How RA Inflammation Affects Your Heart
Researchers explore why having rheumatoid increases the risk of heart disease and recommend better risk assessment.
Among the serious complications people with rheumatoid arthritis (RA) experience, cardiovascular disease heads the list. Having RA doubles the risk of most heart problems, including heart attack, stroke and atherosclerosis — the buildup of fat, cholesterol and cellular debris (plaque) on blood vessel walls.
Research shows that traditional risk factors don’t explain the increased rates in people with RA. “The risk in patients with RA is above and beyond traditional risk factors for heart disease such as high blood pressure, diabetes and smoking,” explains John Davis III, MD, associate professor of medicine at the Mayo Clinic’s Cardio-Rheumatology Clinic in Rochester, Minn. “Those factors are important, but they don’t account for a big part of the risk, which may result from inflammation.”
Why the High Risk if You Have RA?
Daniel H. Solomon, MD, a professor at Harvard Medical School in Boston and a leading researcher on cardiovascular disease and RA, says the inflammatory processes in RA and heart disease are very similar. In RA, inflammation attacks the synovium — the thin layer of tissue that lines your joints — but it can move to other organs, including the heart. One of the possible victims is the endothelium, the innermost layer of blood vessels. Inflammation causes damage to the blood vessel lining, and plaque builds up. This fatty deposit narrows arteries, raising blood pressure and reducing the flow of blood to your heart and other organs.
In a 2015 study in Nature Reviews Rheumatology, British investigators reported that people with RA are more likely to have atherosclerosis than the general population and that they develop it at a faster rate. Plaque is also more brittle and prone to rupture in RA, and more likely to cause a heart attack or stroke. In fact, the risk of ischemic stroke, resulting from a clot in an artery supplying blood to the brain, is nearly doubled in people with RA. Atherosclerosis starts early in the course of RA — often before there are joint symptoms — and progresses rapidly after RA is diagnosed.
Inflammation doesn’t only damage the heart’s arteries. It affects veins, too, increasing the risk of deep vein thrombosis (DVT) and pulmonary embolism — blood clots in the legs or lungs. A 2012 Mayo Clinic study found a three-time greater risk of DVT in people with RA and a more than four-times greater risk of life-threatening pulmonary embolism.
Some research, including a 2015 Mayo Clinic study published in BioMed Research International, suggests that people with RA have a significantly increased risk of atrial fibrillation (AF) — an irregular heartbeat that can increase stroke risk fivefold. The study also reported an association between diastolic dysfunction, an abnormality in how the heart fills with blood, and AF, and that patients with RA are known to have increased prevalence of diastolic dysfunction.
Inflammation of the two-layered sac that surrounds the heart known as the pericardium is also more common in patients with RA. The inflamed sacs rub against each other, causing sharp, intense chest pain.
A Better Risk Assessment
Making sense of how inflammation and other risk factors influence RA-related heart disease will help doctors identify and treat high-risk patients early, before they develop symptoms. The challenge is that current cardiovascular risk assessments, which use medical history and lifestyle information to predict a person’s five-year risk of heart disease, aren’t very useful for RA patients. For one thing, standard risk assessments don’t factor in the effects of inflammation or medication.
“Right now, the Holy Grail is finding a better risk assessment,” says Dr. Solomon. In the May 2015 issue of Arthritis and Rheumatology, he and his colleagues published an expanded and validated risk assessment specifically for RA. In addition to traditional cardiovascular risk factors, they also included RA disease activity, disability, prednisone use and years with RA. The researchers found the expanded assessment improved classification of risk compared with traditional risk assessments.
What it Means for You
Although progress is being made, preventing or reducing heart disease risk in people with RA remains challenging, in part because there are no specific guidelines or recommendations, Dr. Davis says.
“We are trying to communicate that people with RA are at increased risk and that physicians should consider which patients would benefit from early assessment. That would include people with more severe disease, disease that is difficult to control with typical medications and those who already have multiple risk factors. Patients with diabetes or known heart disease need to be assessed carefully, usually by a cardiologist,” he says.
Although Dr. Davis says no one approach is right for every patient, preventive strategies generally include treating RA aggressively to bring inflammation under tight control; reducing use of medications that damage the heart; and supporting patients in their efforts to control lifestyle factors known to play a role in heart disease. Lifestyle changes that help to reduce your risk of heart disease, include being physically activity, eating a healthy diet and working with your doctors to minimize medication side effects. And most of all, if you smoke, stop. “Smoking raises the risk of both RA and heart disease,” Dr. Davis says. “The most important thing you can do is quit.”