Background/Purpose:

 Despite increased cardiovascular (CV) risk in rheumatoid arthritis (RA), chest pain and angina have received little attention among RA patients.  We examined the frequency of chest pain and angina, and their ability to predict CV mortality in an RA cohort, compared to controls from the general population.

Methods:

We recruited consecutive RA patients from public and private rheumatology practices. All patients underwent a comprehensive clinical and psychosocial assessment, and were followed prospectively over time until they died, or were lost to follow-up. Population-based controls were sampled from census tracks and recruited in their homes and followed prospectively as well. Patients and controls were interviewed by certified personnel for the presence of chest pain and angina pectoris using the Rose angina questionnaire, a standardized instrument designed for assessing the presence of angina pectoris in epidemiological studies.  We ascertained deaths from family members, physician or hospital records, obituaries or public databases. We obtained certificates for all deaths. Deaths were attributed to CV causes using established criteria.

We used logistic regression to compare the baseline frequency of chest pain and angina between RA and controls, adjusting for age and sex. We used Cox proportional hazard models to examine the age- and sex-adjusted association of chest pain and angina with CV mortality in cases and controls.

Results:

We studied 1211 RA patients, of whom 906 were women (75%) and 5158 controls, of whom 2937 were women (56%). The mean follow-up time was 8745 person-years for RA cohort and 73,403 person-years for the control group. During this time there were 278 deaths in RA cohort, for a mortality rate 1.3 per 100 person-years, and 547 in the controls, for a mortality rate of 0.3 per 100 person-years.

Chest pain was more frequent in RA than in controls, with an age-sex adjusted frequency of 47% vs 31%, p < 0.0001, as was angina, age- and sex-adjusted frequencies of 11.7% vs 4.2%, p < 0.001, (Figure). Chest pain was a significant predictor of CV mortality in the RA patients (age-sex adjusted) HR 1.65, (95% CI 1.13-2.39), but not in the controls, adjusted HR 1.09 (95% CI 0.85, 1.41). Angina predicted CV mortality in both cohorts, adjusted HR 1.84(95% CI 1.0, 3.36) for RA and adjusted HR 1.77 (95% CI 1.15-2.72) for controls.

Conclusion:

These findings suggest that chest pain and angina are more frequent in RA than in controls, and that these symptoms are significant predictors of CV mortality.   Clinicians should be aware that RA patients experiencing chest pain may be at high risk of death from CV causes.