Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: A population-based cohort study

Mayo Clinic, Rochester, Minnesota 55905, USA.
Arthritis & Rheumatology (Impact Factor: 7.76). 02/2005; 52(2):402-11. DOI: 10.1002/art.20853
Source: PubMed

ABSTRACT To examine the risk of clinical coronary heart disease (CHD) in patients with rheumatoid arthritis (RA) compared with age- and sex-matched non-RA subjects, and to determine whether RA is a risk factor for CHD after accounting for traditional CHD risk factors.
We assembled a population-based incidence cohort of 603 Rochester, Minnesota residents ages >or=18 years who first fulfilled the American College of Rheumatology (ACR) 1987 criteria for RA between January 1, 1955 and January 1, 1995, and 603 age- and sex-matched non-RA subjects. All subjects were followed up through their complete inpatient and outpatient medical records, beginning at age 18 years until death, migration, or January 1, 2001. Data were collected on CHD events and traditional CHD risk factors (diabetes mellitus, hypertension, dyslipidemia, body mass index, smoking) using established diagnostic criteria. CHD events included hospitalized myocardial infarction (MI), unrecognized MI, coronary revascularization procedures, angina pectoris, and sudden CHD deaths. Conditional logistic regression and Cox regression models were used to estimate the risk of CHD associated with RA, both prior to and following RA diagnosis, after adjusting for CHD risk factors.
During the 2-year period immediately prior to fulfillment of the ACR criteria, RA patients were significantly more likely to have been hospitalized for acute MI (odds ratio [OR] 3.17, 95% confidence interval [95% CI] 1.16-8.68) or to have experienced unrecognized MIs (OR 5.86, 95% CI 1.29-26.64), and less likely to have a history of angina pectoris (OR 0.58, 95% CI 0.34-0.99) compared with non-RA subjects. After the RA incidence date, RA patients were twice as likely to experience unrecognized MIs (hazard ratio [HR] 2.13, 95% CI 1.13-4.03) and sudden deaths (HR 1.94, 95% CI 1.06-3.55) and less likely to undergo coronary artery bypass grafting (HR 0.36, 95% CI 0.16-0.80) compared with non-RA subjects. Adjustment for the CHD risk factors did not substantially change the risk estimates.
Patients with RA have a significantly higher risk of CHD when compared with non-RA subjects. RA patients are less likely to report symptoms of angina and more likely to experience unrecognized MI and sudden cardiac death. The risk of CHD in RA patients precedes the ACR criteria-based diagnosis of RA, and the risk cannot be explained by an increased incidence of traditional CHD risk factors in RA patients.

