Does Rheumatoid Arthritis Increase Cardiovascular Risk?

Rheumatoid arthritis increases various inflammatory mediators. These mediators affect the joints and circulate throughout the body and cause inflammation to various organs and systems, including the heart, lungs, skin, and eyes.

Rheumatoid arthritis-related inflammation can affect the heart and blood vessels, increasing the risk of cardiovascular disease.

1. Inflammation
   • Rheumatoid arthritis is primarily an inflammatory condition. The immune system misidentifies and targets healthy tissue surrounding the joints. This assault generates inflammation throughout the body, affecting vital organs and causing pain, swelling, and warmth in the joints.
   • Inflammation irritates blood vessels and increases the chances of plaque formation while simultaneously making plaque less stable. It is more likely to break off, form an embolus, which is a clot traveling in the bloodstream, and block an artery, leading to the brain (resulting in a stroke) or heart (causing a heart attack). It increases the risk of blood clots in deep veins of the legs (deep vein thrombosis), which can move to the lungs and cause a pulmonary embolism.
   • Furthermore, inflammation causes low-density lipoprotein (LDL or bad) cholesterol to oxidize or alter chemically. Oxidized LDL can more easily pass through the lining of coronary veins and become lodged there, causing further inflammation. This is more likely to happen in patients with rheumatoid arthritis who have active illness than in those who are in remission.
   • People with rheumatoid arthritis have higher amounts of inflammatory proteins called cytokines, such as tumor necrosis factor-alpha, which cause inflammation. These proteins promote inflammation (a pro-inflammatory state) and make blood stickier (pro-thrombotic state), increasing the chances of hazardous clots formation (pro-coagulant state), including those that cause heart attacks and strokes.
   • C-reactive protein (CRP) is an inflammatory marker that is frequently increased in patients with rheumatoid arthritis. Higher CRP levels are strongly connected with a higher incidence of myocardial infarction or heart attacks.
2. HDL cholesterol function impairment
   • High-density lipoprotein (HDL) is considered good cholesterol because it is associated with a lower risk of cardiovascular diseases. HDL is responsible for the movement of LDL or bad cholesterol from the blood vessels to the liver, where the LDL is removed from the body.
   • This function of the HDL is impaired with rheumatoid arthritis because the inflammation caused by rheumatoid arthritis alters the composition of HDL. This is especially seen with the high disease activity of rheumatoid arthritis. This increases the risk of cardiovascular diseases in patients with rheumatoid arthritis.
3. The magnitude of traditional risk factors increases
   • Heart disease risk factors are medical conditions or lifestyle choices that increase the probability of developing cardiovascular disease. The following common risk factors are high in people with rheumatoid arthritis:
     • High in all types of lipids
       • LDL cholesterol
       • Triglycerides
     • Increased blood pressure
     • Obesity
     • Diabetes
     • Reduced mobility
     • Smoking
   • These risk factors and inflammation caused by rheumatoid arthritis combine to cause greater negative effects. This increases the risk of cardiovascular diseases.
4. The medications for rheumatoid arthritis can increase the risk of cardiovascular diseases
   • To manage pain and inflammation, rheumatoid arthritis is commonly treated with a variety of drugs. Some of these medicines can potentially increase the risk of heart disease, so discuss it with the rheumatologist accordingly.
     • Corticosteroids: Prednisone influences the heart health negatively, so it is advisable to avoid them or use as little as possible to keep rheumatoid arthritis under control. Steroids can increase lipid values, such as LDL cholesterol and triglycerides. They can increase blood pressure and sugar levels and induce changes in systemic inflammatory reactions.
     • Disease-modifying antirheumatic drugs (DMARDs): The majority of classic DMARDs, such as methotrexate, and newer biologics, such as tumor necrosis factor (TNF) inhibitors, do not increase the risk of cardiovascular issues. Some evidence suggests that they may reduce the risk of heart disease.
   • However, other drugs, such as Janus kinase (JAK) inhibitors (tofacitinib, baricitinib, and upadacitinib) and interleukin (IL)-6 inhibitors (tocilizumab and sarilumab) may elevate cholesterol and triglyceride levels. Though JAK and IL-6 inhibitors remain good alternatives for certain people, they may not be a good fit if cholesterol levels are high. Therefore, it is crucial to check for the lipid levels before beginning these medications.

1. Coronary artery disease: The inflammatory mediators and immune responses damage the endothelium of the blood vessels. As a result, plaques (made of cholesterol and other substances) are formed on the damaged arteries. When a piece of plaque breaks off, it can form a clot, obstruct blood flow to the heart and result in a heart attack. According to studies, patients with rheumatoid arthritis have a higher risk of coronary artery disease than the general population. People who are diagnosed with rheumatoid arthritis have a 50 percent or more chance of having a heart attack than those who do not have it. A heart attack is a result of coronary artery disease.
2. Heart failure: Heart failure is a chronic condition that occurs when the heart is unable to pump adequately, causing weakness. Everyday activities may become difficult. If a person has rheumatoid arthritis, they are two times more likely than others to suffer heart failure.
3. Stroke: A stroke, also called brain attack, happens when the blood supply to the brain is cut off, most commonly owing to a blood clot. People with rheumatoid arthritis could be 60 to 100 percent more likely to suffer a stroke than those who do not have it.
4. Atrial fibrillation: Atrial fibrillation is a form of irregular and typically fast heartbeat that increases the risk of having a stroke or heart attack. People with rheumatoid arthritis are 60 percent more likely to develop this disorder than the general population.
5. Pulmonary embolism: In pulmonary embolism, a blood clot gets lodged in an artery of the lungs. People with rheumatoid arthritis are much more likely than others to suffer a pulmonary embolism, especially those with active rheumatoid arthritis who are most at risk.

It is recommended to all people with rheumatoid arthritis follow a primary prevention strategy to reduce the risk of cardiovascular diseases. This involves the identification of risk factors and following measures to reduce them.

• Cease smoking
• Weight control
• Take lipid-lowering agents
• Following a healthy diet
• Control blood pressure
• Maintain good blood sugar levels
• Increase physical activity