What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is an autoimmune condition that affects about 1% of the adult UK population. It can cause pain and swelling of the joints and affect other organ systems such as the heart, lungs and kidneys.
Not many people are aware of this but RA is associated with a reduced life expectancy and an increased risk of heart problems such as a myocardial infarction (MI), otherwise known as a heart attack.
In people with RA who had a heart attack, there may have been a prior stressful episode such as an operation or a hospital admission for other medical reasons. In this study by Tropea et al, the researchers set out to study the relationship between routine orthopaedic surgery and the risk of heart attacks in people with RA.
What did the study find?
This study was conducted in the state of Victoria, Australia using data routinely collected from all hospital admissions from 2000 to 2007. Over 200,000 individuals were studied; almost 1% had RA.
The risk of heart attack at six weeks and one year after orthopaedic surgery was compared between those patients who had RA and those who did not.
All underwent orthopaedic surgical procedures, of which 1% was performed in patients with RA. Common orthopaedic procedures included hip and knee joint replacements. The risk of heart attack at six weeks and one year after orthopaedic surgery was compared between those patients who had RA and those who did not.
Factors which may influence the risk of heart attack independently such as age, hypertension, smoking and socioeconomic deprivation were adjusted for in the statistical analysis in order to estimate the effect of RA alone on the risk of heart attack. The risk of death from any cause was also studied in the same way.
Cardiovascular disease in this patient group
The researchers found that the risk of death six weeks after orthopaedic surgery was increased in people with RA compared to those who did not have RA. Over the longer term (12 months), the risk of death remained elevated and the risk of a heart attack within 12 months after orthopaedic surgery was also increased in people with RA.
The researchers tried to understand the reasons behind this increased risk, but the way the data was gathered meant that it was not possible to do so. Other factors such as data on medications used to treat RA and cardiovascular disease and secondary preventive strategies post-MI were not available for this analysis; these factors may independently influence the risk of MI rather than the RA itself.
I think it highlights the importance of educating our patients and their doctors, specifically around the fact that cardiovascular disease in this patient group is under-recognized
What does this observation mean for our patients with RA and also the doctors treating patients with RA? First of all, I think it highlights the importance of educating our patients and their doctors, specifically around the fact that cardiovascular disease in this patient group is under-recognized and where possible, to institute preventative measures such as regular blood pressure monitoring, cholesterol checks and stopping smoking.
In short, all the general health advice about reducing cardiovascular disease in the general population should also be applied to our patient group. There may be a burden of ‘silent’ cardiovascular disease in this patient group as they are generally less active due to joint pain and disability, and thus the usual hallmarks of CVD such as angina attacks (which may prompt earlier investigation and treatment) may be less prominent.
Also, we as physicians should be vigilant about the risk of heart attack in the postoperative period in this group of patients.
What are the implications?
This study was conducted in an era where RA treatment algorithms and drugs for RA were different compared to the current practice. Also, we know that the profile of patients with RA has changed over time; with fewer surgeries performed due to less joint damage and the availability of new therapies such as biologic drugs.
Thus it is possible that that the risk of heart attack and death in the postoperative period may change and it would be interesting to have this study repeated in the future.