Background/Purpose: Cardiovascular (CV) disease is one of the major causes of mortality in rheumatoid arthritis (RA). Although the CV risk in RA is well-recognized, detection of high risk patients and prevention of CV disease are still major challenges.  We aimed to determine which CV risk estimation index is better in RA patients and to determine the factors that may improve CV risk estimation in RA.

Methods: Two-hundred and ten consecutive RA patients without history of CV disease or diabetes mellitus were assessed. Systematic Coronary Risk Evaluation (SCORE), 2013 American College of Cardiology/American Heart Association (ACC/AHA) 10-year atherosclerotic CV disease risk (ASCVD), QRisk II indices and their modified versions (mSCORE, mASCVD, mQRisk II) according to EULAR recommendations were calculated. All patients were evaluated with carotid ultrasonography (US). Carotid intima-media thickness (cIMT) > 0.90 mm and/or carotid plaques were used as the gold standard test for subclinical atherosclerosis and high CV risk (US+). Retrospectively, along with disease characteristics, DAS28 scores, ESR and CRP values of each visit during the entire follow-up of RA patients were recorded and average DAS28, ESR and CRP were calculated.

Results: The study cohort consisted of 210 RA patients (F/M= 169/41, mean age 52.5±11.4) with a mean disease duration of 11.1±7.0 years. The EULAR multiplier factor was used in 95 (45.2%) patients. The mean mSCORE was 1.6±2.5%, mASCVD risk was 5.8±7.1%.and mQRisk II was 9.8±9.6%. Eleven (5.2%), 61 (29%) and 80 (38.1%) patients were defined as having high CV risk (mSCORE≥5%, mASCVD≥7.5%, mQRiskII≥10%) according to mSCORE, mASCVD and mQRisk II, respectively. Concerning US results, 50 (23.8%) patients had either cIMT> 0.90 mm or carotid plaques. The mASCVD and mQRisk II indices better identified US+ patients, that 29 (58%) and 30 (60%) of the US+ patients were in high risk group according to mASCVD and mQRisk II, respectively. Whereas only 8 (16%) of the US+  patients were in high risk group according to mSCORE (P<0.0001). However mASCVD and mQRisk II still failed to identify 42% and 40% of US+ patients. When traditional risk factors and disease characteristics of US+ and US- patients were compared, it was found that US+ patients were older at diagnosis, had higher average DAS28 scores, average ESR and CRP levels. Impaired fasting glucose was also higher in US+ patients along with similar rates of biologic treatment, steroids and NSAIDs (Table 1). 

Conclusion: EULAR recommendation for CV risk assessment,  SCORE, seems inadequate even after modification according to RA characteristics. On the other hand QRisk II and ACC/AHA 10-year ASCVD risk indices are better in estimating CV risk in RA patients. However, still additional modifications, like age at disease onset, cumulative disease activity and inflammatory biomarkers are required to fully identify high-risk RA patients. 

Table 1.Characteristics of US(+) and US(–) RA patients

	US(+) (n=50)	US(–) (n=160)	P Value
Female, n (%)	35 (70)	134 (83.8)	0.032
Age (years)	58.8±8.3	50.5±11.5	<0.0001
Age at diagnosis (years)	48.3±8.8	39.3±11.1	<0.0001
Disease duration (years)	10.5±7.6	11.3±6.9	0.49
RF and/or Anti-CCP positivity, n(%)	40 (80)	124 (77.5)	0.70
Extra-articular involvement, n (%)	10 (20)	45 (28.1)	0.25
Average DAS28 score¶	4.04±1.1	3.59±0.97	0.007
HDA visits/Total visits†	24.4±26.9	15.6±21.3	0.018
Average ESR (mm/h) ¶	32.5±14.2	24.4±12.0	<0.0001
Average CRP (mg/L) ¶	14.1±12.2	8.9±8.1	0.001
HAQ score	0.48±0.49	0.58±0.63	0.31
Hypertension, n (%)	19 (38)	53 (33.1)	0.52
Hyperlipidemia, n (%)ƪ	38 (76)	90 (56.2)	0.012
Impaired fasting glucose, n (%)ǂ	12 (24)	19 (11.9)	0.035
Ever-smoked, n (%)	22 (44)	42 (26.2)	0.017
Total cholesterol/HDL-cholesterol	4.0±1.64	3.5±1.09	0.015
mSCORE	2.8±2.5	1.2±2.4	<0.0001
mASCVD	8.9±7.7	4.8±6.6	<0.0001
mQRisk II	14.5±10.8	8.3±8.7	<0.0001
Current corticosteroid, n (%)	29 (58)	83 (51.9)	0.44
Biologic treatment (ever), n (%)	23 (46)	92 (57.5%)	0.15

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