Rheumatoid Arthritis, Cardiovascular Disease and Physical Exercise: A Systematic Review

G. S. Metsios; A. Stavropoulos-Kalinoglou; J. J. C. S. Veldhuijzen van Zanten; G. J. Treharne; V. F. Panoulas; K. M. J. Douglas; Y. Koutedakis; G. D. Kitas


Rheumatology. 2008;47(3):239-248. 

In This Article

Abstract and Introduction

This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.

Rheumatoid arthritis (RA) associates with increased morbidity and mortality from cardiovascular disease (CVD),[1] most of which is due to greater prevalence[2] and worse outcome[3] of ischaemic heart disease, largely attributed to acceleratedatherosclerosis. The exact processes leading to this phenomenon remain undetermined. Much attention has been paid to the potential role of high-grade systemic inflammation[4] and its vascular and metabolic effects.[5] Sometimes this takes the focus awayfrom the indisputable fact that classical modifiable CVD risk factors—such as hypertension,[6,7] dyslipidaemia,[8] insulin resistance/metabolic syndrome,[9] obesity,[10] physicalinactivity[11] and smoking[12]—are highly prevalentbut under-investigated and suboptimally managed in this group of patients.[13] Even though these risk factors are not sufficient to explain the entire magnitude of CVD morbidity and mortality in RA,[2] they represent an easily identifiable target forintervention, using both pharmacological[14,15,16] and behavioural approaches.[17,18]

Exercise is one of the most important behavioural interventions that can have a major beneficial impact on the likelihood to develop, suffer symptomatically or die from CVD. In the context of CVD, people, including those who have RA, could be divided schematically into four categories: those who have neither CVD nor any significant risk factor burden for it; those who have risk factors but no clinical evidence of CVD; those who have clinically apparent vascular and cardiac disease but have not suffered a life-threatening acute cardiovascular event such as a myocardial infarction (MI); and those who have survived an acute cardiovascular event. There is overwhelming evidencethat, in the general population and several at risk subpopulations, exercise provides significant physical and psychosocial benefits, and facilitates management and improvements of outcome in allfour of these categories. It helps maintain a healthy life-style, reduce CVD risk factors including obesity,[19] dyslipidaemia,[20,21] hypertension,[22] diabetes mellitus[23] and possibly even inflammation;[24] it is also effective for preventing acute coronary syndromes.[25,26,27,28,29,30,31,32] Moreover, exercise helps the management of established CVD: both aerobic exercise[33,34] and resistance training[35] improve myocardial contractility and quality of life in patients with chronic heart failure and produce significant functional benefits in people with intermittentclaudication.[36] More importantly, cardiac exercise rehabilitation programmes are an important part in the management of patients after an acute coronary syndrome (ACS)[37] and lead to significantly improved quality of life and reduced mortality rates.[38,39,40] Interestingly, there is evidence that patients with RA are rarely offered the opportunity to participate in cardiac rehabilitationprogrammes even after an ACS.[3] This may be, at least in part, because of the specific considerations required when prescribing exercise to such patients. These include: (i) whether the individual is physically able to perform, and psychologically likely to adhere to exercise regimens designed for cardiovascular improvements; (ii) whether RA health professionals are sufficiently aware of the evidence regarding exercise in RA patients and educate their patients accordingly; and (iii) whether existing exercise programmes and facilities can be adapted to cater for the extra needs that people with some degree of physical disability may have.

In the present review, we describe briefly the settings and types of exercise used for cardiovascular improvement in the general population. We then present systematic reviews of aerobic exercise interventions in RA and of the factors that may influence adherence to exercise in this disease. Finally, we give suggestions for exercise interventions suitable for improving the cardiovascularprofile of people with RA and propose areas for future research in the field.


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