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People with rheumatoid arthritis (RA) develop heart disease — or cardiovascular disease — at nearly twice the rate of people without RA. Cardiovascular disease is the leading cause of death in the U.S., and kills approximately 655,000 Americans each year.
RA is an autoimmune disorder that typically causes swelling and stiffness in joints. Chronic inflammation also damages other parts of the body, including the heart and blood vessels, in approximately 40 percent of RA cases. People with RA are especially vulnerable to a few common forms of heart disease.
Coronary artery disease (CAD) is the most common form of cardiovascular disease, and occurs when plaque — including cholesterol — builds up on the walls of arteries and limits or blocks the flow of blood, which can cause a heart attack or stroke. People with RA develop CAD at up to twice the average rate.
| Article: Why heart problems are 50% more likely for people with RA |
Heart failure, also called congestive heart failure, occurs when the heart is not pumping blood efficiently, causing stress and damage to the heart muscle. Heart failure can be caused by CAD. One study found that people with RA had a 21 percent greater risk of heart failure.
Atrial fibrillation causes a rapid or irregular heartbeat, sometimes called arrhythmia, and occurs due to disorders in the heart’s electrical system. People with RA are 60 percent more likely to develop atrial fibrillation than those without RA.
To learn more about heart disease and RA, myRAteam spoke with Dr. Iris Navarro-Millán, a rheumatologist and assistant professor of medicine at Weill Cornell Medicine and Hospital for Special Surgery in New York City. Dr. Navarro-Millán specializes in rheumatoid arthritis, with an emphasis on risk reduction for cardiovascular disease in people with RA. “Many patients with rheumatoid arthritis are not aware of these problems, so they are not obtaining adequate screening or adequate treatment,” she said. “There is a gap in their care.”
Dr. Navarro-Millán is an advocate for coordinated care, in which people with RA get primary care along with seeing a rheumatologist. She emphasized that primary care doctors and rheumatologists need to stay in close communication when risk factors are identified. “As rheumatologists, we are really focused on controlling pain, decreasing inflammation, and decreasing and monitoring side effects of medication,” Dr. Navarro-Millán said.
But people with RA need to have regular screenings by primary care providers for cardiovascular disease risk factors like hyperlipidemia — high cholesterol — and high blood pressure. “Many of my patients with rheumatoid arthritis say, ‘Well, I don't have anything else but rheumatoid arthritis. Why should I see a primary care provider?’ And that is where things start to fall through the cracks,” she noted.
One myRAteam member described her experience discovering heart problems unexpectedly. “I am in the hospital with high blood pressure and a high heart rate,” she said. “I went to see my rheumatologist and she sent me straight to the emergency room. I don’t have a history of heart problems or high blood pressure.”
Another member, who has had RA for many years, wrote, “I have been having a major flare. The inflammation has exacerbated problems in my lungs, and today I learned, possibly my heart.” She described feeling isolated and emotionally exhausted. “I'm just tired of fighting the chronic disease battle. Any ideas on how to get motivated again?”
Cardiovascular disease with RA can be managed, but it is challenging. “I had a really bad night. Woke up in the early a.m. with my heart racing and my back tight,” said another myRAteam member. “Since I have coronary artery disease, I immediately thought, ‘heart attack.’ Calmed down and took my blood pressure and saw all was fine, but could not get back to sleep.”
People with RA share certain risk factors for heart disease with the general population, including:
Dr. Navarro-Millán explained that reducing inflammation from RA is key to reducing the risk of cardiovascular disease. “Having rheumatoid arthritis under control, where there is almost no swelling in your joints, no stiffness in your joints, is important in order to decrease this risk,” she said.
When RA disease is active, pro-inflammatory cytokines (molecules in the immune system) are released. These cytokines, along with other pro-inflammatory chemicals, attack healthy tissues, particularly joints and blood vessels. People with RA are especially prone to inflammatory conditions that increase their risks for cardiovascular disease, along with other risk factors that are common in the general population.
Arteriosclerosis causes arteries to thicken and harden, because of the buildup of plaque that can occur due to such factors as high cholesterol or smoking. There is evidence that inflammation from RA can increase the risk of arteriosclerosis, which narrows arteries and restricts blood flow to the heart. Arteriosclerosis can cause high blood pressure (hypertension) or CAD, and may lead to stroke, heart attack, or heart failure.
Metabolic syndrome occurs in as many as 45 percent of people with RA. In this condition, clusters of three or more symptoms, including obesity, elevated blood sugar, high triglycerides, and high blood pressure, contribute to a higher risk for cardiovascular disease.
