Oral anticoagulant treatment in rheumatoid arthritis patients with atrial fibrillation results of an international audit

Objective: To describe the prevalence of atrial fibrillation (AF) in patients with rheumatoid arthritis (RA), and to evaluate the proportion of patients with AF receiving guideline-recommended anticoagulation for prevention of stroke, based on data from a large international audit. Methods: The cohort was derived from the international audit SUrvey of cardiovascular disease Risk Factors in patients with Rheumatoid Arthritis (SURF-RA) which collected data from 17 countries during 2014-2019. We evaluated the prevalence of AF across world regions and explored factors associated with the presence of AF with multivariable logistic regression models. The proportion of AF patients at high risk of stroke (CHA(2)DS(2)-VASc & GE; 2 in males and & GE; 3 in females) receiving anticoagulation was examined. Results: Of the total SURF-RA cohort (n = 14,503), we included RA cases with data on whether the diagnosis of AF was present or not (n = 7,665, 75.1% women, mean (SD) age 58.7 (14.1) years). A total of 288 (3.8%) patients had a history of AF (4.4% in North America, 3.4% in Western Europe, 2.8% in Central and Eastern Europe and 1.5% in Asia). Factors associated with the presence of AF were older age, male sex, atherosclerotic cardiovascular disease, heart failure and hypertension. Two-hundred and fifty-five (88.5%) RA patients had a CHA(2)DS(2)-VASc score indicating recommendation for oral anticoagulant treatment, and of them, 164 (64.3%) were anticoagulated. Conclusion: Guideline-recommended anticoagulant therapy for prevention of stroke due to AF may not be optimally implemented among RA patients, and requires special attention.Peer reviewe

Diabetes mellitus and cardiovascular risk management in patients with rheumatoid arthritis: an international audit

Aim: The objective was to examine the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its risk factors among patients with RA with diabetes mellitus (RA-DM) and patients with RA without diabetes mellitus (RAwoDM), and to evaluate lipid and blood pressure (BP) goal attainment in RA-DM and RAwoDM in primary and secondary prevention. Methods: The cohort was derived from the Survey of Cardiovascular Disease Risk Factors in Patients with Rheumatoid Arthritis from 53 centres/19 countries/3 continents during 2014-2019. We evaluated the prevalence of cardiovascular disease (CVD) among RA-DM and RAwoDM. The study population was divided into those with and without ASCVD, and within these groups we compared risk factors and CVD preventive treatment between RA-DM and RAwoDM. Results: The study population comprised of 10 543 patients with RA, of whom 1381 (13%) had DM. ASCVD was present in 26.7% in RA-DM compared with 11.6% RAwoDM (p<0.001). The proportion of patients with a diagnosis of hypertension, hyperlipidaemia and use of lipid-lowering or antihypertensive agents was higher among RA-DM than RAwoDM (p<0.001 for all). The majority of patients with ASCVD did not reach the lipid goal of low-density lipoprotein cholesterol <1.8 mmol/L. The lipid goal attainment was statistically and clinically significantly higher in RA-DM compared with RAwoDM both for patients with and without ASCVD. The systolic BP target of <140 mm Hg was reached by the majority of patients, and there were no statistically nor clinically significant differences in attainment of BP targets between RA-DM and RAwoDM. Conclusion: CVD preventive medication use and prevalence of ASCVD were higher in RA-DM than in RAwoDM, and lipid goals were also more frequently obtained in RA-DM. Lessons may be learnt from CVD prevention programmes in DM to clinically benefit patients with RA .The work was supported by grants from the South Eastern Regional Health Authorities of Norway (2013064 for AGS and 2016063 for SR) and FOREUM (the Foundation for Research in Rheumatology for AMK). Further support was through a collaborative agreement for independent research from Eli Lilly who had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript

Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models

Background: In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. Methods: RA patients aged 30?70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusión criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. Results: A total of 1974 patients were included in the main analyses, and 144 events were observed during followup, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15?32% of patients. C-statistics ranged 0.68?0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. Conclusions: The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive

Smoking cessation is associated with lower disease activity and predicts cardiovascular risk reduction in rheumatoid arthritis patients

