Background/Purpose: Rheumatoid arthritis has been associated with an increased risk of cardiovascular morbidity and mortality.  It is unclear, however, whether this knowledge has translated into improved screening and management of traditional cardiovascular risk factors such as hyperlipidemia in the primary care setting.  The objectives of this study included 1) To determine the prevalence of screening for hyperlipidemia in patients with rheumatoid arthritis (RA) that are followed by primary care physicians; 2) To examine whether current Adult Treatment Panel (ATP) III guidelines for the initiation of lipid-lowering therapy are being followed in patients with RA, and 3) to assess whether proposed modifications to cardiovascular risk calculations change the percentage of RA patients with an indication for therapy.

Methods: A retrospective cohort study was performed among patients with RA in an academic medical center medical record database in the United States between 2005-2010.  A validation study prior to initiation of the study demonstrated a positive predictive value of 96.7% for accurate capture of patients with RA using ICD-9 codes.  Descriptive statistics were used to report the prevalence of screening and use of lipid-lowering therapy (LLT) among those with an indication for LLT.  Factors associated with not receiving lipid screening were examined using logistic regression models.  Finally, indication for and receipt of therapy were assessed following application of the European Union League Against Rheumatism (EULAR) recommended multiplier to the Framingham risk score.

Results: Among 1418 patients with RA followed by primary care physicians, lipid screening was ordered for 780 (55%) within the 3-year follow-up period.  Patients under the age of 50 were significantly less likely to be screened whereas patients with diabetes, hypertension, chronic kidney disease, and obesity were more likely to be screened (Table).  Of those with lipid results (N=419), 50 (12%) patients had an indication for LLT based on the ATP III guidelines.  Among the 50 patients with an indication for LLT, 38 (76%) received therapy.  Applying the EULAR multiplier only changed the indication for LLT in two patients.

Conclusion: Although patients with RA have an increased risk for cardiovascular disease, they are often not receiving optimal management of traditional cardiovascular risk factors, such as screening for hyperlipidemia.  Nevertheless, once hyperlipidemia has been identified, most patients received the appropriate lipid-lowering therapy.  The EULAR multiplier does not seem to have a measurable impact on clinical care, and new methods for assessing cardiovascular risk among patients with RA are needed.

Table. Logistic regression models for non-receipt of screening*