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CV risk management should be mandatory in RA and other types of inflammatory rheumatic disease

June 16, 2008

Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) patients should undergo compulsory cardiovascular (CV) risk management and existing CV risk calculators should be adapted to the increased CV risk in inflammatory rheumatic disease patients, the EULAR Task Force on 'Cardiovascular Risk Management in RA' recommended today at EULAR 2008, the Annual Congress of the European League Against Rheumatism in Paris, France.

RA, AS and PsA are associated with an increased CV risk and, in RA, this risk is at least double the norm and potentially similar to that of type 2 diabetes, a clinically-established cardiovascular risk factor. The EULAR Task Force set out to review existing evidence and expert opinion-based recommendations on CV management in inflammatory rheumatic disease, in order to devise specific EULAR recommendations for future clinical practice.

The EULAR Task Force's multidisciplinary steering committee comprised 21 members, including rheumatologists, cardiologists, internists and epidemiologists, from across nine European countries (France, Germany, Greece, Hungary, Norway, Portugal, Spain, The Netherlands, United Kingdom). Their recommendations were as follows:

1. RA, AS and PsA should become clinically accepted as new CV risk factors.

2. Existing CV-risk calculators, such as the Framingham and Systematic Coronary Risk Evaluation (SCORE), should be adapted, by a multiplier, to reflect the increased CV risk in inflammatory rheumatic disease patients.

3. Annual cardiovascular risk screening is recommended for all RA patients and should be considered for AS and PsA patients.

4. Lifestyle recommendations (on areas including diet, exercise, smoking cessation and stress management) should be given to all inflammatory rheumatic disease patients.

5. Treatment with statins and/or antihypertensives should be considered, and the CV management targets should be set according to local guidelines. If there are no local guidelines, treatment should be considered when the 10 year CV mortality risk with the (newly adapted) Framingham/SCORE function is above a certain value.

6. Aggressive inflammation suppression is recommended to further lower the CV risk in patients with inflammatory rheumatic disease.

Dr Michael Nurmohamed, lead investigator and convenor of this EULAR Task Force said, "Although traditional cardiovascular risk factors occur more frequently in patients with inflammatory rheumatic disease than in the general population, they only partially explain these patients' increased cardiovascular risk. There is mounting evidence that inflammation may be the missing link. Therefore, disease modifying antirheumatic drugs (DMARD) and biologics may lower the cardiovascular risk in inflammatory rheumatic disease patients, whilst statins and hypertensives, such as ACE inhibitors and angiotensin blockers, may even yield greater benefits than in the general population due to their anti-inflammatory properties."

Professor Ferdinand Breedveld, President of EULAR said, "These recommendations have been developed in accordance with the EULAR Standardised Operating Procedures and in line with the EULAR objectives to improve the understanding of musculoskeletal disorders and contribute to the improvement of outcome of patients with rheumatic disorders. The Task Force is to be commended on its excellent recommendations which will directly contribute to improved clinical practice and better understanding of the management of CV factors in rheumatology."

CV risk factor stratification and management is currently conducted on the basis of 10 years absolute risk for a (fatal) CV-event, as derived from a risk formula based on a number of CV-risk factors. The two major standard CV risk calculators are Framingham, a tool based on US population statistics and SCORE, tailored to European populations.

European League Against Rheumatism