Myocardial infarction: arthritis patients are overlooked

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Myocardial infarction: arthritis patients are overlooked

June 16, 2004 Nainggolan

Rheumawire

Berlin, Germany - Despite having the same risk of death from acute

myocardial infarction (AMI) as diabetes sufferers, rheumatoid arthritis

(RA) patients get a raw deal when it comes to treatment for heart

disease, new research shows [1].

Reporting his findings at the EULAR 2004 meeting last week, Dr Gurkipal

Singh (Stanford University School of Medicine, Los Angeles, CA) said,

" The cardiovascular risks attributable to RA have been underrecognized.

The result is that more patients with RA are presenting with heart

attacks requiring hospital treatment. No improvement in hospital

mortality following AMI in the RA population has been seen in the past

10 years. "

This is in contrast to the situation seen in diabetes, he noted. " The

cardiovascular complications of diabetes are well recognized, and there

have been major improvements in the prevention and treatment of heart

disease in these patients. "

Singh and colleagues studied data from the US Nationwide Inpatient

Sample, the only database in the US that has all information on

inpatient care regardless of insurance status. They looked at all

hospitalizations with a primary diagnosis of AMI and a secondary

diagnosis of RA or diabetes mellitus from 1991 to 2001.

In 1991, nearly 11% of all AMI admissions in patients with diabetes were

fatal; by 2001, this case-fatality rate had decreased by 30% to 7.7%

(p<0.05). In contrast, the case-fatality rate of AMI in RA patients

remained relatively stable (a decline of just 0.03% per year) during the

same period.

In 1991, patients with diabetes were 70% more likely to die if admitted

to the hospital with AMI compared with patients with RA, Singh said. But

by 2001, this difference had disappeared (7.6% vs 7.7% case fatality for

RA and diabetes, respectively).

Singh said there have been significant declines in AMI deaths in

patients with diabetes because of early recognition and aggressive

preventive and therapeutic measures, perhaps due to the greater numbers

of patients with diabetes and hence the greater burden on healthcare

systems. The same thing now needs to happen with RA patients, he

stressed.

" Modification of cardiovascular risk factors is not always a high

priority for those treating RA patients, " he said.

Improved routine screening of RA patients for coronary disease and

dietary and behavior modification could help improve this situation,

Singh said. " For example, it is estimated that only about one third of

RA patients are on a regimen of low-dose aspirin as a preventive measure

for coronary events, despite evidence that such therapy has value in

reducing cardiovascular risk. "

He concluded, " Aggressive control of RA disease activity using

methotrexate or newer therapies, such as the TNF-alpha inhibitors, can

not only lead to improved range of motion and joint symptoms but may

also improve long-term cardiovascular morbidity and mortality. "

On the same subject, doctors from Canada reported on the best treatment

to use for RA to avoid cardiac complications [2]. Dr Sammy Suissa

(McGill University Health Center, Montreal, QC) and colleagues found

that current use of all disease-modifying antirheumatic drugs

(DMARDs)including methotrexate, the TNF-alpha inhibitors, and

leflunomidewas associated with a 20% reduction in the risk of AMI in RA

patients, but the current use of selective COX-2 inhibitors was

associated with a 70% increase in this risk.

In their case-control study, they used 2 large American health insurance

databases covering 26 million individuals, including 41 885 RA patients

treated with a DMARD, between 1998 and 2001. The patients were followed

from the date of their first prescription to the occurrence of their

first AMI.

During follow-up, 268 cases of AMI occurred, for a rate of 5.2 per 1000

per year. Rate of AMI was significantly decreased with the current use

of any DMARD (adjusted relative risk 0.6; 95% CI 0.4-1.0). But the rate

was increased with the current use of selective COX-2 inhibitors

relative to noncurrent use (RR 1.7; 95% CI 1.1-2.6). This effect was not

evident for traditional NSAIDs (RR 1.2) or glucocorticoids (RR 1.0),

Suissa noted. The data were adjusted for age, gender and different

comorbidity conditions.

" While some treatments for RA are increasingly effective in slowing down

this debilitating disease, their effects on the heart have been

controversial, " Suissa said. " We believe our study will assist in

clarifying the issue surrounding the use of DMARDs and anti-inflammatory

drugs in RA. " But he warned that further studies are needed to verify

these findings.

Sources

Singh G, Mithal A, Mendelsohn A, et al. Acute

myocardial infarctions in rheumatoid arthritis and diabetes: a tale of

two diseases and a call for action. Presented at: EULAR 2004; Berlin,

Germany; June 9-12, 2004. Abstract OP0037.

Suissa S, Bernatsky S, Hudson M, et al. DMARD use and

the risk of acute myocardial infarction in rheumatoid arthritis.

Presented at: EULAR 2004; Berlin, Germany; June 9-12, 2004. Abstract

OP0038.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org