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Available from: Paulo J Nicola, Sep 26, 2015
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    • "The major symptoms are synovial inflammation and swollen joints, autoantibody production, deformation of cartilage and bone structures, and systemic features such as cardiovascular, pulmonary, psychological, and skeletal disorders (McInnes and Schett 2011). RA is associated with increased risk of cardiovascular diseases (CVD), like atherosclerosis and myocardial infarction, likely due to the chronic systemic inflammation and physical inactivity (Pahor et al. 2006; Solomon et al. 2003; Maradit-Kremers et al. 2005). The overall mortality rate in patients with RA is 1.6 compared to that of the general population, and CVD accounts for 40–50 % of the deaths in this group (Avina-Zubieta et al. 2008). "
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    ABSTRACT: Rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) are inflammatory diseases which involve increased risk of cardiovascular disease (CVD). High intensity interval training (HIIT) is known to be effective in improving cardiovascular health. The aim of this study was to investigate whether 10 weeks of HIIT at 85-95 % of HRmax would improve important risk factors of CVD in rheumatic patients, and if these patients would tolerate exercise intensities above today's recommendations. Seven women with RA and eleven with adult-JIA, 20-50 years, were recruited to this cross-over study. Participants performed HIIT, consisting of 4 × 4 min intervals at 85-95 % of HRmax twice a week for 10 weeks on spinning bikes. Maximal oxygen uptake (VO2max), heart rate recovery, blood pressure, body composition, and blood variables were measured before and after the exercise and control period. Disease activity was determined and questionnaire data were collected. HIIT resulted in 12.2 % increase in VO2max and 2.9 % improvement in heart rate recovery (p < 0.05). BMI, body fat, and waist circumference decreased 1.2, 1.0, and 1.6 %, respectively, whereas muscle mass increased 0.6 % (p < 0.05). A trend toward decreased CRP was detected after HIIT (p = 0.08). No changes were detected in disease activity or pain. Despite rigorous high intensity exercise, no increase was detected in disease activity or pain, indicating that HIIT was well tolerated by these patients. Furthermore, HIIT had positive effects on several CVD risk factors. In light of this pilot study, HIIT seems like a promising non-pharmacological treatment strategy for patients with RA and adult-JIA.
    Arbeitsphysiologie 05/2015; DOI:10.1007/s00421-015-3186-9 · 2.19 Impact Factor
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    • "Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease associated with an increased risk of cardiovascular disease and premature mortality [1] [2]. The primary research focus in vascular disease in patients with RA has been on coronary heart disease. "
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    ABSTRACT: Objective: To investigate the incidence of atrial fibrillation (AF) among patients with rheumatoid arthritis (RA) compared to the general population. Methods: A population-based inception cohort of Olmsted County, Minnesota, residents with incident RA in 1980-2007 and a cohort of non-RA subjects from the same population base were assembled and followed until 12/31/2008. The occurrence of AF was ascertained by medical record review. Results: The study included 813 patients with RA and 813 non-RA subjects (mean age 55.9 (SD:15.7) years, 68% women in both cohorts). The prevalence of AF was similar in the RA and non-RA cohorts at RA incidence/index date (4% versus 3%; P = 0.51). The cumulative incidence of AF during follow-up was higher among patients with RA compared to non-RA subjects (18.3% versus 16.3% at 20 years; P = 0.048). This difference persisted after adjustment for age, sex, calendar year, smoking, and hypertension (hazard ratio: 1.46; 95% CI: 1.07, 2.00). There was no evidence of a differential impact of AF on mortality in patients with RA compared to non-RA subjects (hazard ratio 2.5 versus 2.8; interaction P = 0.31). Conclusion: The incidence of AF is increased in patients with RA, even after adjustment for AF risk factors. AF related mortality risk did not differ between patients with and without RA.
    03/2015; 2015:1-5. DOI:10.1155/2015/809514
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    • "Rheumatoid arthritis (RA) is a chronic inflammatory condition predominantly affecting the synovial joints but leading to extraarticular manifestations. The increased cardiovascular mortality in RA patients (by up to 50%) [1] [2] [3] [4] is not fully explained by the presence of traditional risk factors and remains an important research focus [3,5–13]. The autonomic nervous system (ANS) plays a critical role in the normal regulation of cardiovascular disease through its effects on the heart, peripheral vasculature and kidneys (Fig. 1) [14]. "
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    ABSTRACT: Objectives Rheumatoid arthritis (RA) is a chronic inflammatory condition with increased all-cause and cardiovascular mortality. Accumulating evidence indicates that the immune and autonomic nervous systems (ANS) are major contributors to the pathogenesis of cardiovascular disease. We performed the first systematic literature review to determine the prevalence and nature of ANS dysfunction in RA and whether there is a causal relationship between inflammation and ANS function. Methods Electronic databases (Medline, Central and Cochrane Library) were searched for studies of RA patients where autonomic function was assessed. Results Forty studies in total were included. ANS function was assessed by clinical cardiovascular reflex tests (CCTs)(n=18), heart rate variability (HRV)(n=15), catecholamines (n=5), biomarkers of sympathetic activity (n=5), sympathetic skin responses (n=5), cardiac baroreflex sensitivity (cBRS) (n=2) and pupillary light reflexes (n=2). 9 small studies reported a ~60% (median, range 20-86%) prevalence of ANS dysfunction (defined by abnormal CCTs) in RA. 73% of studies (n=27/37) reported at least one abnormality in ANS function: parasympathetic dysfunction (n=20/26, 77%), sympathetic dysfunction (n=16/30, 53%) or reduced cBRS (n=1/2, 50%). An association between increased inflammation and ANS dysfunction was found (n=7/19, 37%) although causal relationships could not be elucidated from the studies available to date. Conclusions ANS dysfunction is prevalent in ~60% of RA patients. The main pattern of dysfunction is impairment of cardiovascular reflexes and altered HRV indicative of reduced cardiac parasympathetic (strong evidence) and elevated cardiac sympathetic activity (limited evidence). The literature to date is underpowered to determine causal relationships between inflammation and ANS dysfunction in RA.
    Seminars in Arthritis and Rheumatism 12/2014; 44(3). DOI:10.1016/j.semarthrit.2014.06.003 · 3.93 Impact Factor
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