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Usefulness of Risk Scores to Estimate the Risk of Cardiovascular Disease in Patients With Rheumatoid Arthritis

https://doi.org/10.1016/j.amjcard.2012.03.044Get rights and content

Patients with rheumatoid arthritis (RA) have an excess burden of cardiovascular (CV) disease (CVD). CV risk scores for the general population may not accurately predict CV risk for patients with RA. A population-based inception cohort of patients who fulfilled 1987 American College of Rheumatology criteria for RA from 1988 to 2007 was followed until death, migration, or December 31, 2008. CV risk factors and CVD (myocardial infarction, CV death, angina, stroke, intermittent claudication, and heart failure) were ascertained by medical record review. Ten-year predicted CVD risk was calculated using the general Framingham and the Reynolds risk scores. Standardized incidence ratios were calculated to compare observed and predicted CVD risks. The study included 525 patients with RA aged ≥30 years without previous CVD. The mean follow-up period was 8.4 years, during which 84 patients developed CVD. The observed CVD risk was 2-fold higher than the Framingham risk score predicted in women and 65% higher in men, and the Reynolds risk score revealed similar deficits. Patients aged ≥75 years had observed CVD risk >3 times the Framingham-predicted risk. Patients with positive rheumatoid factor or persistently elevated erythrocyte sedimentation rates also experienced more CVD events than predicted. In conclusion, the Framingham and Reynolds risk scores substantially underestimated CVD risk in patients with RA of both genders, especially in older ages and in patients with positive rheumatoid factor. These data underscore the need for more accurate tools to predict CVD risk in patients with RA.

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Methods

This retrospective, population-based study was conducted using the resources of the Rochester Epidemiology Project, a medical records linkage system that allows ready access to the complete (inpatient and outpatient) medical records from all community medical providers.6 An incidence cohort of all residents of Olmsted County, Minnesota, aged ≥18 years who first fulfilled 1987 American College of Rheumatology classification criteria for RA from January 1, 1988, to December 31, 2007, was

Results

The study included 525 patients with RA aged ≥30 years without previous CVD (mean age 57 years, 69% women) who were followed for a mean of 8.4 years and 524 patients without RA of similar age, gender, and follow-up duration. Table 1 lists the characteristics at the incidence or index date for patients with and without RA.

The general Framingham risk score and the office-based Framingham risk score were calculated. The 2 assessments were similar, but the office-based Framingham risk score yielded

Discussion

The Framingham risk score substantially underestimated CVD risk in patients with RA of both genders, especially in older ages and in patients with positive rheumatoid factor and those with persistently elevated erythrocyte sedimentation rates. This indicates that RA disease severity and inflammation play a role in CVD risk that is not accounted for in the Framingham risk score. In addition, the Reynolds risk score underestimated CVD risk in women with RA, despite its inclusion of C-reactive

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    This work was funded by grants from Pfizer, Inc., New York, New York, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR46849), Bethesda, Maryland, and made possible by the Rochester Epidemiology Project (Grant R01 AG034676 from the National Institute on Aging, Bethesda, Maryland).

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