Background/Purpose:
Rheumatoid
arthritis (RA) is associated with increased cardiovascular (CV) morbidity and mortality
as compared to the general population. Recent prospective studies with limited
follow-up suggest a trend towards decreasing CV fatality in RA. Longitudinal
studies of CV mortality trends in RA patients diagnosed in the recent years are
lacking, and the trends in the relative CV mortality in RA versus the general population
are not fully understood. We aimed to assess trends in
CV mortality in patients with incident RA in 2000-2007 compared to the previous
decades, and to evaluate trends in relative CV mortality in RA compared to
non-RA subjects.

Methods: The
study population comprised a retrospectively identified population-based
incidence cohort of patients with RA (age≥18 years, 1987 ACR criteria
met in 1980-2007). A comparison cohort included non-RA subjects from the same
underlying population with similar age, sex and calendar year of index. All
subjects were followed until death, migration, or Jan. 1, 2014. Underlying
causes of death were obtained from state and local death certificates as well
as the National Death Index Plus and grouped according to ICD-9 and ICD-10
chapters. Kaplan-Meier methods were used to estimate CV mortality
rates. Cox
proportional hazards models, adjusting for age and sex, were used to compare CV
mortality by decade.

Results: The
study included a total of 813 RA patients (mean age 55.9
years; 68% female; 66% rheumatoid factor [RF] positive) and 813 non-RA subjects
(mean
age
55.9 years; 68% female). Figure shows CV mortality by decade of RA
incidence/index date and the table summarizes these data. In patients
with incident RA during the 2000–2007 period, the 10-year overall CV mortality
was 2.8% (95% confidence interval [CI]: 0.4%, 5.2%); coronary heart disease (CHD)
mortality was 1.2% (95% CI: 1.0, 1.4%), suggesting significant improvement compared
to those diagnosed in 1990–1999  (hazard ratio [HR] for overall CV death: 0.43;
95% CI: 0.19, 0.94; p=0.035; CHD death: HR 0.21; 95% CI: 0.05, 0.95; p=0.042). Furthermore,
10-year overall CV mortality and CHD mortality in 2000-2007 RA incidence cohort
did not differ from non-RA subjects (p=0.95 and p=0.79, respectively), which
has not been observed in RA patients diagnosed in the prior decades.

Conclusion:
Our
findings suggest significant improvement in overall CV mortality, particularly CHD
mortality, among patients with incident RA in 2000-2007 versus patients with incident
RA in the previous decades. Furthermore, we have shown significant improvement
in the relative 10-year CV mortality, including CHD mortality, in patients with
incident RA in 2000-2007 versus the general population. These findings represent
an important milestone in CV disease management in RA with significant implications
for understanding determinants of improvement of CV disease in RA and in the
general population.