Rheumatologists Should Start Screening for Heart Disease

A significant portion of patients with rheumatoid arthritis may develop cardiovascular disease.

Despite an increased risk of heart disease among patients with rheumatoid arthritis (RA), a majority of rheumatologists do not currently screen for cardiovascular risk factors, including hypertension and lipid levels, according to a session presented at the American College of Rheumatology/Association of Rheumatology Health Professionals

Annual Meeting.

“Cardiovascular disease is like a shark circling just beneath the surface in rheumatologic disease,” said speaker Rekha Mankad, MD. “You don’t know what is there if you don’t look. And in this population, you should have a high index of suspicion and a low threshold to look and to treat.”

During the session, the speakers discussed mounting evidence that patients with autoimmune conditions are at an increased risk of heart disease, which is similar to the link between diabetes and heart disease.

“The inflammation that comes with autoimmune disease increases the risk of cardiovascular disease in itself,” Dr Mankad said. “That is on top of more familiar risk factors such as elevated blood pressure and lipids or obesity, which tend to be undertreated in the autoimmune population.”

While rheumatologists understand that patients may also deal with immune-related heart problems, they may not realize that autoimmune conditions can increase the risk of heart disease, according to the session.

Overall, the prevalence of cardiac complications is amplified among patients with autoimmune diseases, who typically develop heart disease a decade earlier than the general population, according to the panelists.

“The literature would suggest that the potential for cardiovascular disease in this population is under recognized, which is the starting point for this symposium,” Dr Mankad said. “Inflammation is likely driving a lot of this disease. Cardiologists and internists are largely unaware of the association. And although rheumatologists have been aware of the association, they are unlikely to be the ones to address the elevated cardiovascular risk.”

The speakers noted that a significant problem is that the underlying mechanisms of inflammation and cardiac complications are not well-defined.

Additionally, rheumatologists are not trained to recognize the signs and symptoms of cardiac complications and heart disease. As an example, the speakers said that if a patient with rheumatoid arthritis presents with high blood pressure and pain, the rheumatologist may think that the hypertension is a result of the pain, according to the session.

“It’s not that anyone is doing anything wrong. It’s about what is happening at the time,” Dr Mankad said. “So much of rheumatology is about putting out fires. Rheumatologists are trained to address rheumatologic conditions and deal with the pain and destruction related to those conditions.”

Another issue rheumatologists are facing is the extended lifespan of patients due to better treatments. Since patients are living longer, they may be more likely to experience heart disease and other chronic conditions.

“That is most evident in the lupus population, where a patient used to have a high likelihood of dying with lupus due to kidney failure and infection,” Dr Mankad said. “Rheumatologists have gotten so good at treating lupus that the risk of death now comes from heart disease. That’s a new factor to keep in mind.”

Dr Mankad and her group have started screening patients for cardiovascular disease and discovered a high prevalence of atherosclerosis among patients younger than age 65. These patients should not have atherosclerosis due to age and other relevant factors, however, a significant portion show signs of heart disease, according to the session.

“The real question is whether there is a role for being more aggressive,” Dr Mankad said. “Should rheumatologic patients be treated like diabetic patients in terms of cardiovascular risk? Should they be screened and treated more aggressively than the general population? We don’t know for sure, but we do know that if you look for cardiovascular disease in these patients, you will find it and you can treat it.”