Guidelines Issued for Cardiovascular Risk Management in Patients With Inflammatory Arthritis

Laurie Barclay, MD

October 07, 2009

October 7, 2009 — The European League Against Rheumatism (EULAR) has issued 10 recommendations for cardiovascular risk management in patients with rheumatoid arthritis (RA), ankylosing spondylitis, and psoriatic arthritis. The new guidelines are published in the September 22 Online First issue of the Annals of the Rheumatic Diseases. The statement primarily targets rheumatologists but also a broad spectrum of other healthcare providers, reflecting "best practice" for patients with inflammatory arthritis.

"Obviously, management of inflammatory arthritis patients focuses not on cardiovascular (CV) morbidity and mortality," write M.J.L. Peters, MD, from VU University Medical Center in Amsterdam, the Netherlands, and colleagues. "However, standardised mortality ratios (SMRs) are elevated and the majority of premature deaths are attributable to CV disease. CV morbidity is also enhanced and there is an increased prevalence of all stages of atherogenesis from endothelial dysfunction, to increased thickness and plaque in carotid arteries, to fatal and non-fatal myocardial infarction and stroke."

The goal of this statement was to develop evidence-based EULAR recommendations for cardiovascular risk management in patients with RA, ankylosing spondylitis, and psoriatic arthritis. The EULAR Standing Committee for Clinical Affairs convened a multidisciplinary task force of 18 experts from 9 European countries, including rheumatologists, cardiologists, internists, and epidemiologists. The task force identified problem areas and related keywords for systematic literature research, which was conducted with use of MedLine, Embase, and the Cochrane library through May 2008.

In accordance with the EULAR's "standardized operating procedures," the multidisciplinary steering committee developed recommendations for cardiovascular risk screening and management in patients with inflammatory arthritis, based on evidence from this literature review and on expert opinion.

For all patients with RA, annual cardiovascular risk assessment with use of national guidelines is recommended. This should also be considered for all patients with ankylosing spondylitis and psoriatic arthritis. When cardiovascular risk factors are identified, these should be managed according to local guidelines, or according to the Systematic Coronary Risk Evaluation function if no local guidelines are available. To further reduce cardiovascular risk, aggressive suppression of the inflammatory process is recommended.

"Although the increased CV risk is increasingly acknowledged, limited attention is paid to detecting and managing CV comorbid conditions such as hypertension and dyslipidemia," the guidelines authors write. "Early identification, adequate CV risk management, and ongoing monitoring of risk factors are mandatory to reduce the (excess) CV risk. The first principle of management is to assess and control all components of total CV risk, [including] appropriate evidenced-based advice with regard to smoking, physical activity, nutrition, weight and blood pressure."

The task force made 10 recommendations for cardiovascular risk management in patients with inflammatory arthritis. Because evidence for increased cardiovascular risk is most compelling for RA, the strength of the recommendations was greater for patients with RA vs patients with ankylosing spondylitis or psoriatic arthritis.

The 10 recommendations, and their accompanying level of evidence rating and strength of recommendation, are as follows:

  1. RA should be considered as a disease in which cardiovascular risk is elevated, because of both an increased prevalence of traditional cardiovascular risk factors and the inflammatory burden. Although the evidence base is less, this may also apply to ankylosing spondylitis and psoriatic arthritis (level of evidence and strength of recommendation, 2b-3 B).

  2. To lower cardiovascular risk, adequate control of arthritis disease activity is necessary (level of evidence and strength of recommendation, 2b-3 B).

  3. All patients with RA should undergo annual cardiovascular risk evaluation with use of national guidelines. This should also be considered for all patients with ankylosing spondylitis and psoriatic arthritis. When antirheumatic treatment has been changed, risk assessments should be repeated (level of evidence and strength of recommendation, 3-4 C).

  4. For patients with RA, risk score models should be adapted by introducing a 1.5 multiplication factor when the patient meets 2 of the following 3 criteria: disease duration of more than 10 years, rheumatoid factor or anti-cyclic citrullinated peptide positivity, and the presence of certain extra-articular manifestations (level of evidence and strength of recommendation, 3-4 C).

  5. When using the Systematic Coronary Risk Evaluation model for determination of cardiovascular risk, triglyceride/high-density lipoprotein cholesterol ratio should be used (level of evidence and strength of recommendation, 3 C).

  6. Intervention for cardiovascular risk factor management should be performed according to national guidelines (level of evidence and strength of recommendation, 3 C).

  7. Preferred treatment options are statins, angiotensin-converting enzyme inhibitors, and/or angiotensin-II blockers (level of evidence and strength of recommendation, 2a-3 C-D).

  8. The effect of cyclooxygenase-2 inhibitors and most nonsteroidal anti-inflammatory drugs (NSAIDs) on cardiovascular risk is not completely determined and should be studied further. Clinicians should therefore be very cautious in prescribing these drugs, especially to patients with cardiovascular risk factors or with documented cardiovascular disease (level of evidence and strength of recommendation, 2a-3 C).

  9. When corticosteroids are prescribed, this should be at the lowest possible dose (level of evidence and strength of recommendation, 3 C).

  10. Patients should be actively encouraged to stop smoking (level of evidence and strength of recommendation, 3 C).

"Cardioprotective treatment should be initiated when the estimated 10 year CV risk is above the risk threshold for each country, whether 10 or 20%," the guidelines authors conclude. "Finally, the clear relationship between disease activity and CV disease underscores the important role of tight disease control."

EULAR supported development of these guidelines.

Ann Rheum Dis. Published online September 22, 2009. Abstract

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