Closing the Mortality Gap: RA and Heart Disease
It’s called the mortality gap. And none of us like to think about it.
The average life expectancy of people with RA is 10 years less than the general population. RA is a systemic disease that affects not just our joints, but also our internal organs. The mortality gap exists because the systemic inflammation of RA leads to a higher incidence of heart attack and stroke.
But there's good news. A few weeks ago at the 2012 meeting of the European League Against Rheumatism (EULAR) in Berlin, researchers [presented a paper showing a dramatic reduction in heart attacks in people taking anti-TNF medication], such as Enbrel, Humira and Remicade.
There has been some evidence previously that these medications reduce the risk of cardiovascular events, but this new study followed the progress of more than 100,000 people on anti-TNF drugs over time. Results showed that the longer someone takes anti-TNF medication, the lower their risk of heart disease gets. After one year on anti-TNF medication, the risk was lowered 24 percent, after two years 42 percent and after three years 56 percent compared to those who are treated with more conventional DMARDs, such as methotrexate and other non-Biologics.
The researcher who performed the study, Dr. Michael T. Nurmohamed stated in an interview that "It appears that in patients with RA, atherosclerotic plaques rupture earlier … we know that inflammation is very important in that process. It might be that when you treat patients with an anti-TNF drug or other anti-inflammatory, you reduce the inflammatory content of the plaque. Therefore the plaque ruptures later. That may be the way that anti-TNF drugs lower myocardial infarctions.” Further studies are needed to clarify the role anti-TNF drugs play in reducing cardiovascular events.
Does this mean that you need to rush to your rheumatologist and insist on being treated with anti-TNF medication? Dr. Nurmohamed stated that the evidence does not yet support such a decision. He emphasized, however, that "the literature does indicate that effective inflammatory suppression is essential for patients with RA, and that if this is not achieved within a reasonable time frame with high-dose methotrexate or another DMARD then treatment with a biological, anti-TNF drug should be considered."
This is further support for the treat-to-target or tight control model in which the effect of RA treatment is assessed frequently and, if judged to not have sufficient impact, adapted to ensure suppression of active disease. The goal is to treat to remission or low disease activity. Dr. Nurmohamed says the "take-home message is that disease activity should be reduced a much as possible, first by DMARDS. If that is not enough, biologics should be considered."
Managing the Risk
Living with RA includes keeping your eye on a number of issues. Until recently, there has been very little focus on the cardiovascular aspect of RA. Rheumatologists specialize in controlling inflammation and tend to focus primarily on your joints. Therefore, they may not talk to you about the increased risk of heart disease. However, EULAR has released evidence-based recommendations for managing cardiovascular risk in people with RA and other types of inflammatory arthritis. These guidelines are intended both for rheumatologists and general practitioners. The ACR does not appear to have followed suit yet, but with the accumulating evidence about the impact of Biologics on the systemic aspects of RA, this will likely change in the future. Hopefully it will lead to rheumatologists having a more comprehensive view of treating RA in the future.
Your primary care physician is the first contact for issues related to your general health, but most have only limited knowledge about RA in general and the systemic manifestations of the disease in particular. It's important that you advocate for yourself in this respect. Make sure managing the risk of heart disease is an important factor in the care provided to you by your family doctor.
This can include establishing a baseline as early as possible in terms of your blood pressure, cholesterol and blood sugar so you can track changes over time. You should also have a conversation with your doctor about when to start other preventative tests, such as stress tests, balancing the need to stay vigilant with avoiding unnecessary tests. You may also want to talk to both your rheumatologist and your family doctor about whether a referral to a preventative cardiologist would be helpful in managing the risk. For most people, this may not be necessary, but if you have a number of risk factors, such as family history, high blood pressure, smoking, and being overweight, it may be worth considering.
This study showing a reduction in cardiovascular risk in people treating with anti-TNF drugs is very good news. The evidence provided by this study and others shows that suppressing the inflammation of RA has a positive impact on general health and life expectancy. Increased awareness of the systemic aspect of RA, including cardiovascular events, will lead to better health care for those of us who live with the disease.
December, 2015 update: in the three years since this article was written, cardiovascular health in people with RA has continued to improve. A recent study found that in people diagnosed since 2000, the risk of death from cardiovascular disease is now comparable to the general population. The cause for this massive improvement is theorized to be more effective treatments (likely Biologics), efforts to diagnosed earlier, and an increase awareness and vigilance about the cardiovascular risk.