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May/June 2020
Arthritis and Cardiovascular Disease Patients and physicians alike often lack awareness about the association between the diseases. Arthritis is often viewed as an inevitable development in the aging adult. It’s well known that older adults also have an increased risk of developing cardiovascular disease (CVD). What’s less recognized is that arthritis increases one’s risk of developing CVD. Research suggests that older adults with arthritis—especially rheumatoid arthritis (RA)—may not be adequately evaluated for CVD risk, and those who do not have traditional risk factors for CVD (eg, high blood pressure, high cholesterol) may not be as frequently or thoroughly assessed as are others for heart conditions. For example, studies have revealed that cholesterol screening is performed in less than 50% of RA patients. Research has also shown that approximately 70% to 90% of RA patients are not aware of their increased risk of developing CVD.1 Greater awareness of the established links between arthritis and CVD among geriatric medical professionals and their patients and more vigilant assessment of arthritis patients is needed. The catch-all term “arthritis” includes osteoarthritis (OA) and inflammatory arthritis caused by autoimmune conditions. OA, also called degenerative joint disease, is caused by the breakdown of cartilage between joint bones and changes in the affected bones. It most commonly occurs in the joints of the hands, hips, knees, and spine, and generally begins at age 40 or later. Approximately 30 million American adults have OA. About 60% of those aged 65 years and older experience symptoms of OA. Treatments include weight loss, exercise, NSAIDs and other pain medications, certain types of injections around the joint, and surgery when needed.2 RA, the most common autoimmune-related arthritis, causes joint pain and swelling, stiffness, and reduced joint motion. RA most commonly affects small joints in the hands, wrists, and feet. It generally develops between the ages of 30 and 50, but can also develop after age 65 (elderly-onset RA). According to the American College of Rheumatology, more than 1.3 million Americans have RA; approximately half a million of those are older than age 60. RA is treated with disease-modifying antirheumatic drugs (DMARDs) to help relieve symptoms and slow the progression of joint damage. DMARDs may be prescribed with NSAIDs and/or corticosteroids to address pain and swelling. Those with more advanced RA may be prescribed biologic agents (eg, tumor necrosis factor [TNF] blockers) that act on the immune system to slow joint inflammation and deterioration. Other types of autoimmune inflammatory arthritis include psoriatic arthritis and ankylosing spondylitis. Lupus, another autoimmune disease, can also cause inflammatory arthritis. Like RA, all of these are associated with an increased risk of CVD.3-5 Inflammatory Arthritis The exact link between CVD and inflammatory arthritis caused by autoimmune diseases such as RA, lupus, and psoriatic arthritis is still the subject of intense study, says Eric M. Ruderman, MD, a professor of medicine, associate chief for clinical affairs in the division of rheumatology at Northwestern University Feinberg School of Medicine, and Arthritis Foundation medical advisor. “It is postulated that the systemic inflammation associated with this arthritis may exacerbate atherosclerotic cardiovascular disease, which is itself an inflammatory condition.” Research has found that premature atherosclerosis, not necessarily linked with traditional risk factors such as smoking, high cholesterol and blood pressure, and diabetes, commonly occurs in those with RA. Inflammation related to RA may increase arterial stiffness and destabilize plaques, which contributes to the higher risk of heart attack in those with RA.4-7 In addition to atherosclerosis, recent research has revealed that other CVDs are more prevalent in those with inflammatory arthritis. Findings include the following4,5,7: • Heart valve diseases, such as mitral valve regurgitation, may be present in 30% to 80% of patients with RA. • Pericardial disease—inflammation of the pericardium, or tissue sac, that surrounds the heart—may occur in 30% to 50% of patients with severe RA and 20% to 50% of patients with lupus. • Electrical, conduction, and rhythm disorders (eg, atrial fibrillation, arrhythmias, tachycardia) occur at a higher prevalence in those with inflammatory arthritis. Ruderman emphasizes the importance