Patients With Inadequate Response to DMARDs at Higher Risk of Heart Attack

This article was originally published on Practical Cardiology.

Emphasizing the importance of collaborative care between specialties, new research suggests an inadequate response to therapy among patients with rheumatoid arthritis could signal an increased risk of heart attack.

An analysis of more than 7100 patients with rheumatoid arthritis, results of the study indicate patients who had an inadequate response to disease‐modifying antirheumatic drugs (DMARDs) were at a 45% greater risk of acute coronary syndrome but had a similar risk of ischemic stroke as their counterparts with an adequate response to DMARD therapy.

“Physicians should focus on cardiovascular risk during follow‐up in patients with DMARD‐IR rheumatoid arthritis, especially those with hypertension. In addition, the early identification of these patients would mean that they are deemed to be in the DMARD‐IR cohort, and the timely use of biological agents may help prevent cardiovascular events,” wrote study investigators.

With rheumatoid arthritis and other rheumatic conditions linked to increased cardiovascular risk, a team from the Chang Sung Memorial Hospital in Taiwan sought to determine whether response to DMARD therapy could help clinicians identify patients with a greater risk among these patients. With this in mind, the team designed a cohort study using the Chang Gung Research Database, which includes data related to 8.2 million patient visits per year and pulls information from 7 hospital branches in Taiwan.

Performing a search from January 1, 2002, and December 31, 2018, investigators identified 7114 patients with a diagnosis of rheumatoid arthritis through use of ICD-9/10 coders. After excluding those with a diagnosis prior to January 1, 2002, those with a diagnosis before the age of 20 years, and those with diagnoses of other conditions, such as stroke, CKD stage 4 or 5, or a malignancy, investigators were left with a cohort of 2998 patients with newly diagnosed rheumatoid arthritis.

After further reclusion of patients without DMARD use for 6 months, investigators identified 2697 patients for inclusion in their final analysis. This cohort included 663 patients with an inadequate response to DMARDs and 2034 with an adequate response to serve as controls. Investigators noted the use of inverse probability of treatment weighting to keep covariate between the study arms well balanced.

For the purpose of analysis, inadequate response was defined as patients whose disease activity scores of 28 joints continued to exceed 5.1 after 6 months of methotrexate‐based DMARD treatment. For the primary endpoint of their study, investigators chose a composite vascular outcome consisting of acute coronary syndrome and ischemic stroke. A secondary endpoint of individual vascular events was also included in the analysis.

The mean follow-up was 4.7±4.2 years. During this time period, 7.5% and 6.4% of patients in the inadequate response group and control group, respectively, had composite vascular outcomes. Using a Cox proportional hazards model, investigators determined there was no significant difference in risk of the composite outcome for patients with inadequate response compared to controls (HR, 1.16; 95% CI, 0.94-1.41).

When assessing the individual components of the primary endpoint, investigators found no significant difference in risk of ischemic stroke (HR, 1.07; 95% CI, 0.84-1.36), but noted risk of acute coronary syndrome (HR, 1.45; 95% CI, 1.02-2.05) was greater among those with an inadequate response to DMARD therapy compared to the control group.

This study, "Patients With Rheumatoid Arthritis With an Inadequate Response to Disease‐Modifying Antirheumatic Drugs at a Higher Risk of Acute Coronary Syndrome,” was published in the Journal of the American Heart Association.