CV risk management in rheumatic and musculoskeletal diseases: EULAR recommendations
Athens, Greece: A recent study published in Annals of the Rheumatic Diseases reports EULAR recommendations for cardiovascular (CV) risk management in rheumatic and musculoskeletal diseases, including antiphospholipid syndrome and systemic lupus erythematosus.
The recommendations for CVR prediction and management based on systematic literature reviews and expert opinion were formulated by a multidisciplinary task force following European League against Rheumatism (EULAR) standardised procedures.
Four overarching principles emphasising the need of regular screening and management of modifiable CVR factors and patient education were endorsed. Nineteen recommendations (eleven for gout, vasculitis, SSc, MCTD, myositis, SS; eight for SLE, APS) were developed covering three topics: (1) CVR prediction tools; (2) interventions on traditional CVR factors and (3) interventions on disease-related CVR factors.
Recommendations
Gout, vasculitis, SSc, myositis, MCTD and SS
CVR prediction tools
- In patients with gout, vasculitis, SSc, myositis, MCTD and SS, we recommend thorough assessment of traditional CVR factors. The use of cardiovascular prediction tools as for the general population is recommended.
- For ANCA-associated vasculitis the Framingham score may underestimate the CVR. Information from the European Vasculitis Society (EUVAS) model may supplement modifiable Framingham risk factors and is recommended to take into account.
Interventions targeting traditional CVR factors
- In patients with gout, vasculitis, SSc, myositis, MCTD, and SS, blood pressure (BP) management should follow recommendations used in the general population.
- In patients with gout, diuretics should be avoided.
- In patients with SSc beta blockers should be avoided.
- In patients with gout, vasculitis, SSc, myositis, MCTD, and SS, lipid management should follow recommendations used in the general population.
- In patients with gout, vasculitis, SSc, myositis, MCTD, and SS, standard use of low-dose aspirin for primary prevention is not recommended. Treatment with platelet inhibitors should follow recommendations used in the general population.
- In patients with gout, we recommend a SUA level below 0.36 mmol/L (6 mg/dL) to potentially lower the risk of cardiovascular events and cardiovascular mortality.
- In patients with gout there is no preference for a particular ULT from the cardiovascular point of view.
Interventions targeting disease-related CVR factors
- In patients with ANCA-associated vasculitis, remission induction and remission maintenance will also reduce CVR.
- In patients with GCA an optimal glucocorticoid regimen that balances the risk of relapse and glucocorticoid use side effects may be considered to also reduce CVR.
SLE and/or APS
CVR prediction tools
- In patients with SLE and/or APS, a thorough assessment of traditional CVR factors and disease-related risk factors is recommended to guide risk factor modification.
Interventions targeting traditional CVR factors
- In patients with SLE, lower levels of BP are associated with lower rates of cardiovascular events and a BP target of <130/80 mm Hg should be considered.
- In patients with lupus nephritis, ACEi or ARBs are recommended for all patients with urine protein-to-creatinine ratio >500 mg/g or arterial hypertension.
- In patients with APS, hypertension management should follow recommendations used in the general population. n patients with SLE and/or APS, hyperlipidaemia treatment should follow recommendations used in the general population.
- Patients with SLE may be candidates for preventive strategies as in the general population, including low-dose aspirin, based on their individual CVR profile.
- In asymptomatic aPL carriers with a high-risk profile with or without traditional risk factors, prophylactic treatment with low-dose aspirin (75–100 mg daily) is recommended. In patients with SLE and no history of thrombosis or pregnancy complications, prophylactic treatment with low-dose aspirin is recommended for those with a high-risk aPL profile and may be considered for those with a low risk APL profile.
Interventions targeting disease-related CVR factors
- In patients with SLE, low disease activity should be maintained to also reduce CVR.
- In patients with SLE, treatment with the lowest possible glucocorticoid dose is recommended to minimise any potential cardiovascular harm.
- In patients with SLE, no specific immunosuppressive medication can be recommended for the purpose of lowering the risk of cardiovascular events.
- In patients with SLE, treatment with hydroxychloroquine (which is recommended for all SLE patients, unless contraindicated) should be considered to also reduce the risk of cardiovascular events.
The authors conclude, these recommendations can guide clinical practice and future research for improving CVR management in rheumatic and musculoskeletal diseases.
Reference:
Drosos GC, Vedder D, Houben E, et alEULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases, including systemic lupus erythematosus and antiphospholipid syndromeAnnals of the Rheumatic Diseases Published Online First: 02 February 2022. doi: 10.1136/annrheumdis-2021-221733
