Cardiovascular risk and rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion.
OBJECTIVE
To develop clinical practice guidelines for the evaluation and management of cardiovascular risk in patients with rheumatoid arthritis (RA), using the evidence-based approach and expert opinion.


METHODS
Recommendations were developed using the evidence-based approach and expert opinion: A scientific committee used a Delphi procedure to select five questions, which formed the basis for developing the recommendations; Evidence providing answers to the five questions was sought in the literature; Based on this evidence, recommendations were developed by a panel of experts.


RESULTS
The recommendations were as follows: 1) In patients with RA, attention should be given to the risk of cardiovascular disease, which is responsible for an excess burden of morbidity and mortality; 2) It must be recognized that RA may be an independent cardiovascular risk factor. Persistent inflammation is an additional risk factor; 3) The cardiovascular risk should be evaluated, and modifiable risk factors should be corrected; 4) In patients with RA requiring glucocorticoid therapy, the need for cardiovascular risk minimization is among the reasons that mandate the use of the minimal effective dose; 5) It should be recognized that methotrexate may protect against cardiovascular mortality in patients with RA; 6) It should be recognized that TNFalpha antagonists remain contraindicated in patients with RA and severe heart failure. TNFalpha antagonists do not seem to worsen moderate heart failure and may protect against cardiovascular mortality; 7) AFSSAPS recommendations about LDL-cholesterol objectives should be followed, with active RA being counted as a cardiovascular risk factor; 8) In patients with RA, statin therapy should be considered only when cholesterol levels are elevated despite appropriate dietary treatment; 9) RA per se does not indicate aspirin for primary prevention. When aspirin is used for secondary prevention, it should be recognized that concomitant treatment with nonsteroidal antiinflammatory drugs (NSAIDs) may decrease the antiplatelet effects and increase the gastrointestinal side effects of aspirin therapy.
Pham
Thao
T
Service de rhumatologie, CHU de la Conception, Marseille, France.
Gossec
Laure
L
Constantin
Arnaud
A
Pavy
Stephan
S
Bruckert
Eric
E
Cantagrel
Alain
A
Combe
Bernard
B
Flipo
René-Marc
RM
Goupille
Philippe
P
Le Loët
Xavier
X
Mariette
Xavier
X
Puéchal
Xavier
X
Schaeverbeke
Thierry
T
Sibilia
Jean
J
Tebib
Jacques
J
Wendling
Daniel
D
Dougados
Maxime
M
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000188:drug therapy; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D015995:Prevalence; D011379:Prognosis; D012307:Risk Factors; D015996:Survival Rate
D000894:Anti-Inflammatory Agents, Non-Steroidal; D005938:Glucocorticoids; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D007166:Immunosuppressive Agents; D008727:Methotrexate