Reply

G. D. Kitas and N. Erb

Rheumatology, Dudley Group of Hospitals NHS Trust, Tipton Road, Dudley, West Midlands DY1 4SE, UK

Correspondence to: G. D. Kitas. E-mail: g.d.kitas{at}bham.ac.uk

It is encouraging to see the growing interest of the rheumatological community in the prevention of cardiovascular disease (CVD) in rheumatoid arthritis (RA). The findings of Saravana et al. are not surprising. In a similar study of CVD risk factors in rheumatology out-patients, we found even higher levels of comorbid CVD than that detected by Saravana et al. (total cardiovascular comorbidity 34%; angina 16%, previous myocardial infarct 8%, cerebrovascular accident 4%, peripheral vascular disease 2%, treatment for hypertension 28%, and treatment for hypercholesterolaemia 4%). Of more concern is that in the remaining RA patients with no known CVD we also found a high prevalence of hypertension (systolic blood pressure >140 mmHg in 56.4%), hypercholesterolaemia (total cholesterol >5 mmol/l in 71.3%) and obesity (mean body mass index 27.6 kg/m2). Also, 22.3% were current smokers and 5.3% had diabetes mellitus [1]. These results are similar to those of other groups in the UK [2] and the USA [3].

We entirely agree with Saravana et al. that lipids and obesity are important factors in the development of CVD, but we believe that they should not be viewed or managed in isolation. We would advocate using a composite scoring system for the calculation of CVD risk to prevent undue emphasis being placed on any one risk factor to the detriment of others. There are several risk calculators based on the original Framingham data and modified over the ensuing years, as more accurate risk prediction models have been developed. In our clinics we use the Joint Societies Risk calculator [4], which is widely available at the back of the British National Formulary books and as an on-line version, and is rapid and easy to use in the clinical setting.

We recognize that implementing CVD risk assessment in busy rheumatology out-patient departments is difficult. However, we feel that at present this is by far the most appropriate setting. Even though evidence for increased cardiovascular mortality in RA has been around for a long time, awareness of it has started to become widespread amongst the rheumatological community only recently. It is likely (indeed this has been our experience locally) that awareness of this problem in primary care will lag even further behind. Once CVD risk assessment in RA is established in secondary care, and some peculiarities of it in the RA population have been sorted out through further research (e.g. the significance and interpretation of lipid levels during active inflammation), education and support for primary care physicians in undertaking this activity will be easier.

The authors have declared no conflicts of interest.

References

  1. Erb N, Banks MJ, Rowe IF, Kitas GD. Classical risk factors for ischaemic heart disease (IHD) in rheumatoid arthritis (RA). Rheumatology 2001;40S:70.
  2. McEntegart A, Capell HA, Creran D, Rumley A, Woodward M, Lowe GD. Cardiovascular risk factors, including thrombotic variables, in a population with rheumatoid arthritis. Rheumatology 2001;40:640–4.[Abstract/Free Full Text]
  3. Wolfe F, Freundlich B, Straus WL. Increase in cardiovascular and cerebrovascular disease prevalence in rheumatoid arthritis. J Rheumatol 2003;30:36–40.[Medline]
  4. Joint British recommendations on prevention of coronary heart disease in clinical practice: summary. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association. BMJ 2000;320:705–8.[Free Full Text]
Accepted 12 June 2003





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