New recommendations from the European Alliance of Associations for Rheumatology (EULAR) provide both broad and detailed advice for cardiovascular risk management in various rheumatic and musculoskeletal diseases (RMDs), many of which can lead to an increased possibility of cardiovascular disease (CVD).
"The panel believes that these recommendations will enable healthcare providers and patients to mutually engage in a long-term care pathway tailored to patients' needs and expectations for improving cardiovascular health in RMDs," write George C. Drosos, National and Kapodistrian University of Athens, Athens, Greece, and colleagues. The recommendations were published this month in Annals of the Rheumatic Diseases.
EULAR assembled a task force to generate best practices for preventing CVD in patients with gout, vasculitis, systemic sclerosis (SSc), myositis, mixed connective tissue disease (MCTD), Sjögren syndrome (SS), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS).
The cardiovascular risk management of patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis were covered in prior EULAR recommendations.
The task force included 20 members from 11 European countries, including 12 rheumatologists, 2 cardiologists, 1 metabolic medicine physician, 1 healthcare professional, 2 patient representatives, and 2 EMEUNET (Emerging EULAR Network) members. One group of task force members conducted a systematic literature review of 105 articles about gout, vasculitis, SSc, myositis, MCTD, and SS, and another group evaluated 75 articles about SLE and APS. Together, they decided on four overarching principles:
Clinicians need to be aware of increased cardiovascular risk in patients with RMDs, with disease reduction likely decreasing risk.
Rheumatologists — in tandem with other healthcare providers — are responsible for their patients' cardiovascular risk assessment and management.
Screening for cardiovascular risk should be performed regularly in all patients with RMDs, with an emphasis on factors like smoking and blood pressure management.
Patient education and counseling on cardiovascular risk, including important lifestyle modifications, is key for RMD patients.
Specific recommendations from the gout, vasculitis, SSc, myositis, MCTD, and SS group include deploying existing cardiovascular prediction tools as they are used in the general population, with the European Vasculitis Society model suggesting to supplement the Framingham Risk Score for patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. They also recommended avoiding diuretics in patients with gout and beta-blockers in patients with SSc, as well as following the same blood pressure and lipid management strategies that are used among the general population.
Recommendations from the SLE and APS group include thoroughly assessing traditional cardiovascular risk factors in all patients, following typical blood pressure management strategies in patients with APS, and setting a blood pressure target of less than 130/80 mm Hg in patients with SLE. They also recommended administering the lowest possible glucocorticoid dose in patients with SLE, along with treatment with hydroxychloroquine — unless contraindicated — and even common preventive strategies like low-dose aspirin if it suits their cardiovascular risk profile.
As for next steps, the task force noted several areas where additional focus is needed, such as identifying patient subgroups with increased cardiovascular risk. This could include patients with a longer disease duration or more flare-ups, older patients, and those with certain disease characteristics like antiphospholipid positivity in SLE.
Can EULAR's Recommendations Be Implemented in US Rheumatology Practices?
"We have been hearing for years that patients with rheumatic diseases have an increased risk of cardiovascular disease," Ali A. Duarte Garcia, MD, a rheumatologist at the Mayo Clinic in Rochester, Minnesota, told Medscape Medical News. "That has been consistently published for more than a decade now. But any further guidance about it has not been issued. I think there was a void there."
"Certainly, cardiovascular disease risk in rheumatoid and psoriatic arthritis has been front of mind for the last decade or so," Christie M. Bartels, MD, chief of the division of rheumatology at the University of Wisconsin, Madison, said when asked to comment on the recommendations. "But in some of these other conditions, it hasn't been."
When asked if rheumatologists would be ready and willing to implement these recommendations, Duarte Garcia acknowledged that it could be challenging for some.
"It's a different workflow," he said. "You've been trained traditionally to assess inflammation, to keep the disease under control, which is something they recommend, by the way. If you control the disease, patients do better. But I think lipid screening, for example, and testing for cholesterol, smoking cessation, those well-established programs are harder to bring to a rheumatology clinic. It's doable, but it's something that needs to be implemented within the current workflows and could take a few years to take hold."
Bartels, however, noted that her group has done extensive work over the last 5 years incorporating certain interventions into practice, including sending patients with high blood pressure back to primary care.
"It's a sustainable intervention in our clinic that basically our medical assistants and nurses do as a routine operation," she said. "Our primary care providers are grateful to get these patients back. Our patients are grateful because otherwise when they come to the rheumatologist, get their blood pressure measured, and don't get feedback, they assume they're OK. So, we're giving them a false signal.
"We have a similar intervention with smoking," she added. "Often our patients aren't even aware that they're at increased risk of cardiovascular disease or that smoking might make their rheumatic disease and their cardiovascular outcomes worse. No one has had that conversation with them. They really welcome engaging in those discussions.
"Our tobacco intervention takes 90 seconds at point of care. Our blood pressure intervention at point of care, we've timed it, takes 3 minutes. There are ways that we can hardwire this into care."
Along those lines, Duarte Garcia stated that the recommendations — although released by EULAR — are largely intuitive and should be very adaptable to an American healthcare context. He also recognized this moment as an opportunity for rheumatologists to consider patient outcomes beyond what they usually encounter firsthand.
"I don't think we have many rheumatologists with patients who get a stroke or heart attack because if that happens, it's in a hospital context or they go see a cardiologist," he said. "You may see it once it happens if they survive and come and see you — or perhaps if you're in a more integrated practice — but I don't think it's as apparent in our clinics because it is a predominantly outpatient practice and many times those are emergencies or inpatient complications.
"The bottom line," he added, "is these are practical guidelines. It's a push in the right direction, but there is still work to be done. And hopefully some of the recommendations, like measuring high blood pressure and addressing it just as in the general population, are something we can start to implement."
Duarte Garcia reported receiving grant funding from the Rheumatology Research Foundation and the Centers for Disease Control and Prevention. Bartels reported that her group's tobacco cessation work is funded by Pfizer's Independent Grants for Learning and Change.
Ann Rheum Dis. Published online February 5, 2022. Full text
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Cite this: EULAR CVD Management Guidance Focuses on Gout, Lupus, Vasculitis - Medscape - Feb 24, 2022.