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Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus.

ABSTRACT: OBJECTIVE:Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant preoperative CV assessment as is performed for patients with DM. We aimed to determine whether the risks of perioperative death and CV events among patients with RA differed from those among unaffected controls and patients with DM. METHODS:We used 1998-2002 data from the Nationwide Inpatient Sample (NIS) database of the Healthcare Cost Utilization Project (HCUP) to identify hospitalizations of patients undergoing elective noncardiac surgery. Using established guidelines, surgical procedures were categorized as either low risk, intermediate risk, or high risk of having CV events. Logistic models provided the adjusted odds of study end points in patients with RA, DM, or both relative to patients with neither condition. RESULTS:Among 7,756,570 patients undergoing a low-risk, intermediate-risk, or high-risk noncardiac procedure, 2.34%, 0.51%, and 2.12%, respectively, had a composite CV event, and death occurred in 1.47%, 0.50%, and 2.59%, respectively. Among those undergoing an intermediate-risk procedure, death was less likely in RA patients than in DM patients (0.30% versus 0.65%; P < 0.001), but the difference in mortality rates among those undergoing low-risk versus high-risk procedures was not significant. Patients with RA were less likely to have a CV event than were patients with DM for procedures of low risk (3.38% versus 5.30%; P < 0.001) and intermediate risk (0.34% versus 1.07%; P < 0.001). In adjusted models, RA was not independently associated with an increased risk of perioperative death or a CV event. CONCLUSION:RA was not associated with adverse perioperative CV risk or mortality risk, which suggests that current perioperative clinical care does not need to be changed in this regard.

SUBMITTER: Yazdanyar A

PROVIDER: S-EPMC3442932 | biostudies-literature | 2012 Aug

REPOSITORIES: biostudies-literature

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Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus.

Yazdanyar Ali A Wasko Mary Chester MC Kraemer Kevin L KL Ward Michael M MM

Arthritis and rheumatism 20120801 8

<h4>Objective</h4>Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant preoperative CV assessment as is performed for patients with DM. We aimed to determine whether the risks of perioperative death and CV events among patients with RA differed from those among unaffected controls and patients with DM.<h4>Methods</h4>We used 1998-2002 data from the Nationwide Inpatient Sample (NIS) database of the He ...[more]

PMID: 22354534

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Project description:Lower levels of low-density lipoprotein (LDL) cholesterol may be associated with increased cardiovascular (CV) risk in rheumatoid arthritis (RA). This study was undertaken to determine whether the complex relationship between levels of LDL and high-density lipoprotein (HDL) cholesterol and CV risk is different in RA patients as compared to non-RA controls.Using data from a US health insurance plan (2003-2012), we conducted a cohort study that included patients with RA and non-RA control subjects matched with regard to age, sex, and index date. The nonlinearity of associations between lipid levels and incidence of major adverse CV events (MACE) was tested. We used multivariable Cox proportional hazards regression models to examine for an interaction between lipid levels and RA status in relation to the risk of MACE, after adjustment for CV risk factors.In total, 16,085 RA patients and 48,499 non-RA controls were studied. The mean age was 52.6 years and 78.6% were women. The relationship between LDL cholesterol levels and incidence of MACE was nonlinear and similar between RA patients and non-RA controls (P for interaction?=?0.72). No significant increase in CV risk was observed between the lowest quintile of LDL cholesterol levels (?91.0 mg/dl) and the second, third, or fourth quintiles, whereas the highest quintile (>190.0 mg/dl) conveyed a 40% increase in risk of MACE (hazard ratio [HR] 1.40, 95% confidence interval [95% CI] 1.17-1.68). The relationship between HDL cholesterol levels and incidence of MACE was also nonlinear and similar between RA patients and non-RA controls (P for interaction?=?0.39). Compared to the lowest quintile of HDL cholesterol levels, each successive quintile was associated with a reduced risk of MACE (HR 0.45, 95% CI 0.48-0.72 for lowest quintile [?43.0 mg/dl] versus highest quintile [>71.0 mg/dl]).The complex relationship between LDL cholesterol levels, HDL cholesterol levels, and risk of MACE was nonlinear in RA patients and also not statistically significantly different from that in an age- and sex-matched non-RA cohort.

Project description:Cardiovascular disease (CVD) is the leading cause of death in rheumatoid arthritis (RA) patients. This study is the first to report the association of hydroxychloroquine (an antirheumatic medication that has been associated with decreased risk of diabetes, a less atherogenic lipid profile, and antithrombotic properties) with CVD in RA. A retrospective incident RA cohort from January 1, 2001, to October 31, 2013, excluding patients with CVD prior to RA diagnosis, was constructed. Patients were categorized as hydroxychloroquine users versus nonusers and were allowed to contribute time to either group according to hydroxychloroquine exposure. The primary outcome was adjudicated incident CVD defined as a composite of coronary artery disease, stroke, transient ischemic attack, sudden cardiac death, and peripheral artery disease with arterial revascularization procedure. The secondary outcome was a composite of incident coronary artery disease, stroke, and transient ischemic attack. Cox time-varying regression models were used to estimate the association between hydroxychloroquine exposure and development of CVD, after adjusting for propensity score and relevant confounders, including demographics, CVD-related comorbidities, RA severity, and activity indicators and medications. We included 1266 RA patients, 547 hydroxychloroquine users, and 719 nonusers. During the observation period, 102 CVD events occurred, 3 in hydroxychloroquine users and 99 in nonusers. The fully adjusted Cox model showed a hazard ratio of 0.28 (95% CI 0.12-0.63, P=0.002) for incident CVD and 0.30 (95% CI 0.13-0.68, P=0.004) for incident composite coronary artery disease, stroke, and transient ischemic attack for hydroxychloroquine users versus nonusers, respectively. In this hypothesis-generating study, hydroxychloroquine use was associated with a 72% decrease in the risk of incident CVD in RA patients. If these preliminary results are confirmed in larger studies, our findings may be used as a rationale for a randomized study of hydroxychloroquine use for primary prevention of CVD in RA or nonrheumatic high-risk patients.