Objectives: Smoking is a major risk factor for the development of both cardiovascular disease (CVD) and RA and may cause attenuated responses to anti-rheumatic treatments. Our aim was to compare disease activity, CVD risk factors and CVD event rates across smoking status in RA patients. Methods: Disease characteristics, CVD risk factors and relevant medications were recorded in RA patients without prior CVD from 10 countries (Norway, UK, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico). Information on CVD events was collected. Adjusted analysis of variance, logistic regression and Cox models were applied to compare RA disease activity (DAS28), CVD risk factors and event rates across categories of smoking status. Results: Of the 3311 RA patients (1012 former, 887 current and 1412 never smokers), 235 experienced CVD events during a median follow-up of 3.5 years (interquartile range 2.5-6.1). At enrolment, current smokers were more likely to have moderate or high disease activity compared with former and never smokers (P < 0.001 for both). There was a gradient of worsening CVD risk factor profiles (lipoproteins and blood pressure) from never to former to current smokers. Furthermore, former and never smokers had significantly lower CVD event rates compared with current smokers [hazard ratio 0.70 (95% CI 0.51, 0.95), P = 0.02 and 0.48 (0.34, 0.69), P < 0.001, respectively]. The CVD event rates for former and never smokers were comparable. Conclusion: Smoking cessation in patients with RA was associated with lower disease activity and improved lipid profiles and was a predictor of reduced rates of CVD events

Prediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models

Background In younger individuals, low absolute risk of cardiovascular disease (CVD) may conceal an increased risk age and relative risk of CVD. Calculation of risk age is proposed as an adjuvant to absolute CVD risk estimation in European guidelines. We aimed to compare the discriminative ability of available risk age models in prediction of CVD in rheumatoid arthritis (RA). Secondly, we also evaluated the performance of risk age models in subgroups based on RA disease characteristics. Methods RA patients aged 30–70 years were included from an international consortium named A Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis (ATACC-RA). Prior CVD and diabetes mellitus were exclusion criteria. The discriminatory ability of specific risk age models was evaluated using c-statistics and their standard errors after calculating time until fatal or non-fatal CVD or last follow-up. Results A total of 1974 patients were included in the main analyses, and 144 events were observed during follow-up, the median follow-up being 5.0 years. The risk age models gave highly correlated results, demonstrating R 2 values ranging from 0.87 to 0.97. However, risk age estimations differed > 5 years in 15–32% of patients. C-statistics ranged 0.68–0.72 with standard errors of approximately 0.03. Despite certain RA characteristics being associated with low c-indices, standard errors were high. Restricting analysis to European RA patients yielded similar results. Conclusions The cardiovascular risk age and vascular age models have comparable performance in predicting CVD in RA patients. The influence of RA disease characteristics on the predictive ability of these prediction models remains inconclusive

Implementation of cardiovascular risk factor recording in a rheumatology outpatient clinic

Background: The high cardiovascular (CV) risk in patients with rheumatoid arthritis (RA) is under-recognized and under-assessed in both primary and secondary health care. Our aim was to evaluate the quality of CV risk recording in rheumatology outpatient clinics and to evaluate strategies for optimizing CV risk factor screening in RA patients. Methods: RA patients (n=1142) who visited the rheumatology outpatient clinic at the Hospital of Southern Norway in 2012, either attended the regular rheumatology outpatient clinic (RegROC), or an arthritis clinic (AC) that included a structured, systematic, interdisciplinary team-based model with annual CV assessments. Both patient groups had CV risk factors recorded in the patient medical journal, as well as in a computerized journal program, GoTreatIT-rheuma (GTI-r). We conducted thorough searches in both journals to ascertain how many patients had recorded CV risk factors. Results: The AC patients had significantly more CV risk factors recorded compared to the RegROC patients (p-values <0.001). The relative risks for CV risk factors being recorded in the patient journals were 2.2-2.8 for various lipid values, 3.1 for brachial blood pressure and 3.3 for glucose. The discrepancies between AC and RegROC patients regarding CV risk factor recording were even more pronounced in the GTI-r journals, relative ratios being: 6.5 for lipid values, 8.4 for brachial BP and 10.2 for a complete CV risk profile. Conclusion: We have shown that in RA patients attending a rheumatology outpatient clinic, an arthritis clinic approach with a systematic, team-based model of CV risk data collection is superior to CV risk data collection in a regular rheumatology outpatient clinic