of assessing older adults with inflammatory arthritis for CVD, stressing two key reasons. “First, comorbidities of any sort increase the risk of adverse medical events in patients with arthritis of any kind. Second, for patients with inflammatory arthritis, it is important to recognize that the risk of cardiovascular disease is increased … above and beyond that related to usual risk factors like hypertension, hyperlipidemia, and metabolic syndrome.” Underlying mechanisms for chronic inflammation as a cause of atherosclerosis in RA are not fully understood. However, significantly lower rates of CVD in RA patients treated with drugs that control inflammation, such as TNF blockers and DMARDs, support the theory that RA-associated atherosclerosis is caused by inflammation rather than by traditional cardiovascular risk factors.4,5 “There is data suggesting that the cardiovascular disease seen in RA may be related to RA disease activity, as well as data suggesting that the risk of cardiovascular disease may be ameliorated with aggressive therapy and control of RA disease activity.” However, control of inflammatory arthritis conditions may also require treatment with medications that can contribute to greater risk of CVD. NSAIDs and corticosteroids may be prescribed for pain control during acute inflammation flares. Both of these medication classes have been found to increase risk of cardiovascular adverse events. Newer kinase inhibitors for treating inflammatory arthritis have been found to increase cholesterol levels.1 Therefore, side effects of all medications must be considered when assessing the geriatric patient for cardiovascular risk and managing inflammation with the goal of preventing CVD development. Focusing on control of autoimmune inflammation should not supersede traditional CVD risk evaluation and management. “For these patients, early recognition of subclinical CVD can lead to more aggressive management of these risks and potential reduction in clinical events,” Ruderman notes. Comprehensive risk assessment of the individual risk for CVD is a necessity for older patients with inflammatory arthritis. However, standard risk assessment scoring tools do not account for inflammatory arthritis as a risk factor. Geriatric care providers must consider the added risk when relying on current standard cardiovascular risk scoring tools, such as the Framingham Risk Score, Systemic Coronary Risk Evaluation, and the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease risk calculator. All of these risk assessment tools may underestimate risk in patients with inflammatory arthritis.6,8 In addition, none of these risk assessment tools considers autoimmune inflammatory arthritis medications and their associated risks and benefits. A multidisciplinary management approach is necessary to reduce autoimmune-associated inflammation as well as traditional cardiovascular risk factors. Lifestyle changes and treatment of risk factors such as high cholesterol and hypertension, combined with medications to control inflammatory disease activity, are essential for older adults with inflammatory arthritis.6,7 “Geriatric medical professionals need to be aware of the link between inflammatory arthritis, particularly RA, as these patients—like those with diabetes—may require more aggressive management of other modifiable risk factors, such as hypertension, weight, and lipid parameters, to minimize the risk of cardiovascular events,” Ruderman notes. CVD in those with inflammatory arthritis conditions may be asymptomatic, or “clinically silent.” Hence, it’s recommended that patients with inflammatory rheumatic diseases such as RA, lupus, and others should be routinely evaluated with ECG and echocardiography (cardiac ultrasound) to detect cardiovascular abnormalities. Other imaging tests that may provide valuable diagnostic and prognostic information for those with inflammatory arthritis and clinically silent CVD include carotid ultrasound, cardiac CT, and cardiac MRI.4,5 The European League Against Rheumatism has issued guidelines on managing cardiovascular risk associated with inflammatory arthritis, including the following9: • Rheumatologists are best suited for managing CVD risk and prevention in those with inflammatory arthritis conditions. • Disease activity should be optimally controlled to lower CVD risk in all patients with RA and other inflammatory arthritis diseases. • CVD risk assessment is recommended for all patients with RA at least once every five years and should be reconsidered following