RA, Hypertension, and Vascular Disease: What's True?

Although rheumatoid arthritis (RA) is identified and defined primarily by its joint complications, I submit that it is a disease in need of contemporary reframing. Patients with RA have a substantively increased risk of myriad cardiovascular diseases. When did you last have reason to consider the cardiovascular accompaniments of RA? Try these 2 very short tests of your current knowledge.

Which of the following statements is/are true?

A. Patients with RA have both increased carotid intima media thickness as well as a higher annual rate of increasing carotid intima thickness than patients without RA.

B. The prevalence of peripheral vascular disease is twice as high in patients with RA as age-matched controls without RA.

C. Coronary artery calcification and abdominal aortic calcification are more frequent and more severe in patients with RA than in age-matched controls.

D. A decreased GFR is relatively common in RA and is associated with hypertension.

Answer, discussion, and next question, next page>>

Answer: All statements are true.^1,2,3

RA has evolved into a prominent cardiovascular risk factor and is associated with accelerated disease in multiple vascular territories. In the specific context of hypertension, RA appears to accelerate target organ damage in those afflicted with elevated blood pressures.

Which of the following statements is/are correct?

A. The presence of asymptomatic cardiovascular damage in RA patients is associated more with hypertension than with inflammatory activity.

B. Left ventricular diastolic function, but not systolic function, is affected by hypertension in RA patients.

C. Blood pressure “dipping” (a normal drop in nocturnal blood pressure) is unaffected by RA.

D. Hypertensive patients with RA have inappropriately increased left ventricular mass.

Answer and discussion, next page>>

Answer: Options A and D are correct.^4,5,6

Not only is RA associated with a significant increase in cardiovascular risk, the concurrence of RA and hypertension causes both diastolic and systolic heart dysfunction as well as chronic renal disease. In fact, when patients with diabetes, aortic stenosis, and RA were compared with respect to left ventricular mass, RA was the strongest variable in predicting increased left ventricular mass.⁶

Although the primary treatment of RA per se is managed by rheumatologists, other subspecialists and primary health care providers have a critical role in the management of RA patients. It is best to assume that any and every patient with RA is a ticking vascular time bomb. Statins and antihypertensives are as integral to RA care as methotrexate and the biologicals.

What are some models for specialty and primary care that help mitigate RA-mediated vascular complications?

• Develop a close relationship with the rheumatologists who treat your RA patients. Treating RA to target, thereby reducing systemic inflammation, is critical. In addition to the vascular pathology already mentioned, inflammation destabilizes plaques.

• Calculate RA patients’ Framingham or other CV risk score and treat risk factors accordingly and aggressively.

• Treating blood pressure to target is a primary care imperative in patients with RA.

References

1. Mitrovic J, Morovic-Vergles J, Horvatic I, et al. Ambulatory arterial stiffness index and carotid intima-media thickness in hypertensive rheumatoid patients: a comparative cross-sectional study. Int. J Rheum. Dis. 2015; May 20; epub ahead of print. https://www.ncbi.nlm.nih.gov/pubmed/25990366

2. Paccou J, Renard C, Liabeuf S, et al. Coronary and abdominal aorta calcification in rheumatoid arthritis: relationships with traditional cardiovascular risk factors, disease characteristics, and concomitant treatments. J. Rheumatol. 2014; 41:2137-2144. http://www.jrheum.org/content/41/11/2137.long

3. Couderc M, Tatar Z, Pereira B, et al. Prevalence of renal impairment in patients with rheumatoid arthritis: results from a cross sectional multicenter study. Arthritis Care Res. 2016; 68:638-644. https://www.ncbi.nlm.nih.gov/pubmed/?term=Arthritis+Care+Res.+2016%3B+68%3A638-644.

4. Midtbo H, Gerdts E, Kvien TK, et al. The association of hypertension with asymptomatic cardiovascular organ damage in rheumatoid arthritis. Blood Press. 2016; 25:298-304. https://www.ncbi.nlm.nih.gov/pubmed/27123584

5. Hamamoto K, Yamada S, Yasumoto M, et al.  Association of nocturnal hypertension with disease activity in rheumatoid arthritis. Am. J Hypert. 2016; 29:340-347. https://www.ncbi.nlm.nih.gov/pubmed/26208672

6. Cioffi G, Viapiana O, Ognibeni F, et al. Prevalence and factors related to inappropriately high left ventricular mass in patients with rheumatoid arthritis without overt cardiac disease. J Hypertens. 2015; 33:2141-2149. https://www.ncbi.nlm.nih.gov/pubmed/?term=Prevalence+and+factors+related+to+inappropriately+high+left+ventricular+mass+in+patients+with+rheumatoid+arthritis+without+overt+cardiac+disease