April 23, 2019

Rheumatoid Arthritis and Heart Disease

By Kristi V. Mizelle, MD, MPH, FACR

 

For many patients with moderate to severe rheumatoid arthritis (RA), treatment advances in recent years have significantly improved disease outcomes and quality of life. However, RA is not limited to joints but is a systemic inflammatory process that also can increase the risk of heart disease in RA patients. Therefore, a focus on whole-body health, in addition to pharmacological interventions to manage and control RA, is crucial.  

Often for RA patients, this debilitating disease brings with it many life-altering aspects, from medication management to multiple appointments, flare-ups and joint deterioration. If one adds the often monumental shift in routines and overall health management, the fight to control this disease can seem insurmountable. Fortunately, advancements in medication are helping to alleviate some of these challenges, but the multifaceted approach needed to manage this often complex condition and its comorbidities can be challenging to communicate to patients.

As with many conditions, the treatment and ongoing management of RA are intimately connected to whole-body health. Outside of the characteristic symmetrical joint swelling, pain and prolonged morning stiffness, other more severe systemic manifestations, such as pleurisy, pericarditis, vasculitis, and uveitis, among others, are much less well known. A particularly concerning and often silent RA comorbidity is heart disease, particularly coronary artery disease. 

RA treatment efforts often focus – and rightfully so – on management and disease control to achieve remission, but consideration of the disease’s long-term effects must also be taken into account. Counseling and interventions on diet, exercise, smoking, and diabetes have a significant impact on the management of risk factors for heart disease and cannot be stressed enough for RA patients. Fortunately, in the primary care setting, these conversations are happening daily. 

To take it a step further, early identification of patients at an increased risk for RA, before primary or systemic manifestations occur, can make a tremendous impact on the treatment and management of RA. 

There is no perfect answer or protocol to detect RA early. At this time, symptoms, family history, laboratory studies like elevated c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and autoantibodies like rheumatoid factor and anti-cyclic citrullinated peptide, routine joint exams, and imaging studies like x-rays, MRIs, and ultrasound are the best diagnostic tools available. However, suspected diagnosis and referral to a rheumatologist as soon as possible can make all the difference in controlling RA to avoid the irreversible damage that this disease is capable of inflicting.

As it relates to heart disease, RA should be considered just as significant a risk factor for coronary artery disease as diabetes. Much of the focus and energy devoted to managing risk factors for diabetic patients can inform the treatment methods for RA patients, who, like those with diabetes, are as vulnerable to coronary artery disease if not well managed. 

Controlling for these factors will require a significant emphasis on the importance of whole-body health and the complex interplay of risk factors. Collaboration between an RA patient’s rheumatologist, primary care provider and cardiologist can help RA patients control their disease and achieve remission while mitigating heart disease risk for better outcomes.

Kristi V. Mizelle, MD, MPH, FACR is a Board-certified Rheumatologist in Newport News. To learn more about Dr. Mizelle and her practice, visit MyTPMG.com