Autoimmune Rheumatic Diseases

Autoimmune rheumatic diseases (AIRDs), including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), are associated with higher rates of cardiovascular morbidity and mortality.¹⁵¹ Cardiovascular disease is the main cause of death among RA patients, primarily due to ischemic heart disease secondary to atherosclerosis,¹⁵¹ and CHD is the leading cause of death among women with SLE.¹⁰⁶

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• Increased Coronary Risk
• How Do AIRDs Increase Coronary Risk?
• Issues in CAD Screening

Increased Coronary Risk

• SLE patients are at ≥5 times increased risk for CAD,¹⁰⁷ and RA is an independent risk factor for multi-vessel CAD.¹⁰⁸
• Among patients with CAD, those with RA were significantly more likely to have multi-vessel disease than those without RA.¹⁰⁸
• RA patients have a significantly higher prevalence of angina pectoris.¹⁰⁹
• Women with RA are at increased risk of MI.¹¹⁰
• The risk of MI in women with RA is twice that of women without RA, even after adjusting for a variety of variables.
• Women who have had RA for ≥10 years are at >3 times the risk of MI compared with women without RA.
• SLE patients have a 5-fold increased incidence of MI,¹¹¹ and 35- to 44-year-old women with SLE were 52 times more likely to have an MI compared with non-SLE controls.¹¹²
• The most notable findings of increased CHD mortality in RA are among younger women, aged 15 to 49,¹¹³ and young women with SLE, who normally have a low risk of ischemic heart disease (IHD), are at the highest risk.¹¹³

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How Do AIRDs Increase Coronary Risk?

While the precise reasons for the increased coronary risk in patients with AIRDs have not been clearly identified, a number of factors have been implicated:

• Inflammatory components of the immune system^{108,110,113,114,151}:
• CRP is elevated in RA^108,110
• CD4+CD28- T cells are involved in the pathogenesis of both RA and atherosclerosis^108,151
• Adhesion molecules (CD40 and CD40L in SLE and ICAM-1 in RA) have been implicated^113,114
• Traditional risk factors^113,151
• Reduced physical activity associated with RA¹¹⁰
• Corticosteroid use (although evidence is inconsistent)^108,113,151
• Increased homocysteine levels^114,151
• Hormonal factors¹¹³

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Issues in CAD Screening

• AIRD patients should be treated as belonging to a high cardiovascular risk group and may be targets for early identification and preventive therapy for CAD.¹⁵¹
• AIRD patients have been shown to have an increased risk for advanced subclinical atherosclerosis, which may precede the appearance of clinical disease.¹⁵¹
• It may be prudent to consider aggressive cardiac preventive measures aimed at established CAD risk factors in RA patients.¹¹⁰
• Given the increased mortality at a younger age and the subclinical atherosclerosis noted in AIRDs,^112,113,151 earlier CAD screening may be warranted in AIRDs patients compared with the general population.

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