Markers of Progression and Regression of Atherosclerotic Cardiovascular Disease in Patients with Inflammatory Joint Diseases

Pasienter med revmatoid artritt (RA) og andre betennelsesaktige leddsykdommer (BLS) har høy risiko for aterosklerotisk hjerte-karsykdom (HKS). Risikoen er sammenlignbar med diabetes og skyldes kronisk betennelse i tillegg til en høy forekomst av risikofaktorer for HKS, slik som høyt blodtrykk (BT) og røyking. Ikdahls artikkel I og II beskriver bedring av BT, karfunksjon og karstivhet etter statinbehandling i RORA-AS studien, der 100 pasienter med BLS og plakk i halspulsåren fikk intensiv kolesterolsenkende behandling i 1.5 år. Intensiv kolesterolsenkning kan reversere den aterosklerotiske prosessen, såkalt «aterosklerotisk regresjon», og selv om det foreligger lite dokumentasjon har bedring av karfunksjonen vært foreslått som en viktig mekanisme i denne prosessen. I artikkel I presenteres for første gang kliniske bevis som understøtter denne hypotesen, ettersom bedret karfunksjon i RORA-AS var relatert til minkede halspulsåreplakk. Behandling for å redusere karstivhet vært foreslått som en ny angrepsvinkel for BT-behandling ettersom økt karstivhet er relatert til stigende BT. Ikdahl demonstrerer i artikkel II at BT og karstivhet er relatert også når de senkes, dette var ikke tidligere kjent. Det er et problem at tradisjonelle risikokalkulatorer for fremtidig HKS underestimerer risikoen til RA-pasienter og nye, mer nøyaktige metoder etterspørres stadig. I artikkel III presenterer Ikdahl for første gang bevis på at karstivhetsmarkører kan ha verdi som prediktorer for HKS hos RA-pasienter. Artikkelen støtter også tidligere data som indikerer at markører på tidlige stadier av aterosklerose har en prediktiv verdi. QRISK-II lifetime er en ny risikokalkulator som beregner livstidsrisiko for HKS og som inkluderer RA og kronisk nyresvikt som risikofaktorer for HKS. Ikdahl finner i sin siste artikkel at også QRISK-II lifetime, nevnt i Joint British Society’s seneste anbefalinger for forebygging av HKS, sannsynligvis underestimerer HKS-risikoen hos pasienter med RA og kronisk nyresykdom

Rosuvastatin improves endothelial function in patients with inflammatory joint diseases, longitudinal associations with atherosclerosis and arteriosclerosis: results from the RORA-AS statin intervention study

Introduction Endothelial dysfunction is an early step in the atherosclerotic process and can be quantified by flow-mediated vasodilation (FMD). Our aim was to investigate the effect of long-term rosuvastatin therapy on endothelial function in patients with inflammatory joint diseases (IJD) with established atherosclerosis. Furthermore, to evaluate correlations between change in FMD (ΔFMD) and change in carotid plaque (CP) height, arterial stiffness [aortic pulse wave velocity (aPWV) and augmentation index (AIx)], lipids, disease activity and inflammation. Methods Eighty-five statin-naïve patients with IJD and ultrasound-verified CP (rheumatoid arthritis: n = 53, ankylosing spondylitis: n = 24, psoriatic arthritis: n = 8) received rosuvastatin treatment for 18 months. Paired-samples t tests were used to assess ΔFMD from baseline to study end. Linear regression models were applied to evaluate correlations between ∆FMD and cardiovascular risk factors, rheumatic disease variables and medication. Results The mean ± SD FMD was significantly improved from 7.10 ± 3.14 % at baseline to 8.70 ± 2.98 % at study end (p < 0.001). Improvement in AIx (p < 0.05) and CP height reduction (p = 0.001) were significantly associated with ΔFMD (dependent variable). Conclusions Long-term lipid lowering with rosuvastatin improved endothelial function in IJD patients with established atherosclerotic disease. Reduced arterial stiffness and CP regression were longitudinally correlated with the improvement in endothelial function measured by FMD. Trial registration ClinicalTrials.gov NCT01389388 . Registered 16 April 2010

