Cardiovascular risk in Rheumatoid Arthritis and other inflammatory disorders: Clinical management and interventional aspects

Maaike Heslinga

    Research output: PhD ThesisPhD Thesis - Research VU Amsterdam, graduation VU Amsterdam

    118 Downloads (Pure)

    Abstract

    The risk for cardiovascular disease in rheumatoid arthritis (RA) patients has been a concern for the last two decades; since research showed that this risk is increased compared to the general population. In 2009, the European League Against Rheumatism (EULAR) task force recommended screening, identification of CVD risk factors and CVD risk management in RA patients. Since then, substantial new insights in this field has been published, largely based on expert opinion. In the updated recommendations on cardiovascular risk management from the EULAR task force, three overarching principles and 10 recommendations were formulated. These recommendations, are meant to facilitate CVD risk management in daily clinical practice, ultimately leading to a decreased CVD burden in RA patients. We conducted the I-CaRe Project in Reade, Amsterdam, and Antonius Hospital, Sneek to investigate and optimize cardiovascular risk management. Over half of our patients (53%) were found to have a high cardiovascular risk. Furthermore, we identified (under) treatment of CV risk factors in these patients. In total, 69% had an indication to use cholesterol lowering or antihypertensive drugs. Of those, 42% received inadequate treatment and 40% received no treatment at all. Despite clear guidelines, both local (Dutch guideline) and international, like the EUAR guideline, and the active implementation of a screening program, we have to conclude that optimal CV risk management remains a major challenge in the RA population. Not only cardiovascular risk management, but also the prediction of cardiovascular risk itself remains a challenge in the RA population. It appears to make most sense to calculate cardiovascular risk during the period that RA patients are in a state of low or stable disease activity. This of course needs to be further investigated by studies using longer follow up. As stated in de EULAR recommendations, patients with RA not only suffer from a higher cardiovascular burden, but also demonstrate increased prevalence of other inflammatory autoimmune disorders. We demonstrated an increased prevalence proportion of type 1 diabetes, hypothyroidism, psoriasis and Crohn’s disease/ulcerative colitis in patients with inflammatory arthritis compared with controls. Moreover, patients with inflammatory arthritis more often had one or more concomitant autoimmune disorders. We confirmed once again the increased cardiovascular risk for patients with inflammatory arthritis, and found that this risk was further amplified in the presence of another coexistent autoimmune disorder. The amplification of cardiovascular disease risk in inflammatory arthritis patients with multiple autoimmune disorders warrants greater awareness for this phenomenon, and since autoimmune disorders often co-exist, the need for cardiovascular risk management in these patients is once again emphasized. In a study using data from a longstanding prospective cohort we investigated the effect of thyroid dysfunction on incident CVD compared to euthyroid RA patients. We found that patients with RA and subclinical hypothyroidism had an increased risk for new CVD. We demonstrated associations between RA disease activity and the biomarkers NT-proBNP and sRAGE in a cohort of very early arthritis patients that started anti-rheumatic treatment. During 6 months of treatment with anti-inflammatory medication, NT-proBNP decreased and sRAGE increased, independent of the type of medication used. In an observational cohort, we studied the effects of etanercept on lipid metabolism and other cardiovascular risk factors in patients with psoriatic arthritis. As coagulation and inflammation are closely linked, we investigated the changes in markers of coagulation in patients with AS starting the TNF-blocker golimumab.
    Original languageEnglish
    QualificationPhD
    Awarding Institution
    • Vrije Universiteit Amsterdam
    Supervisors/Advisors
    • Nurmohamed, Mike, Supervisor, External person
    • Smulders, Y.M., Supervisor, External person
    • Simsek, S., Co-supervisor, External person
    • Griep, E.N., Co-supervisor, External person
    Award date19 Mar 2021
    Publication statusPublished - 19 Mar 2021

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