major changes in antirheumatic therapies. • Cardiovascular risk prediction models should be adapted for patients with RA by a 1.5 multiplication factor if RA is not included as a risk factor in the model. • Carotid ultrasound screening for asymptomatic atherosclerotic plaques may be used in patients with RA. • Lifestyle recommendations should emphasize the benefits of a healthful diet, regular exercise, and smoking cessation for all patients with inflammatory arthritis. • NSAIDs in RA and psoriatic arthritis should be prescribed with caution, especially for those with documented CVD or risk factors. Osteoarthritis This increased risk is speculated to be linked to reduced capacity to exercise due to disability and increased used of NSAIDs. Pain associated with OA often limits physical activity for many older adults; a majority of those with hip and knee OA do not meet recommendations for daily physical activity. Insufficient exercise is itself a risk factor for CVD. Thus, those with OA severe enough to limit movement have added CVD risk from inactivity. Regular high-dose NSAID use—common in those with OA-related pain—has been shown to triple CVD risk, including risk of heart attack, stroke, angina, and hypertension.8 Recent research suggests that OA may be associated with chronic low-grade inflammation, even though it’s been classified as a noninflammatory condition. Chronic low levels of inflammation over the long term contribute to the development of CVD.8,10 Metabolic and physiologic processes that affect collagen in joints, causing the stiffness and damage associated with OA, are similar to those that cause arterial wall stiffening and subsequent increases in blood pressure. Hypertension is a primary risk factor for CVD and also occurs more frequently in those with OA. Metabolic syndrome and obesity are also more prevalent in older adults with OA. Approximately 60% of those with OA also have metabolic syndrome—a cluster of several conditions, including hypertension, high blood glucose, abdominal obesity, and high cholesterol. Excess body weight stresses the joints, increasing OA pain and disability, limiting physical activity, and further raising the risk of CVD.8,10 For older adults with OA, assessing cardiovascular risk involves evaluating physical activity limitations, diagnosing comorbidities that affect pain and daily functioning, and cataloging and assessing medication use (eg, NSAIDs) that may increase risk. Unlike inflammatory arthritis conditions, which are generally managed by a rheumatology specialist, OA might be managed by a primary care physician, orthopedic specialist, or rheumatologist. A comprehensive assessment of cardiovascular risk may not recognize OA and its contribution to disease risk when the older adult sees multiple physicians for different medical issues. Increasing awareness of the links between OA, inflammatory arthritis, and CVD risk among geriatric health professionals is essential to improve patient outcomes. — Jennifer Van Pelt, MA, is a health care researcher and freelance writer in the Lancaster, Pennsylvania, area.
References 2. Wang H, Bai J, He B, Hu X, Liu D. Osteoarthritis and the risk of cardiovascular disease: a meta-analysis of observational studies. Sci Rep. 2016;6:39672. 3. Arthritis and heart disease. Arthritis Foundation website. https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/arthritis-and-heart-disease 4. Buleu F, Sirbu E, Caraba A, Dragan S. Heart involvement in inflammatory rheumatic diseases: a systematic literature review. Medicina (Kaunas). 2019;55(6). pii: E249. 5. Castañeda S, Nurmohamed MT, González-Gay MA. Cardiovascular disease in inflammatory rheumatic diseases. Best Pract Res Clin Rheumatol. 2016;30(5):851-869. 6. Chodara AM, Wattiaux A, Bartels CM. Managing cardiovascular disease risk in rheumatoid arthritis: clinical updates and three strategic approaches. Curr Rheumatol Rep. 2017;19(4):16. 7. Castañeda S, Vicente-Rabaneda EF, García-Castañeda N, Prieto-Peña D, Dessein PH, González-Gay MA. Unmet needs in the management of cardiovascular risk in inflammatory joint diseases. Expert Rev Clin Immunol. 2020;16(1):23-36. 8. Fernandes GS, Valdes AM. Cardiovascular disease and osteoarthritis: common pathways and patient outcomes. Eur J Clin Invest. 2015;45(4):405-414. 9. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76(1):17-28. 10. Osteoarthritis could be risky to your heart. Arthritis Foundation website. https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/osteoarthritis-could-be-risky-to-your-heart |
