk factor for cardiovascular disease. Findings that researchers have revealed include:

• There is an excess risk of cardiovascular disease that occurs early in the disease course of rheumatoid arthritis, which may even pre-date disease onset.
• Inflammation plays a key role in cardiovascular disease, and RA is an inflammatory condition. The more severe your RA, the more inflammation you have.
• While some "severity indexes" exist to determine RA's severity in the first two years after diagnosis, data has shown them to be unreliable. Patients should work with physicians to determine severity and treatment options as they apply to CVD risk.
• People with rheumatoid arthritis appear to have accelerated atherosclerosis, which is itself considered an inflammatory condition. It may be that the inflammatory process of rheumatoid arthritis along with an excess of proinflammatory cytokines (common in rheumatoid arthritis) contribute to the formation of plaque.
• The autoimmune-mediated inflammation of rheumatoid arthritis contributes to increased endothelial dysfunction, oxidative stress, and the activation and migration of leukocytes (white blood cells) within blood vessels. The adhesion of leukocytes to vascular endothelium (tissue in blood vessels) is the distinguishing characteristic of the inflammatory process.
• Heart attack isn't the only risk. A Journal of the American Heart Association study of more than 300,000 people found that RA also raised the risk of heart failure.
• CVD with RA is a one-two punch: Systemic inflammation associated with RA in combination with cardiovascular risk factors that are associated with lifestyle may contribute to CVD. For example, metabolic syndrome from excess weight, insulin resistance, a high sugar/high fat diet, and low fitness raises systemic inflammation by itself, but combined with the inflammation of RA the inflammatory condition becomes more dangerous.

People who have had rheumatoid arthritis for a long time, those with extra-articular manifestations (the disease affects more than just the joints), as well as those with rheumatoid factor and anti-CCP (autoantibodies) have the highest risk of cardiovascular mortality. Managing the risk is essential.

In 2009, EULAR (the European League Against Rheumatism) assembled a task force to put forth physician recommendations for managing cardiovascular risk in people with rheumatoid arthritis (ankylosing spondylitis and psoriatic arthritis, also inflammatory conditions, were included). The recommendations were updated in 2015/2016.

There are three overarching principles provided by EULAR—and 10 recommendations offered.

Overarching Principles:

1. Doctors must be aware of the higher risk of cardiovascular disease in people with rheumatoid arthritis compared to the general population.

2. The rheumatologist should ensure that cardiovascular disease risk management is performed in rheumatoid arthritis patients and other inflammatory joint diseases.

3. The use of NSAIDs (nonsteroidal anti-inflammatory drugs) and corticosteroids should be according to specific recommendations from EULAR and ASAS (Assessment of Spondyloarthritis International Society).

The 10 recommendations include:

1. Disease activity should be controlled optimally in rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis so as to lower the risk of cardiovascular disease.

2. Cardiovascular disease risk assessment is recommended for those with rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis at least once every five years and possibly following any major change to treatment.

3. Risk estimation for cardiovascular disease in people with rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis should be performed according to national guidelines, and the SCORE CVD risk prediction model if no guidelines exist.

4. Total cholesterol and high-density lipoprotein cholesterol should be used in cardiovascular risk assessment of rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis and lipids should be measured when disease activity is stable or in remission. Non-fasting lipids are acceptable.

5. Cardiovascular risk prediction models should be adapted for people with rheumatoid arthritis by multiplying by 1.5.

6. Screening for asymptomatic atherosclerotic plaques using carotid ultrasound may be considered as part of cardiovascular risk assessment in those with rheumatoid arthritis.

7. Lifestyle recommendations should emphasize healthy diet, regular exercise, and smoking cessation.

8. Cardiovascular disease risk management should be carried out according to national guidelines for rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. Anti-hypertensives and statins may be used as they are in the general population.

9. NSAIDs should be prescribed with caution for rheumatoid arthritis and psoriatic arthritis, especially for people with known cardiovascular disease or known risk factors.

10. For prolonged treatment, the dose of corticosteroids should be kept low and should be tapered if remission or low disease activity occurs. Continuation of corticosteroids should be regularly reconsidered.

Typical first-line RA medications may help. Data shows a protective effect from non-biologic disease modifying anti-rheumatic drugs (DMARDs) and biologics on cardiovascular events among patients with RA.

Also, common sense lifestyle factors can't be underestimated because aside from taking prescribed medication, lifestyle is the one factor every RA patient can control. All of the following have proven anti-inflammatory benefits in the body:

• A smart diet. Plant-based foods, high-fiber foods, and foods high in healthy fats (such as from fish, avocadoes, olive oil, and nuts).
• Regular physical activity. Even brisk walking is enough to provide benefits. Regular strength training can help take stress off of joints.
• Stress management. Relaxation techniques like meditation, mindfulness, and deep breathing can help.
• No smoking. And monitor how much alcohol you consume.

For far too long, the increased risk of cardiovascular disease in people with rheumatoid arthritis has been overlooked and under-managed. The risk imposed by hypertension, obesity, smoking, low fitness, and elevated blood lipids, along with the inflammatory process that is ongoing in rheumatoid arthritis, should not be ignored.

There is a need for rheumatology and primary care doctors to work in conjunction to control cardiovascular risk factors and disease activity related to rheumatoid arthritis. Talk to your doctors about all the steps you can take to lower your heart disease risk while managing your RA.