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 rheumatic 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, studies show. High uric acid levels – found in many people with gout – have been linked to a 44 percent increased risk of high blood pressure, according to a 2011 review of 18 studies published in Arthritis Care & Research. “Two studies have made us think that uric acid is causal,” says Boston Medical Center rheumatologist Peter Grayson, MD, lead author of the review.

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 percent more likely to die of cardiovascular disease than those who didn’t have OA. Women were at a 26 percent 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? Here’s a rundown of the reasons.

Chronic inflammation. If there’s an alpha-dog villain that places people with inflammatory arthritis at greater risk of heart disease, it’s 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. “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. Some researchers speculate that there may be a link between the bone damage in OA and blood vessel damage.

But, as indicated in a Johns Hopkins University study published online in Arthritis & Rheumatism, inflammation doesn’t act alone. Researchers found that RA patients had to have high levels of inflammation plus other heart disease risk factors, such as high blood pressure or diabetes, before inflammation increased 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 lead study author, who was at Johns Hopkins at the time.

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

Also key: Don’t ignore risk factors for heart disease while trying to manage your arthritis. “Having a strong relationship between your rheumatologist and primary doctor can play a big role,” Dr. Giles says. “Your primary doctor can keep [your rheumatologist] aware of risk factors like cholesterol and blood pressure levels. Then you can all work toward the same goal.”

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 percent of people with diabetes have arthritis, and 53 percent with arthritis have high blood pressure. Sixty-six percent of people with arthritis are overweight. And about 20 percent 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.

Here’s how these lifestyle factors affect your heart health.

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. According to a study presented at the Endocrine Society’s 91st Annual Meeting, nicotine also promotes insulin resistance, or prediabetes, which raises the risk of heart disease.

“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.” In fact, according to the Cleveland Clinic, one year after quitting, heart disease risk drops to half that of a smoker. After five years, stroke risk drops to that of a non-smoker.

Diet and exercise can help you lose weight, lower blood pressure and cholesterol, and manage diabetes – although that’s often easier said than done, especially for those with OA who are overweight or obese. In fact, an August 2011 study in Arthritis & Rheumatism found that 40 percent of men and 57 percent of women with knee OA were classified as “inactive” – that is, they did not get even one 10-minute session in a week of moderate to vigorous activity.

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. You can take control of lifestyle factors by starting slowly and sticking with it. Try a few simple dietary changes: for instance, swap one daily sugar-sweetened beverage for a glass of water, fried chicken for grilled chicken or a cupcake for a handful of heart-healthy nuts.

The U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans recommend that everyone, including those with arthritis, get 150 minutes of moderate exercise per week. That's 30 minutes a day, five days a week. But if you’re in constant pain or just inactive, the key is to just get moving. Start with a walk down the street and back every day, if that’s all you can handle – and build up gradually. Your joints will feel better and your heart will be healthier. According to the University of Maryland Medical Center, people who are active have a 45 percent lower risk of heart disease than do couch potatoes and a 35 percent lower risk of high blood pressure. 

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, associate professor of medicine at Harvard Medical School. 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 may raise heart disease risk. A 2011 study published in the Annals of Rheumatic Diseases found that risk of cardiovascular events or death rose as the prednisone dose rose. “Prednisone can cause a worsening of blood pressure,” says Dr. Grayson. “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. “Obviously, 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, and the evidence keeps mounting. A 2011 Swiss review of 31 trials published in the journal BMJ found that COX-2 inhibitors and traditional NSAIDs, except for naproxen (Aleve), raised the incidence of heart attack, stroke or heart-related deaths by two to four times. Danish researchers reported in Circulation, Cardiovascular Quality and Outcomes that diclofenac had the highest threat, increasing the relative risk of a fatal heart attack or stroke by 91 percent. 

     Even short-term NSAID use appears to be a problem. A 2011 study published in Circulation found that NSAIDs taken for up to seven days raised the risk of heart attack by 45 percent in patients who had already had one attack. After three months, the risk increased to 55 percent, Copenhagen University Hospital researchers found.

NSAIDs, including the COX-2 inhibitor celecoxib (Celebrex) also can raise the risk of atrial fibrillation, according to a 2011 Danish study published in BMJ.

“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 drugs, commonly called anti-TNF drugs,such as etanercept (Enbrel), infliximab (Remicade) or adalimumab (Humira), had a reduced risk of heart disease. They block inflammation-inducing cytokines involved not only in RA, but also in psoriatic arthritis and ankylosing spondylitis. The Johns Hopkins study that found inflammation plus other heart disease factors are at work in raising RA patients’ heart risks also found that those taking TNF inhibitors had a 37 percent lower rate of thickening in their carotid arteries than those not taking it, says Dr. Giles. Thickened arteries signal early atherosclerosis.

     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.
  • Hydroxychloroquine (Plaquenil). A 2011 British review published in Current Opinions in Lipidology found that hydroxychloroquine, an antimalarial drug used to treat RA and lupus, 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.

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