The new study, which appears in the December issue of the Journal of Internal Medicine, is not the first to link RA and heart disease, but it does show that an increased risk of heart attack begins one year after RA diagnosis.
RA is an autoimmune disease that occurs when the body’s immune system misfires against its own joints and connective tissues, causing inflammation, pain, and problems with dexterity and mobility. This inflammation may also play a role in risk for heart disease.
Marie Holmqvist of Karolinska Instituet in Stockholm, Sweden, and colleagues followed 7,469 people who were diagnosed with RA from 1995 to 2006 for about 12 years to see how many of them developed heart disease and heart attacks compared with 37,024 people without RA.
Among people with RA, the risk of heart attack was 60% higher and the risk of other forms of ischemic heart disease was 50% higher beginning one year after their diagnosis compared to their counterparts without RA. "Our research underlines the importance of clinicians monitoring patients diagnosed with RA for an increased risk of heart problems, in particular heart attacks," Holmqvist says in a news release. "It is also very clear that more research is needed to determine the mechanisms that link these two health conditions.”
In recent years, the emphasis has been on early, aggressive RA treatment in the hopes of preventing many RA complications, including mobility issues and potential heart disease. In the new study, however, this increased heart risk was still seen in people who were diagnosed in the past decade and presumably treated aggressively.
Heart Risk Occurs Sooner After RA Diagnosis Than Thought
“We have long known there is an increased cardiovascular risk in patients with RA and other inflammatory diseases, but the new perspective is how this risk quickly occurs,” says David Pisetsky, MD, chief of rheumatology at Duke University Medical Center in Durham, N.C.
“Most of us would have thought that it would have taken longer for this risk to be seen, but this study says the risk increases almost from the time of diagnosis,” he says.
This timing is important in terms of understanding why this increased cardiovascular risk occurs, he says.
“There are conventional heart disease risk factors and there are others that people don’t fully understand, such as the contributors of inflammatory mediators to heart disease,” he says. People with RA have active immune systems, and that promotes inflammation in the blood vessels as well as in the joints, which may affect the heart, he says.
Efforts Aimed at the Prevention and Awareness of Heart Disease Risk Factors in RA
Until researchers sort out the all the whys, people with RA need to be aware of the symptoms of heart attack and heart disease. “It can be clear-cut like crushing chest pain, but people with RA have pain and it is easy to say ‘my chest or shoulder hurts because of RA,’ but in fact it may be related to heart disease,” Pisetsky says. Women, especially, experience more nontraditional heart attack symptoms, such as dizziness, nausea, and fatigue. Women are also disproportionately affected by RA.
“Get the RA under control and address any of the modifiable risk factors for heart disease,” he says. “People with RA shouldn’t smoke and they should lose weight, if they are overweight, and exercise.”
Martin J. Bergman, MD, the chief of the division of rheumatology at Taylor Hospital in Ridley Park, Pa., and a clinical associate professor at Drexel University College of Medicine in Philadelphia says, “The heart attacks are occurring much earlier than we thought. We always knew about this risk, but we thought it was down the line.”
“Despite aggressive therapies, people with RA still have an increased risk of heart attacks, which is somewhat dismaying,” he says.
Is Early, Aggressive RA Treatment Aggressive Enough?
“We know that current treatments are reducing heart attack risk compared to no treatment, but that we are still not eliminating RA-heart disease risks, so this says there is something else going on besides what we are treating.”
Jane Salmon, MD, a senior scientist and Colette Kean Research Chair, Hospital for Special Surgery in New York City, agrees.
“We may not be targeting the right inflammatory mediators or early aggressive treatment may not be aggressive enough,” she says. “There may still be smoldering inflammation.”
Low disease activity doesn’t mean no disease activity, she says.
“We don’t know how low is low enough to affect inflammation in the cells that line the blood vessels,” she says, adding that this inflammation may be present before RA symptoms occur, and a diagnosis is established.
“At this time, all we can say is rigorous attention to other cardiovascular risk factors is critical in RA patients,” she says.
“If you have RA, your chance of having a heart attack is definitely higher than someone who does not have RA,” says Eric Matteson, MD, chair of the department of rheumatology at the Mayo Clinic in Rochester, Minn. “If you smoke, quit; and work to get your general and heart health under control, including cholesterol and blood pressure, if they are elevated,” he says. “If you have diabetes, get that under control and try to be fit and exercise to what you can tolerate [due to joint pain].”