I've heard that people with rheumatoid arthritis are prone to heart disease. Is that true?
Yes, patients with RA have an increased risk of developing atherosclerosis and cardiovascular disease. In particular, RA is associated with a 40% increased risk for myocardial infarction (heart attack) and a 60% increased risk for congestive heart failure (CHF). The heart disease associated with RA accounts for 30% to 50% of deaths in patients with RA. Death occurs at an earlier age in individuals with RA as compared with those without RA who have similar heart disease risk factors. By some estimates, patients with RA die 17 years earlier than people without RA.
Why people with RA have a higher rate of heart attacks is unknown. We do know that the changes that RA causes in a person's body can damage the lining of the arteries. This damage results in inflammation in the lining of the arteries, which in turn leads to cholesterol deposits. These cholesterol deposits (called atheroma or plaque) can block arteries and cause heart attacks. In addition, RA has been associated with other changes that can result in coronary artery blockages, including increased levels of cholesterol and fat (triglycerides) in the bloodstream and an increase in clotting factors.
The increased risk for heart disease observed in persons with RA is independent of the usual risk factors for heart disease, which include high cholesterol, high blood pressure, advanced age, diabetes, smoking, obesity, and family history of heart disease. The risk of heart disease has been correlated with the severity of the RA: The worse the RA, the greater the amount of inflammation, and the higher the risk of heart disease. Researchers have also found an association between an RA patient's C-reactive protein (CRP), sedimentation rate (ESR), and risk for cardiovascular death: The higher the person's ESR, the higher the risk of cardiovascular death. Some researchers believe that decreasing the amount of inflammation a patient has can decrease his or her risk of heart disease. In medical studies, patients who used methotrexate or biologic agents (e.g., Remicade, Humira, and Enbrel) to treat their RA had a lower risk of heart disease. Conversely, the use of prednisone (a potent anti-inflammatory medication) tended to increase the risk of atherosclerosis and heart attack.
C-reactive protein (CRP)
A type of protein that is made in the liver. The amount of CRP rises in the blood in conjunction with the inflammation produced by certain conditions.
Individuals who have RA should be aware of their increased risk for heart attacks. They should discuss this risk with their physicians and develop a plan to modify those risks. While some heart disease risk factors cannot be modified (such as family history of heart disease), others can. You should work to reduce your modifiable risk factors for heart attacks—for example, stop smoking (if you currently smoke), follow a low-fat diet, and exercise. Make these changes only after consulting with your physician.
Individuals who have RA should be aware of their increased risk for heart attacks and should work to reduce their modifiable risk factors for heart attacks.
Here are some questions to discuss with your physician:
- How do I stop smoking?
- How do I change my diet to reduce my fat and cholesterol intake and to achieve an optimal weight?
- Which exercises should I do, given the limitations imposed by my RA? How frequently and how long should I exercise? (Exercising 30 minutes three times per week is usually recommended.)
- Would I benefit from a cholesterol-lowering medication? A class of cholesterol-lowering drugs called statins should be evaluated in this regard. Not only can statins improve your lipid levels, but they also appear to have anti-inflammatory properties. Recent clinical trials suggest that statins offer a dual benefit of both protection against cardiovascular disease and prevention of RA progression.
- Should I take methotrexate to lower the amount of inflammation in my body?
- Will taking biologic agents such as Remicade, Humira, and Enbrel improve my arthritis and decrease my risk of heart disease?
Other heart complications associated with RA include inflammation of the heart's outer covering (pericardium) and the heart muscle (myocardium). When the pericardium is inflamed by RA, the condition is referred to as rheumatic pericarditis. Rarely, an inflammation of the heart muscle, called myocarditis, can develop. Both of these conditions can lead to CHF, which is characterized by shortness of breath and fluid accumulation in the lungs.
Individuals with RA should have their blood pressure, blood sugar level, and cholesterol level checked at least every year. For older patients or those with a family history of heart disease, an electrocardiogram (EKG) or a cardiac stress test may be indicated. If you have additional risk factors, your doctor may recommend a consultation with a cardiologist.