Heart failure

Experts disagree on heart risk in RA

A large registry study that finds people with rheumatoid arthritis are at an increased risk of heart failure has left international and local experts at odds over whether there’s enough evidence to routinely screen patients for heart disease.

The JACC study of more than 50,000 RA patients matched in a 1:10 ratio to controls found heart failure occurred in people with RA 4.1 per 1,000 person-years compared to 3.2 per 1,000 person-years in controls (HR 1.22).

The risk was highest for people with positive for rheumatoid factor (HR: 1.45 vs. 0.97 for those negative for rheumatoid factor).

According to the authors, while the association cannot yet be explained the findings highlighted the importance of assessing people with RA for signs of heart failure.

And writing in a linked editorial, US cardiologist Dr Paul Heidenreich said that despite a lack of effective treatments for heart failure directly targeting inflammation the data supported routine screening in the patient population.

But cardiologists in Australia say more evidence is needed before such a practice could be recommended in Australia.

According to Perth cardiologist Dr Mark Nidorf the link between heart failure and rheumatoid arthritis remains ‘vague’.

He says that based on the numbers seen in the study, the suggestion to routinely screen patients for heart disease simply doesn’t add up.

“The numbers are really small (2-4 per thousand) so screening a lot of people to pick up a little in an asymptomatic phase does not really make a lot of sense,” said Professor Nidorf who is currently overseeing a large international trial investigating the use of low dose colchicine for the secondary prevention of coronary disease.

“We don’t see our clinics full of rheumatoid patients, in fact we rarely see these sorts of patients, so the average cardiologist would scratch his head at that and say [an association] might be there but it’s not what we’re seeing,” he told the limbic.

He also refutes the school of thought that ‘all inflammation is the same’.

“That’s why rheumatoid looks like rheumatoid and psoriasis looks like psoriasis – the inflammatory process is different,” he said.

While he acknowledged that there will be some overlap between the two inflammatory pathways, it is uncertain whether that component is a major driver of heart failure and whether it could be modified to improve outcomes.

“We’re far from being certain about this association [between RA and heart failure] but in the next two years as more RCT trial data comes out we’ll be closer to the truth,” he said.

Meanwhile, National Heart Foundation CEO and Chief Medical Advisor, Professor Garry Jennings, said the fact that the data came from one of the best epidemiology registries in the world was in itself strong evidence of an association between rheumatoid arthritis and, by implication, inflammation and heart failure.

“While it can’t tell us about cause and effect the researchers have rather cleverly taken people through from the diagnosis of rheumatoid when there was no excess in heart failure and followed them out and shown that the incidence in the rheumatoid group compared to controls is about 20-30% greater. I think that pretty much nails the association,” he told the limbic.

What drives that association though is much harder tease out, he says.

While Professor Jennings doesn’t think the evidence is strong enough yet to support the practice of routinely screening for heart failure in RA patients, he said the evidence is building.

““People with rheumatoid arthritis may not be doing much activity to bring out symptoms of heart failure so it’s a question of [clinicians] having a high index of suspicion and doing a little more in terms of clinical evaluation and perhaps imaging if there is any suggestion of symptoms or signs of heart failure,” he said.

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