title: Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies.
abstract: OBJECTIVE
  To determine the magnitude of risk of cardiovascular mortality in patients with rheumatoid arthritis (RA) compared with the general population through a meta-analysis of observational studies.
  
  
  METHODS
  We searched Medline, EMBase, and Lilacs databases from their inception to July 2005. Observational studies that met the following criteria were assessed by 2 researchers: 1) prespecified RA definition, 2) clearly defined cardiovascular disease (CVD) outcome, including ischemic heart disease (IHD) and cerebrovascular accidents (CVAs), and 3) reported standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs). We calculated weighted-pooled summary estimates of SMRs (meta-SMRs) for CVD, IHD, and CVAs using the random-effects model, and tested for heterogeneity using the I(2) statistic.
  
  
  RESULTS
  Twenty-four studies met the inclusion criteria, comprising 111,758 patients with 22,927 cardiovascular events. Overall, there was a 50% increased risk of CVD death in patients with RA (meta-SMR 1.50, 95% CI 1.39-1.61). Mortality risks for IHD and CVA were increased by 59% and 52%, respectively (meta-SMR 1.59, 95% CI 1.46-1.73 and meta-SMR 1.52, 95% CI 1.40-1.67, respectively). We identified asymmetry in the funnel plot (Egger's test P = 0.002), as well as significant heterogeneity in all main analyses (P < 0.0001). Subgroup analyses showed that inception cohort studies (n = 4, comprising 2,175 RA cases) were the only group that did not show a significantly increased risk for CVD (meta-SMR 1.19, 95% CI 0.86-1.68).
  
  
  CONCLUSIONS
  Published data indicate that CVD mortality is increased by approximately 50% in RA patients compared with the general population. However, we found that study characteristics may influence the estimate.
authors.affiliation: University of British Columbia and Arthritis Research Centre of Canada, British Columbia, Canada. azubieta@arthritisresearch.ca
authors.forename: J Antonio
authors.initials: JA
authors.lastname: Aviña-Zubieta
authors.forename: Hyon K
authors.initials: HK
authors.lastname: Choi
authors.forename: Mohsen
authors.initials: M
authors.lastname: Sadatsafavi
authors.forename: Mahyar
authors.initials: M
authors.lastname: Etminan
authors.forename: John M
authors.initials: JM
authors.lastname: Esdaile
authors.forename: Diane
authors.initials: D
authors.lastname: Lacaille
mesh_terms: D001172:Arthritis, Rheumatoid / Q000150:complications*; D002318:Cardiovascular Diseases / Q000401:mortality*; D016001:Confidence Intervals; D006801:Humans; D017202:Myocardial Ischemia / Q000401:mortality; D020521:Stroke / Q000401:mortality