Risk factors

Call for cardio-rheumatology subspecialty

Professor Paul Ridker

A subspecialty of cardio-rheumatology would help address the unique needs of patients with autoimmune disease given growing awareness of their increased cardiovascular risk.

Writing in The Lancet, Professor Paul Ridker said the fact that autoimmune disorders were associated with substantial cardiovascular risk can no longer be ignored by the clinical community.

“Just as the subspecialty of cardio-oncology emerged a decade ago to address a unique unmet clinical need, the current data additionally support training programmes in a second emerging subspecialty, cardio-rheumatology,” he said.

Professor Ridker, Director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital and the Eugene Braunwald Professor of Medicine at Harvard School of Medicine, was responding to a study demonstrating the increased cardiovascular risk in 19 autoimmune diseases.

The population-based study, also presented this week at the European Society of Cardiology Congress, compared the incidence of 12 cardiovascular outcomes in patients with or without a newly diagnosed autoimmune disease between Jan 1, 2000 and Dec 31, 2017 from a UK cohort of 22 million individuals.

It found 15·3% of people with autoimmune diseases and 11·0% without autoimmune diseases developed incident cardiovascular disease during a median of 6·2 years of follow-up.

“The incidence rate of cardiovascular disease was 23·3 events per 1000 patient-years among patients with autoimmune disease and 15·0 events per 1000 patient-years among those without an autoimmune disease (HR 1·56 [95% CI 1·52–1·59]).”

The study, led by Dr Nathalie Conrad from KU Leuven in Belgium, found all 19 of the most common autoimmune diseases were associated with increased cardiovascular risk. Risk increased even further with two concomitant autoimmune diseases (HR 2.63) and ≥3 autoimmune diseases (HR 3.79).

Among autoimmune diseases, systemic sclerosis (HR 3·59), Addison’s disease (HR 2·83), systemic lupus erythematosus (HR 2·82), and type 1 diabetes (HR 2·36) had the highest overall cardiovascular risk.

“The association between autoimmunity and risk of cardiovascular disease was significant for each individual cardiovascular disease and was highest for myocarditis and pericarditis, peripheral artery disease, and infective endocarditis,” it said.

The study found that people with an autoimmune disease had a considerably higher risk of developing premature cardiovascular disease ie. <45 years (HR 2.33), 45-54 years (HR 2.07) and 55-64 years (HR 1·76).

It also found that patients with autoimmune diseases had an increased risk of hospital admissions for and mortality from cardiovascular causes compared with individuals without an autoimmune disease.

The researchers said that autoimmunity per se, rather than any individual condition, was the risk factor and that its potential contribution to cardiovascular disease was under-recognised.

“The risks associated with presence of any autoimmune disease were similar to those identified in previous studies based on the CPRD dataset for a 20 mm Hg increase in systolic blood pressure (HR 1·26 [95% CI 1·25–1·28]), 5 kg/m² increase in BMI (1·21 [1·20–1·22]), and diagnosis of type 2 diabetes (1·62 [1·49–1·77]).”

“Yet, there is little awareness of this association and thus most patients with autoimmune disease do not receive cardiovascular prevention measures that could help reduce this burden or undergo screening to detect cardiovascular disease.”

They said the increased risk was beyond traditional cardiovascular risk factors such as blood pressure, BMI, smoking or cholesterol.

“These findings are consistent with the inflammatory hypothesis and clinical trial data, which have shown that inhibiting chronic inflammation, even without altering lipids or other risk factors, reduces the rate of cardiovascular events.”

In the accompanying Comment article, Professor Ridker said basic cardiovascular screening and prevention should become routine for most individuals with chronic inflammatory diseases.

As well, the use of statins has also been found to improve cardiovascular outcomes among individuals with increased inflammatory markers.

As reported earlier in the limbic, the European Alliance of Associations for Rheumatology (EULAR) has recently published updated recommendations for cardiovascular risk management in patients with rheumatic and musculoskeletal diseases.

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