Getting to the Heart of Cardiovascular Outcomes in Rheumatic Diseases
Although never considered to be a risk factor for the development of cardiovascular disease, there is now increasing evidence that indeed there is a relationship between cardiovascular events and the presence of rheumatological diseases.
What are rheumatological diseases?
The diseases include psoriasis/psoriatic arthritis, systemic lupus erythematosus (SLE) and rheumatoid arthritis. These diseases exhibit higher rates of traditional CV risk, such as hypertension, hyperlipidemia and metabolic syndrome. According to Michael Garshick,MD, director of the Cardio-Rheumatology Clinic at NYU, the traditional risk factors can synergistically increase cardiac risk in the inflammatory rheumatological patients. There is now increasing awareness in the rheumatology - medical community of this association, however the risk stratification used in the general population such as the Framingham and Reynolds risk scores have proven suboptimal in rheumatology patients.
The mechanism of this increased risk seems to stem from the generally higher rates of systemic inflammation that is present in the rheumatological patient as evidenced by higher levels of C-reactive protein. The difficulty in dealing with this problem is that the traditional treatments for many of these diseases, such as chronic steroid use can be a double edged sword, as this form of treatment is associated with weight gain, elevation of BP, salt retention and with a potential for lipid abnormalities. Another class of drugs used in clinical practice in the rheumatology community, the NSAIDs (Motrin and Alleve) has been implicated in increased CV disease but with an important qualification. The risk seems to be greater in persons who already have heart disease. The good news is that there are other drugs that are being used more frequently in treating these patients. This includes methotrexate, and possibly hydroxycholoroquine (known from the early days of Covid) which also have anti-inflammatory properties and do not seem to have any negative cardiac effects in these patients.
According to Dr. Elaine Husni from the Cleveland Clinic, at this point in time, treating these patients by lowering systemic inflammation and treating hyperlipidemia to target is the most important step toward mediating cardiovascular risk. In this regard low dose aspirin and statins seem to work well in patients with rheumatic diseases. Although most of the attention has been put on the effects of these diseases on the coronary arteries there is also concern that chronic inflammation can also effect the heart muscle itself making these patients more susceptible to heart failure.
Much work is ongoing in coming up with sets of guidelines in treating these patients but at this time the traditional treatments of anti-inflammatory medications along with keeping risk factors at a minimum with weight and BP reduction and possibly lipid reduction as well are the key components in doing the best for the rheumatological patients.