Most rheumatologists do not screen patients for hypertension, lipids, and other cardiovascular risk factors even though patients with rheumatoid arthritis (RA) and other autoimmune diseases have an increased risk for cardiovascular disease.
“Cardiovascular disease is like a shark circling just beneath the surface in rheumatologic disease,” said Rekha Mankad, MD, Director of the Cardio-Rheumatology Clinic at the Mayo Clinic in Rochester, MN. “You don’t know what is there if you don’t look. And in this population, you should have a high index of suspicion and a low threshold to look and to treat.”
Dr. Mankad will explore the little-known connection between autoimmune disease and cardiovascular disease during a clinical symposium Getting to the Heart of the Matter: The Heart in Autoimmune Diseases on Monday from 7:30 – 8:30 am in Room 20 D. Mounting evidence suggests that patients with autoimmune disease are at increased risk for cardiovascular disease in the same way that patients with diabetes are at increased risk, and for some of the same reasons.
“The inflammation that comes with autoimmune disease increases the risk of cardiovascular disease in itself,” Dr. Mankad said. “That is on top of more familiar risk factors such as elevated blood pressure and lipids or obesity, which tend to be undertreated in the autoimmune population.”
Rheumatologists generally recognize that many patients must also deal with immune-mediated cardiac complications, but they may not recognize that autoimmunity itself can be a risk factor for cardiac complications. Cardiovascular disease is far from ubiquitous in patients with autoimmune disease, but the prevalence is elevated. And when cardiovascular disease does occur, it occurs about a decade earlier than would be expected in the general population.
“The literature would suggest that the potential for cardiovascular disease in this population is under recognized, which is the starting point for this symposium,” Dr. Mankad said. “Inflammation is likely driving a lot of this disease. Cardiologists and internists are largely unaware of the association. And although rheumatologists have been aware of the association, they are unlikely to be the ones to address the elevated cardiovascular risk.”
Part of the problem is that while inflammation is widely recognized as a contributing factor to cardiovascular disease, the mechanism of inflammation in cardiac complications is not well defined or quantified.
Selective focus is another factor. Rheumatologists are trained to focus on the signs and symptoms of rheumatologic disease. When an RA patient comes into the office with persistent pain and also has elevated blood pressure, it is easy to see hypertension as a byproduct of physical discomfort.
“It’s not that anyone is doing anything wrong. It’s about what is happening at the time,” Dr. Mankad said. “So much of rheumatology is about putting out fires. Rheumatologists are trained to address rheumatologic conditions and deal with the pain and destruction related to those conditions.”
Clinical success in treating rheumatologic disease is another element. As more and more finely targeted agents are developed, rheumatologists have become more and more successful at dealing with rheumatologic disease. Patients are surviving longer.
“That is most evident in the lupus population, where a patient used to have a high likelihood of dying with lupus due to kidney failure and infection,” Dr. Mankad said. “Rheumatologists have gotten so good at treating lupus that the risk of death now comes from heart disease. That’s a new factor to keep in mind.”
Cardiovascular disease considerations are so new there is relatively little broadly based epidemiological research. Dr. Mankad’s group has been screening rheumatologic patients for cardiovascular risk and has seen surprising levels of atherosclerosis in patients younger than 65. These patients should have little or no evidence of atherosclerosis based on age and other factors, yet a significant percentage show clear signs of disease.
“The real question is whether there is a role for being more aggressive,” she said. “Should rheumatologic patients be treated like diabetic patients in terms of cardiovascular risk? Should they be screened and treated more aggressively than the general population? We don’t know for sure, but we do know that if you look for cardiovascular disease in these patients, you will find it and you can treat it.”