A session on Monday will explore the effect of rheumatoid arthritis (RA) disease activity on cardiovascular disease (CVD) outcomes in patients with RA.
Joan M. Bathon, MD, Professor of Medicine and Chief of Rheumatology at Columbia University Medical Center in New York, will discuss the common cardiovascular manifestations in patients with rheumatoid arthritis during Treatment for RA in Patients with Concomitant Cardiovascular Disease from 9:00 – 10:00 am, in Room 20 D.
Heart disease is the leading cause of death in patients with RA. The high risk of CVD in this patient population has been attributed to inflammation, which is an important risk factor for heart disease in the general population, as well.
“It’s well recognized that patients with rheumatoid arthritis are at higher risk of having heart attacks and having heart failure; however, the cause of that has been relatively unclear,” Dr. Bathon said. “The reigning theory is that the inflammation driving the rheumatoid arthritis also drives the enhanced risk of cardiovascular disease.”
Dr. Bathon noted that some recent studies have reported data suggesting that RA patients who have heart attacks have elevated levels of disease activity prior to the cardiovascular event.
“So, we know that inflammation is characteristic of rheumatoid arthritis, and there’s good evidence suggesting that inflammation also enhances the risk of cardiovascular disease, so that raises the question as to whether the anti-inflammatory, disease-modifying drugs that we use for RA might suppress heart attacks or reduce the risk of heart attacks,” Dr. Bathon said. “That’s a big area of research right now and there are some data suggesting that anti-TNF drugs, like etanercept and adalimumab, reduce cardiovascular risk.”
While this has yet to be demonstrated in clinical trials, Dr. Bathon believes there is enough observational evidence to support a two-fold approach to reducing cardiovascular risk in RA patients.
“First, we need to be very aggressive in managing their traditional cardiovascular risk factors, such as high blood pressure, diabetes and hyperlipidemia,” she said. “Secondly, we have to continue to take a very aggressive approach to minimize their disease activity and get them into remission.”
Also during this session, Katherine P. Liao, MD, MPH, Assistant Professor of Medicine at Harvard University Medical School and Brigham and Women’s Hospital in Boston, will discuss current understanding of the impact of disease-modifying anti-rheumatic drugs and other treatments used in RA patients with known cardiovascular disease.
“As clinical rheumatologists, when we treat rheumatoid arthritis patients with cardiovascular disease, it’s important to think about how we’re defining cardiovascular disease; it can really be a mixed bag,” Dr. Liao said. “Someone who had a heart attack may require a different approach than someone who has congestive heart failure (CHF). They are overlapping, but not everyone with CHF has ischemic heart disease, so depending on what they have, that affects how you might think about which therapies you would use.”
Historically, Dr. Liao said, there has been some concern that the use of TNF inhibitors in RA patients with CHF might exacerbate the condition, possibly leading to acute decompensated heart failure.
“The recent data suggest that anti-TNFs can be used safely in patients with mild CHF, but it’s still something to consider when treating a patient with any history of CHF,” she said. “I always have a conversation with a cardiologist before I start these patients on anti-TNFs.”
For RA patients not diagnosed with cardiovascular disease, Dr. Liao said there are some recent and ongoing studies looking at the impact of anti-inflammatory therapies on reducing the risk of cardiovascular disease. Dr. Liao is a co-investigator and Dr. Bathon is co-PI of the TARGET trial, which is comparing triple therapy (methotrexate, sulfasalazine, and hydroxychlorquine) versus methotrexate plus TNF inhibitor to determine the impact of either strategy on cardiovascular risk.
“We’ve been pretty certain for some time now, based on what we’ve seen in large observational studies, that reducing inflammation reduces cardiovascular risk, but it’s never actually been tested in a randomized controlled trial,” Dr. Liao said. “This study will help us definitely answer that question. Additionally, TARGET will provide us with much-needed information regarding whether the choice of drugs matters and whether they help reduce cardiovascular disease risk beyond just reducing inflammation.”
Dr. Liao said that determining these links can help identify strategies to reduce CVD risk in RA and also lead to potential targets of treatment in the general population.