Cardiovascular disease profile in patients with established rheumatoid arthritis at King Edward VIII Hospital.

Abstract

Rheumatoid arthritis (RA) is one of the most common chronic systemic autoimmune inflammatory diseases, which is associated with an increased mortality rate, attributed to premature cardiovascular disease (CVD). Key drivers of mortality from CVD in RA are fuelled by multiple factors. Rheumatoid arthritis disease profiling, particularly seropositivity, presence of extra-articular disease and high disease activity, confer an increased mortality risk. Traditional CVD risk factors (hypertension, diabetes mellitus, dyslipidaemia, obesity) are influenced by both inflammation inherent to RA, and pharmacodynamics of anti-rheumatic drugs. Notwithstanding the above, the current paradigm shift recognises RA as an independent risk factor for CVD. Similar to the rest of Africa, local data on the prevalence of CVD in RA are limited. With an increase in non-communicable diseases and longevity, the RA burden in South Africa (SA) is expected to increase. Local studies are needed to stratify practice in cardio-protective strategies and improved long term outcomes in RA. This study aims to determine the prevalence of CVD in RA, describe the prevalence of CVD risk factors in RA and describe the relationship between RA disease activity and CVD. A retrospective, chart review of all patients with RA according to the American College of Rheumatology 1987/2010 Classification criteria, attending the arthritis clinic in King Edward VIII hospital, a tertiary public healthcare academic teaching hospital in KwaZulu-Natal, SA, during the period August 2017 to March 2018, was undertaken. Patients younger than 18 years of age, or with RA and any other concomitant connective tissue disease or overlap syndrome were excluded. The study group included 150 patients with RA. The demographic details, duration of the RA disease, traditional CVD risk factors, simplified disease activity index (SDAI) and health assessment questionnaire (HAQ) were documented. In addition, results of electrocardiogram, echocardiogram, haemoglobin, glycated haemoglobin, lipid studies and estimated glomerular filtration rate were recorded. Cardiovascular disease was found in 16% of the total study cohort, with an age, gender and ethnic differential. Coronary artery disease was the most common CVD finding in RA patients. The burden of traditional CVD risk factors in RA is high, with hypertension, diabetes mellitus, dyslipidaemia, physical inactivity and chronic kidney disease of particular concern. No significant correlation was observed between RA disease activity, seropositivity and CVD in RA however, extra-articular disease was more common among patients with CVD. Echocardiographic evidence of subclinical cardiac disease in RA is common. Significant disparity was observed between various CVD risk assessment models at different levels of risk, which cautions a comprehensive CVD risk assessment model that stratifies discriminately is needed in patients with RA. The study provides knowledge of CVD burden and risk in RA patients locally, and serves as a foundation for further research in preventative strategies that offer significant survival benefits. The main limitation in this study is that the study cohort consisted mainly of Black and Indian patients and therefore the findings may not be generalised across all ethnic groups. Furthermore as this was a relatively small study conducted in a single public hospital, which is urban based, conclusions from this study may not be applicable to a rural setting or to all socio-economic classes.