Systemic inflammation appears to contribute to an increased risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) due to accelerated atherosclerosis. However, the impact of varying levels of disease activity over time on the progression of subclinical atherosclerosis (AP+) in patients with early RA (ERA) remains uncertain. A recent research article published in Rheumatic & Musculoskeletal Diseases Open suggests that maintaining long-term low disease activity (LDA) or achieving remission could potentially halt the advancement of atherosclerosis in ERA patients.
In a comprehensive 5-year prospective study led by Dr. Meng and colleagues, 120 patients were recruited from the rheumatology clinic at the Prince of Wales Hospital between December 2012 and December 2015. Remarkably, 52 individuals (50% of the participants) achieved sustained LDA or remission, while 40.4% exhibited atherosclerotic plaque positivity (AP+). Notably, patients in the AP+ category were characterized by advanced age and a higher prevalence of traditional cardiovascular risk factors at the study’s outset. Multivariate logistic regression analysis revealed that individuals with persistent moderate or high disease activity, as indicated by a cumulative average disease activity score 28-erythrocyte sedimentation rate (ca-DAS28-ESR) >3.2, had a significantly elevated risk of AP+ (OR 5.05, 95% CI 1.53–16.64, P=0.008) compared to those who consistently achieved remission. Moreover, the risk of AP+ was found to be comparable between patients maintaining persistent LDA and those in persistent remission.
A meta-analysis by Arts et al. has also addressed the clinical significance of subclinical AP+. They found that a decrease in carotid intima-media thickness (cIMT) progression by 10 µm/year correlated with a relative risk (RR) of CVD at 0.84 (95% CI 0.75–0.93). In a study encompassing 873 patients with ERA and a median (IQR) follow-up time of 5 (3–9) years (totaling 4560 patient-years), maintaining a low disease activity score of 28 joints (DAS28 ≤3.2) was significantly associated with a reduced risk of CVD (HR 0.65, 95% CI 0.43–0.99) compared to DAS28 >3.2.
The findings of the present study underscore the importance of maintaining sustained LDA over time as a key factor in reducing the risk of AP+. These results highlight the implementation of an effective inflammation suppression strategy through a treat-to-target approach to prevent CVD in individuals with ERA. The evidence strongly suggests that strategies focused on achieving persistent LDA or remission may serve as a preventive measure, significantly reducing the risk of CVD by impeding the progression of atherosclerosis in ERA patients.
Reference
- Meng H, Cheng IT, Yan BPY, Lee AP, So H, Tam LS. Moderate and high disease activity levels increase the risk of subclinical atherosclerosis progression in early rheumatoid arthritis: a 5-year prospective study. RMD Open. 2024 Jan 10;10(1):e003488.
- Arts EE, Fransen J, Broeder AAD, Riel PLCM van, Popa CD. Low disease activity (DAS28≤3.2) reduces the risk of first cardiovascular event in rheumatoid arthritis: a time-dependent Cox regression analysis in a large cohort study. Annals of the Rheumatic Diseases. 2017 Oct 1;76(10):1693–9.