Arthritis & Heart Disease

Why People With Arthritis Are at Greater Risk for Heart Disease

You’re probably all too aware of how arthritis affects your joints. But the unfair news is that having arthritis – osteoarthritis (OA), but especially inflammatory conditions like rheumatoid arthritis (RA), gout, lupus and psoriatic arthritis – puts you at increased risk of developing heart disease. That includes heart attack, stroke, atrial fibrillation (irregular heartbeats), high blood pressure, heart failure and atherosclerosis (plaque in the arteries).

People with RA tend to be at highest risk. More than 50 percent of premature deaths in people with rheumatoid arthritis result from cardiovascular disease, according to a 2011 review of 24 mortality studies published in Nature Reviews Rheumatology.

People with gout also have a higher risk of heart attack and death from cardiovascular and coronary heart disease. High uric acid levels – a cause gout – have been linked to a 44% increased risk of high blood pressure, according to a 2011 review published in Arthritis Care & Research.

As for people with OA, a study of 8,000 people in Finland, published in the Annals of Rheumatic Diseases, found that men with OA in even a single finger joint were 42% more likely to die of cardiovascular disease than those who didn’t have OA. Women were at a 26% higher risk than those without the disease. The link may be excess weight.

So, why the double whammy of increased heart disease risk when you have arthritis?

Chronic Inflammation 

“Inflammation, regardless of where it comes from, is a risk factor for heart disease,” says rheumatologist Jon T. Giles, MD, assistant professor of medicine at Columbia University School of Medicine in New York City. “So it’s not surprising that people with inflammatory arthritis like RA, lupus and psoriatic arthritis have more cardiac events.”

Inflammation’s cardiac troublemaking works somewhat like this: The inflammatory cells get into blood vessel walls where they make cytokines, immune system proteins that promote more inflammation, says Dr. Giles. “Then the cytokines recruit more inflammatory cells, so they perpetuate the process.”

Inflammation also reshapes blood-vessel walls, making the deposited plaque more prone to rupture. A rupture, in turn, can trigger a heart attack.

The risk isn’t limited to those with inflammatory arthritis. Although OA is not in itself inflammatory, its damage can cause inflammation, which increases the risk of heart disease.

But, as indicated in a 2011 Arthritis & Rheumatism review, inflammation doesn’t act alone. RA patients have to have high levels of inflammation plus other heart disease risk factors, such as high blood pressure or diabetes, before inflammation increases the risk of atherosclerosis.  “The implication is that, in order to reduce cardiovascular risk, you have to reduce not just inflammation, but also the conventional risk factors like high blood pressure, diabetes, high lipids [body fats] and smoking,” says Dr. Giles, the review author.

You do that, he says, by making sure your rheumatologist works with you to get inflammatory arthritis under control so that you have the lowest amount of systemic inflammation possible.

Lifestyle Factors 

According to the American Heart Association, there are six independent risk factors for heart disease that you can modify or control: smoking, high cholesterol, high blood pressure, inactivity, obesity and diabetes.

These also correlate with arthritis. According to the Centers for Disease Control and Prevention (CDC), 52% of people with diabetes have arthritis, 53% with arthritis have high blood pressure, 66% with arthritis are overweight, and about 20% of people with arthritis smoke. Those risks appear to culminate in another formidable figure: According to a National Health Interview Survey, one in four adults with any form of arthritis also has heart disease.

Smoking raises blood pressure and makes it tougher to exercise. It also lowers HDL, or good cholesterol, and speeds up plaque build-up in arteries. “Smoking raises the risk of RA and of heart disease,” says Mayo Clinic researcher Cynthia Crowson. “The best thing you can do is to stop smoking.”

Diet and exercise can help you lose weight, lower blood pressure and cholesterol, and manage diabetes. Getting that exercise can be especially difficult for those with OA who are overweight or obese. It’s a vicious cycle: You’re in pain, so you don’t exercise, and not exercising means your joints hurt more. That can lead to a sedentary lifestyle that increases your heart disease risk. But you can reduce your risk of heart disease by starting slowly and sticking with a diet and exercise program.

Medications

Most ironic is that some of the very medications that help control arthritis can raise heart disease risk. On the flip side, some reduce risk. Here’s a breakdown of what the research shows so far.

Those that may harm the heart:

• Tocilizumab (Actemra). Approved by the FDA in January 2010, this drug for RA remains under scrutiny. “The FDA has required the makers to study its cardiovascular safety,” says rheumatologist Daniel H. Solomon, MD, professor of medicine and the Matthew H. Liang distinguished chair in arthritis and population health at Harvard Medical School in Boston. The drug raises cholesterol levels, he adds, so anyone taking it should have her cholesterol monitored, and, if it is high, take statin medications.
• Prednisone. This corticosteroid commonly used to control inflammation may oddly enough raise heart disease risk. “Prednisone can cause a worsening of blood pressure,” says Boston Medical Center rheumatologist Peter Grayson, MD. “You retain fluids with steroids and gain weight, which can increase heart disease risk even when you’re lowering inflammation.” You always want to try to be on as low a dose of steroids as possible, says Dr. Solomon. “Steroids have an incredible effect at reducing inflammation. So the goal is to balance the potential benefit on pain and function with the deleterious effects on the heart.”
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). It’s not news that these drugs can affect the heart. “The reason that NSAIDs and COX-2 inhibitors raise risk is not entirely clear,” says Dr. Solomon. “They appear to have a deleterious effect on the body’s ability to keep its blood vessels open, and that raises blood pressure. But they also have beneficial effects on pain. Again, you need to balance the potential benefits and the risks.”

Other common arthritis medications offer heart-protective benefits, including these: 

• Tumor necrosis factor-alpha inhibitors. A 2011 study published in the Annals of Rheumatic Diseases found that patients who took these biologics, such as etanercept (Enbrel), infliximab (Remicade) or adalimumab (Humira), had a reduced risk of heart disease. A 2011 Johns Hopkins study found that RA patients taking TNF inhibitors had a 37% lower rate of thickening in their carotid arteries than those not taking it, says Dr. Giles. However, a study published in the American Heart Journal found that, in elderly patients with RA, TNF inhibitors raised the risk of heart failure. The effect of TNF inhibitors is clearly different on the heart muscles than it is on the arteries, says Dr. Giles. 
• Methotrexate. This disease-modifying antirheumatic drug (DMARD) is often the first drug given to people with RA. A 2010 British review of 18 studies, published in Rheumatology, found that people with RA taking methotrexate lowered their heart disease risk. “A large amount of research shows that methotrexate can reduce the risk of heart disease,” says Dr. Solomon, possibly by reducing the build-up of plaque in the arteries. A current NIH-funded trial is studying the effects of methotrexate on heart disease risk.
• Hydroxychloroquine (Plaquenil). A 2011 British review published in Current Opinions in Lipidology found that hydroxychloroquine improved heart disease risk factors such as blood sugar and cholesterol levels – though Dr. Solomon notes that the drug is not directly associated with a reduced risk of heart disease.

It may seem terribly unjust when you have arthritis to be forced also to worry about your heart. But the silver-lining insight may be that caring for both your heart and your arthritis will keep you eating well, exercising and smoke-free, which will keep you healthy in many other ways.