Blodtransfusjon ved akutt øvre gastrointestinal blødning : implementering av lavere hemoglobingrense for blodtransfusjon

Bakgrunn/emne Optimalt nivå for hemoglobin (Hb) før blodtransfusjon ved akutt øvre gastrointestinal blødning (AØGIB) er ikke fullstendig kartlagt. Flere sykehus opererer ikke med fastsatt grense, men anbefaler transfusjon ved Hb 8-9 g/dL. Verken nasjonale eller internasjonale retningslinjer gir klare anbefalinger for Hb-grense ved transfusjon, og det er store forskjeller i forbruk av blodprodukter mellom sykehus og mellom land. Ved Diakonhjemmet Sykehus anvendes i dag en Hb-grense på 8-9 g/dL for blodtransfusjon. Det er dog stor variasjon i praksis mellom legene og ingen klare anbefalinger i metodehåndbøkene. Kunnskapsgrunnlag Det er nylig publisert en stor randomisert kontrollert studie som viste økt overlevelse etter 6 uker hos pasienter som fikk transfusjon ved Hb 7 g/dL. Studien er direkte årsak til at Uptodate nå anbefaler blodtransfusjon først ved Hb < 7 g/dL hos denne pasientgruppen (Grade 1B). Tiltak, kvalitetsindikator og metode Vi anbefaler flere tiltak for å sikre at pasienter med AØGIB får blodtransfusjon etter de nye anbefalingene. Aktuelle tiltak inkluderer oppdatering av metodehåndbok og elektronisk kvalitetshåndbok, samt morgenundervisning, skriftlig informasjon, påminnelser på e-post og veggavis. Tiltakene vurderes som enkle, kontrollerbare og kostnadseffektive. Tiltakets effekt kan måles med prosessindikatoren: andelen pasienter som får blodtransfusjon ved Hb > 7 g/dL i denne pasientgruppen. Organisering/Ledelse Vi foreslår at det opprettes en prosjektgruppe med forankring i ledelsen som har ansvar for implementering av tiltakene. Gruppen bør møtes jevnlig og sørge for å kontrollere effekten av tiltaket ved å måle prosessindikatoren etter seks måneder og etter ett år. Dette kan gjøres enten ved retrospektiv journalgjennomgang eller ved fortløpende registrering av denne pasientgruppen. Vurdering Vi anbefaler innføring av en restriktiv holdning til blodtransfusjon ved akutt øvre gastrointestinal blødning ved Diakonhjemmet sykehus, såfremt det ikke foreligger kontraindikasjoner. Anbefalingen kommer med forbehold døgnkontinuerlig tilgang til endoskopisk undersøkelse og behandling

Degree of arterial stiffness is comparable across inflammatory joint disease entities

Objectives: Inflammatory joint disease (IJD) is associated with an increased risk of developing cardiovascular disease (CVD). Arterial stiffness is both a risk factor and a surrogate marker for CVD. This study aims to compare arterial stiffness across patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis, and, by extension, to explore the relationship between arterial stiffness and the estimated CVD risk by the Systematic COronary Risk Evaluation (SCORE) algorithm. Method: During the study period, from April 2017 to June 2018, 196 patients with IJD visited the Preventive Cardio-Rheuma Clinic in Oslo, Norway. A CVD risk stratification was performed, including the assessment of traditional risk factors and the measurement of arterial stiffness. Results: Thirty-six patients (18.4%) had elevated aortic pulse wave velocity (aPWV) (≥ 10 m/s). After adjustment for age and heart rate, arterial stiffness was comparable across the IJD entities (p = 0.69). Associated factors, revealed by regression analysis, were age, blood pressure, heart rate, presence of carotid plaques, establis hed CVD, non-steroidal anti-inflammatory drugs, and statin use. Furthermore, aPWV was positively correlated with estimated CVD risk (r = 0.7, p < 0.001) and patients with a very high predicted CVD risk (SCORE ≥ 10%) had significantly higher aPWV than patients at lower CVD risk (9.2 vs 7.5 m/s, p < 0.001). Conclusion: The degree of arterial stiffness was comparable across the IJD entities and was highly associated with the estimated CVD risk. Our findings support the need for an increased focus on prevention of CVD in all patients with IJD