Cardiovascular risk and RA

Guidelines in RA / Cardiovascular Risk

During the 2nd Excellence in Rheumatology Conference in Madrid at the end of January, 2012, NRAS CEO Ailsa interviewed Professor of Rheumatology, Ian Bruce (MD FRCP) about questions raised during the patient workshops (about implementation of guidelines and cardio vascular risk) which ran concurrently with the scientific programme and which were organised by NRAS, Lupus UK and the patient organisation in the Netherlands.

Cardiovascular risks in rheumatoid arthritis – A missed opportunity in primary care

Taken from NRAS magazine: Autumn 2012

It is well established that patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD) including heart attacks and strokes. A number of guidelines on the management of RA recommend screening for CVD risk in patients with this disease.

Screening for CVD risk in the general population is normally the remit of GPs and there are well known procedures used to measure known risk factors such as high blood pressure, raised cholesterol, diabetes and obesity.

The primary care centre of Arthritis Research UK at Keele University recently performed a study which looked at the screening of CVD risk in rheumatoid patients in primary care. They used two regional primary care databases to look at consultations in patients with a diagnosis of RA compared with a control group of patients without RA and looked at the recording of known risk factors. 401 rheumatoid patients were identified. The findings showed that there was no difference between the two groups in the rate of screening of blood pressure, weight, cholesterol and blood sugar and only a slight increase in smoking status. Only 25% in both groups had a full CVD screen.

This study shows that the increased CVD risk in rheumatoid patients is not being translated into increased CVD screening in primary care. There are two possible solutions. One is that rheumatology units inform GPs on the need for CVD screening or they undertake the screening themselves and inform the GPs on the need for treatment. It would help everyone if current CVD risk procedures in primary care included RA in the same way as it does for diseases like diabetes.

NRAS Comment - If this study is representative of other primary care services, then patients with RA need to ensure that they are being assessed for CVD risk by someone and clarify with their GP or rheumatology team who should be responsible for this.

The use of assessment tools to decide upon your risk of cardiovascular disease (CVD)

14/01/09: by Susan M Oliver RN MSc, Nurse Consultant Rheumatology, Chief Nurse Adviser for the National Rheumatoid Arthritis Society, Chair of the Royal College of Nursing Rheumatology Forum and Joint Chair of the Rheumatology Futures Project Group

Taken from NRAS magazine, Winter 2008

Background information

Reducing the risk of heart disease is an international problem as it not only shortens people’s lives but can have a powerful impact on quality of life and general health.

There are many reasons why you may have an increased risk of heart disease and these include factors such as age, sex, health and lifestyle factors as well as family history. So the assessments of your risk factors have routinely included:

  • Your age (the risk of heart disease generally increases with age so screening programmes tend to target people over 40 years of age)
  • Sex (there are differences between male and female risk factors especially in some populations)
  • Smoking history and current health status
  • Blood pressure
  • Cholesterol levels 

We have known that some populations can also have an increased risk of heart disease for example:

  • Asian populations have a high risk of heart disease and this can vary between different Asian sub-groups and also between men and women. For example Bangladeshi men have a higher risk than Bangladeshi women of the same age
  • People who have a condition that results in some form of on-going inflammation or auto-immune condition in the body such as diabetes or rheumatoid arthritis carry an added risk of cardiovascular disease

How do I know if I have been assessed for my risk of cardiovascular disease?

Your doctor may have undertaken an assessment of your risk with you by asking you about:

  • Your smoking history
  • Checking your blood pressure
  • Taking a fasting blood test to measure your cholesterol
  • Asking you about your family history
  • Checking your diet and lifestyle
  • Reviewing your medical history to see if you carry additional risks, for example if you’re diabetic

The Framingham Scoring System to assess the next 10 years' risk of CVD

Risk is calculated using an algorithm that considers all the different factors outlined above and is given as a percentage of risk of CVD over the next 10 years. The risk is colour-coded

< 10% risk - Green

10-20% risk - Orange

> 20% risk - Red

This algorithm is called the (modified) Framingham Score. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest that a formal risk assessment should be undertaken if your Framingham risk is calculated as >20%

OR if you already have:

  • Coronary heart disease (history of previous heart attack) or major atherosclerosis
  • A family tendency to have a high cholesterol level
  • Kidney disease including problems with your kidneys related to diabetes
  • Diabetes (type I or type II)

The scoring system should not be used to calculate your risks and you need your doctor to undertake an individual review of your risks

Other models to assess risk of CVD

Your doctor may have already assessed your specific risks and in discussion given you some choices about the next steps in your treatment or advised you on the best way to reduce your risks without medication. We know that having good control of your RA is one important way of reducing the risk of CVD. NICE has produced a patient information leaflet that you might find helpful (www.nice.org.uk – lipids modification/information for the public).

New tools to assess CVD

Recently a new tool called QRISK2 has been developed to assess people at high risk of CVD. It is early days but it appears to be an improved tool compared to the Framingham score because it includes in its calculations:

  • Specific issues related to ethnicity that affect the 10 year risk of CVD
  • Calculations based on other factors such as RA, renal disease and atrial fibrillation (a type of heart condition)
  • Social issues that can increase an individual’s risks. For example, people who are socially deprived have a higher risk of CVD

There is also a medical paper about the QRISK2 – Author: Hippisley-Cox J et al entitled: Predicting cardiovascular risk in England and Wales; prospective derivation and validation of QRISK2. It can be accessed online from: British Medical Journal; (2008)336.a 332. www.bmj.com

What should I do when I see my general practitioner?

It is important to ask whether your risk of cardiovascular disease has been assessed. If you have had your risk assessed you might want to know more about your score and what advice your doctor suggests you take to reduce this. You might also want to ask them about how your RA was taken into account in the assessment. Remember it is early days with the QRISK2 and it will take a while for it to be fully implemented and further researched …. but it may be a good point for discussion with your doctor.

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