Background/Purpose Previous studies have suggested that disease modifying anti-rheumatic drugs (DMARDs) may reduce cardiovascular risk among patients with rheumatoid arthritis (RA). This analysis examined whether DMARD use after an initial acute myocardial infarction (MI) was associated with reduced risk of having a recurrent MI and mortality among older RA patients.

Methods We identified RA patients who were enrolled in Medicare (which covers more than 90% of all individuals 65 or older in the U.S.) and had an acute MI from 2006 to 2011. Eligibility criteria included the following: 1) had ≥2 rheumatologist visits with a diagnosis code for RA during a baseline period of at least 365 days prior to follow-up start; 2) had an acute MI defined as having an inpatient hospital claim with a discharge ICD-9 diagnosis code 410.X (excluding 410.x2) in any position and at least one overnight inpatient stay, unless the patient died.  Follow-up started at time of discharge from the hospital after the initial MI. We used multivariable proportional hazard regression to examine the association between DMARD use after the initial MI and risk of having a recurrent MI and mortality, adjusting for factors ascertained during baseline (socio-demographics and CHD risk factors [diabetes, hypertension, chronic kidney disease, abdominal aortic aneurism, peripheral arterial disease, atrial fibrillation, hyperlipidemia, tobacco use, overweight/obese, heart failure, chronic obstructive pulmonary disease]), and after MI (medications for hypertension, hyperlipidemia, and RA). Exposure to DMARDs after MI was categorized into the following exclusive hierarchical groups: 1) any anti-TNF biologic DMARD use; 2) any non-anti-TNF biologic DMARD use; 3) any methotrexate (MTX) use; 4) any non-MTX non-biologic DMARDs use (reference group, mostly hydroxychloroquine, sulfasalazine, and leflunomide use); and 5) no DMARD use.

Results We identified 13,985 eligible RA patients with mean age 74 (SD 11) years, 74% of whom were women. Compared to the reference group of any non-biologic and non-MTX DMARD use, non-TNF biologic DMARD use was associated with reduced mortality (hazard ratio [HR] 0.30 and ; 95% confidence interval [CI] 0.14-0.68]) and recurrent MI (HR: 0.22, 95% CI: 0.07-0.69).  Compared to the same reference group, any MTX use was associated with reduced mortality (HR: 0.71, 95% CI: 0.62-0.81) but not with recurrent MI.  Oral glucocorticoid use (compared to no use) was significantly associated with increased mortality at low (≤ 7.5mg/d [HR: 1.26, 95% CI: 1.18-1.34]) and high doses (> 7.5mg/d [HR: 1.73, 95% CI: 1.60-1.87]) and with recurrent MI at doses > 7.5 mg/d (HR: 1.29, 95% CI: 1.12-1.48).

Conclusion Our findings suggest that among older RA patients, non-TNF biologic use and MTX use after an acute MI were associated with reduced risk of having a recurrent MI and mortality compared to non-biologic and non-MTX DMARD use, where glucocorticoid use was associated with increased risk of both outcomes. These results should be interpreted with caution given the possibility of residual confounding in observational studies.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/dmard-use-after-an-initial-acute-mi-is-associated-with-reduced-risk-of-a-recurrent-event-and-mortality/