Some drugs that are commonly used to treat pain and inflammation in RA have been linked to risks for developing heart disease. Nonetheless, some people with RA may still be advised by their doctors to take these drugs when the benefits outweigh the risks.
NSAIDs are available over-the-counter (OTC) and by prescription. They have been linked to an increased risk of heart attack and stroke. Common NSAIDs include aspirin, Advil and Motrin (ibuprofen), Aleve (naproxen sodium), Celebrex (celecoxib), and Voltaren and Solareze (diclofenac sodium), among others.
Prednisone and other steroids that decrease inflammation have also been linked to an increase in the risk of heart disease.
On the other hand, some drugs that are commonly used to treat RA have been shown to have a protective effect on the heart by reducing inflammation that increases the risk of heart disease. These drugs are used to fight inflammation in a number of autoimmune diseases, including RA, and can have side effects that should be discussed with your doctors.
DMARDs are immunosuppressive and immunomodulatory, and are used individually or in combination to fight the underlying cause of autoimmune disease, rather than suppressing symptoms like pain. DMARDs may help protect against heart disease. There are several types of DMARDs.
Older, conventional synthetic DMARDS such as Rheumatrex (methotrexate), Azulfidine (sulfasalazine), and Plaquenil (hydroxychloroquine) have been used to treat RA for decades. Also referred to as synthetic DMARDs, some studies have shown that they may help protect the heart. Methotrexate in particular was shown to decrease the risk of heart failure by approximately 25 percent.
Targeted synthetic DMARDs include Janus kinase inhibitors such as Xeljanz (tofacitinib) and Olumiant (baricitinib), a class that was introduced more recently.
Biologic medications are derived from living cells or tissues. Actemra (tocilizumab), Humira (adalimumab), Enbrel (etanercept), Orencia (abatacept), and Remicade (infliximab) are biologic DMARDs that are commonly prescribed for RA and can be beneficial against heart disease.
One comparative review of studies on the risk of heart problems and RA found that Actemra was associated with a lower risk of major adverse cardiovascular events, while synthetic DMARDs raised the risk. Yet another study found that Orencia was associated with a lower risk for heart attacks compared to biologics that target tumor necrosis factor (TNF), a substance associated with inflammation.
Statins, a class of drugs used to lower cholesterol, have been studied to evaluate the potential to reduce the risk for cardiovascular complications in RA. One study involving 3,002 people found that the statin Lipitor (atorvastatin) could safely and significantly lower cholesterol in people with RA.
Lifestyle changes can also decrease the risk of cardiovascular disease among people with RA. “The American Heart Association and the American College of Cardiology recommend, first and foremost, lifestyle changes,” said Dr. Navarro-Millán.
Quitting smoking is essential, not only to reduce the risk of heart disease, but also to reduce disease activity in RA, Dr. Navarro-Millán said. “Patients with RA who smoke tend to have more aggressive RA, and their disease is more resistant to our current therapies. So quitting smoking is a win-win, because you can achieve better control of your RA and lower the risk for cardiovascular disease,” she said.
Dr. Navarro-Millán also recommends consuming a healthy diet low in fried foods, processed foods, refined sugar, and red meat. Fresh produce and foods with good fats, such as fatty fish like salmon, olive oil, and avocados are good for people with RA.
Physical activity is also important, she said. It not only helps the heart, but can also aid people with RA in losing weight, which is another risk factor for heart disease. Because people with RA have pain and mobility issues, Dr. Navarro-Millán recommends asking your rheumatologist for a referral for physical therapy. “Getting a good evaluation by a physical therapist who can give you a series of exercises that you can do at home is something that can help,” she said. “There are a few studies that have shown that with an adequate program, with some resistance exercises, many patients with rheumatoid arthritis do not experience flares.”
On myRAteam, you’ll find a community of almost 143,000 people who have RA. These members come together to ask questions, give advice, and share their stories with other people who understand life with rheumatoid arthritis.
What is your experience with heart disease and RA? How are you coping with managing your condition? Share your perspectives in the comments below, or go to myRAteam and start a conversation.
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Iris Navarro-Millán, M.D.
is an assistant professor of medicine at Weill Cornell Medicine and the Hospital for Special Surgery in New York City.
Learn more about her here.
Joan Grossman
is a freelance writer, filmmaker, and consultant based in Brooklyn, NY.
Learn more about her here.
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