Rheumatoid Arthritis and the Risk to Your Heart
Rheumatoid arthritis (RA) is often thought of as a disease of the joints, but it’s really much more than that. The chronic inflammation that causes pain and stiffness in the joints can afflict other organs throughout the body, including the heart. In fact, it’s well established that people with RA have an increased risk for heart disease. If you have RA, understanding how the condition affects your heart, and how your treatment and self-care regimen influence your cardiovascular risk, could be a lifesaver.
A threat to the heart
People with RA are up to twice as likely as individuals who don’t have it to develop coronary artery disease (CAD)—the most common form of heart disease and the leading cause of death in the United States. In CAD, the arteries that deliver oxygen-rich blood to the heart become narrowed and clogged due to the buildup of cholesterol-laden plaques. Over time, the buildup can grow and decrease blood flow to the heart, causing chest pains, or angina.
A heart attack, or myocardial infarction, occurs when the blood flow is completely blocked by the buildup or by a blood clot that forms after a plaque has suddenly burst. Although not all heart attacks are fatal, people with RA have a 60 percent increased risk of dying from one.
RA is also associated with other cardiovascular problems. For example, RA patients are twice as likely as people who don’t have the disease to experience heart failure, a condition in which the heart is unable to pump an adequate supply of blood to tissue throughout the body. RA patients are also two to three times more likely to develop blood clots in veins in the legs or other parts of the body, a condition called deep vein thrombosis. A 2012 study in The BMJ found that people with RA are at increased risk for atrial fibrillation (a rapid irregular heartbeat), which is an important risk factor for stroke.
A puzzling connection
One potential reason for the link: Certain factors that increase the risk for RA also heighten the likelihood of developing heart disease. For instance, obesity, which recent research suggests modestly increases the chances of developing RA, is also known to heighten the risk for heart disease. Likewise, cigarette smokers have double the likelihood of developing RA, and it’s well-known that smoking tobacco damages the heart.
However, such associations don’t adequately explain the high rates of CAD among RA patients. Instead, a critical common factor appears to be inflammation. While there is still some debate over this connection, many cardiologists believe that chronic inflammation, which occurs in people with RA, conspires with other factors, such as abnormal cholesterol levels, to increase the risk for cardiovascular disease. Some support for this theory comes from a study showing that RA patients with C-reactive protein levels (a surrogate measure of inflammation in the body) of 5 mg/L or higher had a threefold increased risk of having a fatal heart attack.
There are several other factors that may boost the risk of CAD in people with RA. For example, if RA has affected parts of your body other than the joints, such as the eyes, skin and gastrointestinal system, your heart could be a target, too. In addition, testing positive for rheumatoid factor (RF) and anti-CCP antibodies (antibodies produced when the thin tissue that lines the joint surface [synovium] breaks down) is associated with a greater risk for CAD (though that includes the majority of people with RA). Also, the longer that you have RA, the more likely you are to develop cardiovascular problems.
The role of medications
The drugs you take to manage your RA symptoms can affect your risk for heart disease, in both negative and positive ways. Some commonly used medicines for treating RA symptoms may make you more vulnerable to heart problems (though that concern must be weighed against the potential benefits these drugs offer). Corticosteroids, for example, can increase the risk for heart trouble, especially when administered in high doses. A study in Arthritis & Rheumatism found that RA patients who tested positive for RF and were treated with 7.5 mg of prednisone or more daily tripled their chances of developing cardiovascular disease.
Nonsteroidal anti-inflammatory drugs (NSAIDs)—another mainstay of RA treatment—have been linked to cardiovascular disease, too. In 2015, the U.S. Food and Drug Administration ordered manufacturers of prescription and over-the-counter NSAIDs to strengthen the warnings about heart attack and stroke risks on their products’ labels. If your doctor prescribes an NSAID, he or she will likely recommend the lowest possible dose, and that you use the medication only as needed. If you already have heart disease or a gastrointestinal disorder such as ulcers, your doctor may not recommend NSAIDs.
Meanwhile, some of the same medications that keep RA symptoms under control could also lower the risk for CAD. Take, for example, the disease-modifying antirheumatic drug (DMARD) methotrexate. One study of 40 people with RA found that treatment with methotrexate increased HDL cholesterol—the “good” kind that unclogs arteries—and lowered LDL cholesterol, the dangerous type. Importantly, ultrasound studies of the methotrexate users showed that the thickness of the walls of their carotid arteries (which are located on each side of the neck) had decreased; increasing thickness of these walls indicates a high risk for developing cardiovascular disease in the future. The verdict is still out on tumor necrosis factor (TNF) inhibitors, which include drugs such as adalimumab (Humira) and etanercept (Enbrel). However, some evidence suggests they may offer cardiovascular protection, too.
A 2011 review of several different types of studies found that treatment with TNF inhibitors may slash the risk for cardiovascular disease by as much as 50 percent. However, when only the “gold standard” studies known as randomized controlled trials were considered, the heart benefits of TNF inhibitors were far less clear-cut. Consequently, more research is needed to clarify whether TNF inhibitors actually offer any heart benefits.
Interestingly, some individuals with RA who take a cholesterol-lowering statin drug, such as atorvastatin (Lipitor) or simvastatin (Zocor), to reduce CAD risk report that their RA symptoms improve slightly, possibly because statins produce a mild anti-inflammatory effect.
Protect your joints—and your heart
The good news is that some of the lifestyle measures that can help manage RA will also lower the risk for cardiovascular disease. Following are three:
1. Fight fat. If you’re overweight or obese, consuming a healthy, calorie-controlled diet with the goal of losing weight is not only helpful for easing stress on your joints, but also necessary for heart health. Particularly worrisome is body fat that forms around the abdomen, which greatly increases the risk for high blood pressure and insulin resistance (a cause of type 2 diabetes, which raises the risk for heart disease). Fat also increases inflammation.
2. If you smoke, quit. Smoking lowers HDL cholesterol levels, damages blood vessels and promotes atherosclerosis (hardening of the arteries) and blood clot formation.
3. Exercise. If you don’t already exercise regularly, talk to your physician about starting a workout plan. As a person with RA, you’ll need to think carefully about what type of exercise makes sense for you, since many patients need to avoid activities that are tough on the joints, like jogging or tennis. But that still leaves a wide number of options—such as walking, swimming or tai chi—that can help keep your joints moving and heart pumping.
Additional heart-healthy moves that you should make: Get your blood pressure and your cholesterol levels checked regularly, and if your doctor prescribes medication for hypertension or high cholesterol, be sure to take it.