DMARD Treatment for Early RA Improves Heart Disease

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Vascular stiffness―which is often the precursor to a major cardiovascular event―appears to be present in early rheumatoid arthritis, shows a new study published in the Annals of the Rheumatic Diseases.

The study, by Maya H Buch, Ph.D. FRCP, of the University of Manchester in the United Kingdom, finds that DMARD therapy, in this case etanercept and methotrexate, or initial methotrexate-treat-to-target strategy, improved vascular stiffness in early rheumatoid arthritis patients.

The report is significant because rheumatoid arthritis patients have a mortality risk that is three times higher than the general population, which is largely due to premature cardiovascular disease, particularly, atherosclerosis and heart failure. The risk is comparable to that of traditional high-risk populations, such as type two diabetes patients.

The study is based on an analysis of 81 patients with early rheumatoid arthritis who were enrolled in a phase four randomized trial in which they received either etanercept with methotrexate or a methotrexate treat-to-target escalation strategy of etanercept and methotrexate. While neither treatment strategy performed significantly better than the other, the notable improvement was in the presence of vascular and myocardial abnormalities.

The patients in this trial―the first of its kind―had no history of cardiovascular disease and no more than one traditional risk factor. Cardiac magnetic resonance imaging taken at baseline and years one and two showing that aortic distensibility was significantly lower (3.0×10−3 mm Hg−1 (2.7–3.3) vs 4.4×10−3 mm Hg−1 (3.7–5.2), p<0.001); left ventricular mass was significantly lower (78.2 g (74.0–82.7), n=81 vs 92.9 g (84.8–101.7), n=30, p<0.01); and myocardial extracellular volume increased (27.1% (26.4–27.9), n=78 vs 24.9% (23.8–26.1), n=30, p<0.01).

Aortic distensibility improved significantly in all patients from baseline to the first year (3.0×10−3 mm Hg−1 (2.7–3.4) to 3.6×10–3 mm Hg−1 (3.1–4.1), respectively, p<0.01), maintained at year 2. The improvement in aortic distensibility did not differ between the two treatment arms and DAS28-erythrocyte sedimentation rate-defined responders versus non-responders.

"These data imply benefits of therapy beyond suppression of systemic inflammation, likely suggesting cardiometabolic changes and targeted effects on key immune mediators of cardiovascular disease," the authors wrote. "This study builds on the concept of targeted therapeutics in atherosclerosis, whereby immune modulating treatment may be personalized in stratified patients with rheumatoid arthritis to not only improve joint specific outcome, but also cardiovascular disease."

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REFERENCE

Plein S, Erhayiem B, Fent G, et al. Cardiovascular effects of biological versus conventional synthetic disease-modifying antirheumatic drug therapy in treatment-naïve, early rheumatoid arthritis. Annals of the Rheumatic Diseases Published Online First: 28 August 2020. doi: 10.1136/annrheumdis-2020-217653