Background/Purpose: Rheumatoid arthritis (RA) is a disease associated to accelerated atherogenesis leading to increased incidence of cardiovascular (CV) mortality. Adequate stratification of the CV risk in patients with RA is still far from being completely established. Several validated noninvasive imaging techniques may be useful to determine subclinical atherosclerosis, such as the assessment of carotid intima-media thickness (cIMT) and the presence of plaques by carotid ultrasonography (US) and the assessment of  coronary artery calcification (CAC)  by the Multi-Detector Computed Tomography (MDCT). Objective: To determine the ability of CAC Score (CACS) and carotid US to detect subclinical atherosclerosis in patients with RA.

Methods: A set of 104 consecutive RA patients without history of CV events was studied to determine CACS, cIMT and carotid plaques. The Systematic Coronary Risk Evaluation (SCORE) modified according to the EULAR recommendations (mSCORE) was also assessed.

Results: The mean disease duration was 10.8 years, 72.1% had rheumatoid factor and/or anti-CCP positivity and 16.4% extra-articular manifestations. Nine were excluded because they had type 2 diabetes mellitus or chronic kidney disease. CV risk was categorized in the remaining 95 RA patients according to the mSCORE as follows ( Table 1) : low (n=21), moderate (n=60) and high/very high risk (n=14). Most patients with low mSCORE (16/21; 76.2%) had normal CACS (zero), and none of them CACS>100. However, a high number of patients with carotid plaques was disclosed in the groups with CACS 0 (23/40; 57.5%) or CACS 1-100 (29/38; 76.3%). Seventy-two (75.8%) of the 95 patients fulfilled definitions for high/very high CV as they had mSCORE ≥5% or mSCORE <5% plus one of the following findings: severe carotid US findings (cIMT>0.9 mm and/or plaques) or CACS>100 ( Table 2 ) . A CACS>100 showed sensitivity similar to mSCORE (23.6% versus 19.4%). In contrast, the presence of severe carotid US findings allowed identifying most patients that met definitions for high/very high CV risk (70/72; sensitivity 97.2% [95% CI: 90.3-99.7]). 

Conclusion: Carotid US is more sensitive than CACS for the detection of subclinical atherosclerosis in RA.

Table 1. SCORE risk, mSCORE risk im 95 RA patients without CV events. EULAR mSCORE according to the CACS>100, cIMT > 0.90 mm and carotid plaques
	SCORE	mSCORE	mSCORE	mSCORE	mSCORE	mSCORE
Cardiovascular Risk			CACS	Carotid US	Carotid US	Carotid US
	n	n	CACS >100 n= 17 (%)	cIMT >0.90 mm n=14 (%)	Carotd plaques n=69 (%)	cIMT>0.90 mm and/or carotid plaques n=70 (%)
Low (< 1%)	21	21	0/21 (0.0)	0/21 (0.0)	7/21 (33.3)	7/21 (33.3)
Moderate (≥1% and < 5%)	63	60	12/60 (20.0)	8/60 (13.3)	51/60 (85.0)	51/60 (85.0)
High (≥ 5% and < 10%)	9	10	4/10 (40.0)	5/10 (50.0)	8/10 (80.0)	9/10 (90.0)
Very High (≥ 10%)	2	4	1/4 (25.0)	1/4 (25.0)	3/4 (75.0)	3/4 (75.0)
High plus Very High	11	14	5/14 (35.7)	6/14 (42.8)	11/14 (78.6)	12/14 (85.7)

 

Table 2. Sensivity of high/very high CV risk in RA patients without CV events, using EULAR mSCORE, carotid US findings (cIMT>0.90 mm or plaques) or CACS >100
Gold standard	n=72/95
mSCORE >5%	n=14 of 72 19.4% (95% CI:11.1-30.5)
CACS >100	n=17 of 72 23.6% (95% CI:14.4-35.1)
cIMT >0.90 mm and/or carotid plaques	n=70 of 72 97.2% (95% CI: 90.3-99.7)
mSCORE > 5% or mSCORE <5% plus CACS >100	n=26 of 72 36.1% (95% CI:25.2-48.3)
mSCORE >5% or nSCORE <5% plus one of the following: cIMT >0.90 mm or carotid plaques	n=72 of 72 100% (95% CI:95.0-100)
Note: Gold Standard for high/very high cardiovascular risk: a) mSCORE ≥5% or b) mSCORE <5% plus one of the following: severe carotid US findings (cIMT>0.90 mm or carotid plaques) or CACS >100

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