Background/Purpose: Rheumatoid arthritis (RA) is associated with increased risk of cardiovascular disease (CVD). Disease severity, including extra-articular rheumatoid arthritis (ExRA) manifestations, has previously been demonstrated to be a major risk factor for CVD. With improved treatment possibilities, it is important to assess potential changes in the effect of disease severity measures on development of CVD in patients with RA. The aim of this study was to investigate the impact of patient reported outcome measures (PROMs) and severe ExRA on the risk of CVD in a community based sample of patients with RA.

Methods:

A dynamic community based cohort of patients with RA (n=1977) was studied. Information on CVD events was obtained from a regional health care register. Clinical records were reviewed from January 1, 1998 to December 31, 2011, and cases with severe ExRA (i.e. pericarditis, pleuritis, vasculitis, interstitial lung disease, neuropathy, episcleritis/scleritis, Felty’s syndrome and glomerulonephritis), classified according to predefined criteria, were identified. The impact of time dependent incident severe ExRA on CVD was examined in Cox regression models. Questionnaires including the Health Assessment Questionnaire (HAQ) and visual analogue scales (VAS) for current pain and global health were sent to the patients in 1997, 2002, 2005 and 2009. The impact of baseline PROMs, based on the first available questionnaire for each patient, on the risk of CVD was examined in Cox regression models.

Results:

There were 1436 (72.6%) women and 541 (27.6%) men in the study cohort. At the start of follow-up the mean age was 59.9 years and the median disease duration was 5.0 years. During the follow-up, 619 patients had at least one CVD event. There were 387 cases with coronary artery disease (CAD), 221 with cerebrovascular disease and 185 with peripheral artery disease (PAD). Seventy-two patients with a previous history of severe ExRA were excluded. Incident severe ExRA (n=121) did not predict CVD overall [age and sex adjusted HR 0.99; 95% CI 0.70-1.39], CAD, cerebrovascular disease or PAD. In a sensitivity analysis, episcleritis and pleuritis (n=34), which may be regarded as milder ExRA manifestations, were excluded. Severe ExRA was still not associated with a significantly increased risk of CVD (age-sex adjusted HR 1.21; 95 % CI 0.85-1.71), although there was a borderline association with PAD (age-sex adjusted HR 1.68; 0.99-2.84). Greater disability, measured by HAQ at baseline, was predictive of CVD [age and sex adjusted HR (per SD) 1.13, 95% CI 1.03-1.25]. There was a positive association between HAQ and CAD as well as PAD, but not with cerebrovascular disease. Similar patterns were seen in models including VAS for current pain and global health, which were both predictive of CVD overall, CAD and PAD, but not of cerebrovascular events.

Conclusion: Severe ExRA did not predict cardiovascular disease in this cohort of patients with RA. Potential explanations for this discrepancy from previous studies include differences in case selection and improved management of ExRA over time. Disease severity, measured by PROMs, predicted the occurrence of CVD, with the exception of cerebrovascular disease.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-impact-of-severe-extra-articular-manifestations-and-patient-reported-outcome-measures-on-cardiovascular-disease-in-rheumatoid-arthritis/