Project description:BackgroundWe explore the spectrum of comorbidities in psoriatic arthritis (PsA) patients in comparison with other high comorbidity-burden diseases like rheumatoid arthritis (RA) and diabetes mellitus (DM).MethodsTwo hundred and fifteen PsA patients, cross-sectionally collected from two tertiary hospitals, were compared with 215 RA and 215 DM patients (age/sex-matched, similar disease duration). Cardiovascular risk factors [hypertension, current smoking, hyperlipidaemia, obesity (body mass index (BMI) ⩾30)], coronary artery disease (CAD), stroke, major adverse cardiac events (MACEs; combined CAD and stroke), depression, osteoporosis and malignancies were recorded. Odds ratios (ORs) for stroke, CAD and MACE were adjusted for age, sex, hypertension, smoking, hyperlipidaemia, BMI, glucocorticoids use and those for depression were adjusted for age, sex, disease duration, skin involvement and smoking. Within the PsA group, associations between comorbidities and demographic/clinical features were assessed.ResultsDepression [OR (95% confidence interval (CI)): 3.02 (1.57-5.81)], obesity [OR (95% CI): 2.83, (1.65-4.86)] and hyperlipidaemia [OR (95% CI): 1.96 (1.32-2.90)] were more prevalent in PsA compared with RA, while no differences were observed for CAD, stroke, MACE and malignancies. Depression [OR (95% CI): 4.85 (2.37-9.93)] and osteoporosis [OR (95% CI): 6.22 (1.33-29.2)] were more common in PsA than in DM. Hypertension, but not the other cardiovascular risk factors, was more frequent in DM [OR (95% CI) 0.49 (0.33-0.74)]. However, prevalence of stroke, CAD and MACE did not differ between PsA and DM. Within PsA group, depression was associated with age [OR (95% CI): 1.03 (0.99-1.06)], female sex [OR (95% CI): 3.47 (1.51-7.99)] and smoking [OR (95% CI): 2.78 (1.31-5.88)] while MACEs were associated with age [OR (95% CI): 1.08 (1.00-1.17)], male sex [OR (95% CI) for females: 0.26 (0.06-1.23) and hypertension [OR (95% CI): 6.07 (1.12-33.0)]. No differences were recorded in comorbidities between the different PsA phenotypes.ConclusionDepression was more prevalent in PsA compared with RA and DM, while cardiovascular comorbidity was comparable to both groups, supporting the need for their assessment and management.

Project description:To determine, using data from a real-world setting, the overall and sex-specific risk of cardiovascular (CV) events in patients with rheumatoid arthritis (RA), with or without comorbid hyperlipidemia, relative to those in a non-RA cohort.This retrospective cohort study using claims data from a US commercial health plan (2005-2011) included patients with RA and a matched non-RA cohort. Cox proportional hazards regression model determined the hazard ratio (HR) for CV events (myocardial infarction, stroke, revascularization procedures), using the presence of RA and hyperlipidemia as the independent variables, controlling for other covariates (age, sex, diabetes, and hypertension).The incidence of CV events per 1000 person-years was 10.19 for the RA cohort and 6.41 for the non-RA cohort (crude rate ratio [RR] =1.59). Within the RA cohort, incidence was 15.54 for patients with hyperlipidemia and 7.05 for patients without hyperlipidemia (crude RR=2.21); in the non-RA cohort, incidence was 10.55 and 3.82 for those with and without hyperlipidemia, respectively (crude RR=2.76). After controlling for covariates, the HR of CV events among RA patients was 1.68 (95% CI: 1.50, 1.87) relative to non-RA patients. After multivariable adjustment, hyperlipidemia conferred a significant risk of CV events in both RA and non-RA patients; the interaction between RA and hyperlipidemia was not significant (p=0.13).This real-world analysis demonstrates that patients with RA have an increased risk of CV events. Similar to a non-RA cohort, CV event rates were incrementally higher for those patients with hyperlipidemia.Cardiovascular disease is an increasingly visible topic of concern in the rheumatoid arthritis community. However, there are only limited data that informs both the absolute and relative rates of CVD events, and the contribution of various risk factors such as hyperlipidemia, compared to non-RA populationsThe 'lipid paradox' hypothesis in RA suggests that elevated LDL cholesterol has a negligible effect on CVD risk in RA, unlikely in the general population where it is a well-accepted CVD risk factorThe incidence of CVD events in RA patients was 10/1000 patient years, a 1.6 fold greater risk compared to non-RA patientsThe contribution of hyperlipidemia to CVD risk was associated with comparable or greater absolute increases in the rate of CV events compared to non RA patients, a finding that does not support the lipid paradox.

Dataset Information

Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus.

Publications

Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus.

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