Early DMARD therapy for rheumatoid arthritis lowers CVD risk: BMJ
UK: Cardiovascular abnormalities are present in early rheumatoid arthritis (ERA) which can be improved using disease-modifying antirheumatic drug (DMARD) therapy, suggests a recent study in the BMJ journal Annals of the Rheumatic Diseases.
Rheumatoid arthritis (RA) patients are at a threefold increased risk of mortality as compared to the general population. This is due to the increased frequency of premature cardiovascular disease (CVD) -- particularly heart failure and atherosclerosis. The risk is as high as that of patients having major CVD risk factors including type 2 diabetes and obesity.
Epidemiological studies have shown an association between contemporary management of RA and reduction in cardiovascular (CV) events. Clinical imaging studies have demonstrated abnormal CV measures mainly in established RA with a varying association to poor prognosis factors of RA. Sven Plein, University of Leeds, Leeds, UK, and colleagues determined whether patients with ERA have CVD that is modifiable with DMARD therapy, comparing first-line etanercept (ETN) + methotrexate (MTX) with MTX strategy.
In this study, the patients from a phase IV ERA trial were randomized to ETN+MTX or MTX strategy±month 6 escalations to ETN+MTX with no CVD and maximum one traditional factor underwent cardiovascular magnetic resonance (CMR) at baseline, years 1 and 2. 30 matched controls underwent CMR. The primary outcome measure was aortic distensibility (AD) between controls and ERA, and baseline to year 1 AD change in ERA.
A total of 81 patients were recruited in the study.
Key findings of the study include:
- In ERA versus controls, respectively, baseline AD was significantly lower (3.0×10−3 mm Hg−1 vs 4.4×10−3 mm Hg−1); LV mass significantly lower (78.2 g, n=81 vs 92.9 g, n=30); and ECV increased (27.1%, n=78 vs 24.9%, n=30).
- Across all patients, AD improved significantly from baseline to year 1 (3.0×10−3 mm Hg−1 to 3.6×10–3 mm Hg−1, respectively), maintained at year 2.
- The improvement in AD did not differ between the two treatment arms and disease activity state (Disease Activity Score with 28 joint count)-erythrocyte sedimentation rate-defined responders versus non-responders.
"We report the first evidence of vascular and myocardial abnormalities in an ERA randomized controlled trial cohort and show improvement with DMARD therapy. The type of DMARD (first-line tumour necrosis factor-inhibitors or MTX) and clinical response to therapy did not affect CVD markers," concluded the authors.
The study, "Cardiovascular effects of biological versus conventional synthetic disease-modifying antirheumatic drug therapy in treatment-naïve, early rheumatoid arthritis," is published in the Annals of the Rheumatic Diseases.
DOI: http://dx.doi.org/10.1136/annrheumdis-2020-217653
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