Surprise rheumatoid arthritis link to aortic stenosis

3 minute read

A large cohort study found people with the condition were also 34% more likely to have an aortic valve intervention.

A large US cohort study has found an increased risk of aortic stenosis in people with rheumatoid arthritis.

The study, published in JAMA Internal Medicine, reported that people with RA had a 48% increased risk of aortic stenosis, independent of traditional cardiovascular risk factors, when compared with matched controls.

People with RA were also 34% more likely to have an aortic valve intervention, suggesting a more severe disease course necessitating procedural intervention, and had a 26% increased risk of aortic stenosis-related death.

The authors said that the findings emphasise the potentially underrecognised contribution of valvular heart disease to the cardiovascular disease-related mortality gap in RA patients.

“We hope that these findings highlight to providers that aortic stenosis and valvular heart disease should be considered in addition to CV diagnoses more often studied, such as coronary artery disease and heart failure when thinking about cardiovascular risk in RA,” lead author Dr Tate Johnson of the University of Nebraska Medical Center told The Medical Republic.

“This could be applied, for instance, to an RA patient with exercise intolerance or shortness of breath that might be mistakenly attributed to reduced functional status as a product of their articular disease alone”, said Dr Johnson.

“As part of their evaluation, providers should think about valvular heart disease in this scenario and consider echocardiographic screening.”

Using data from US medical databases, the researchers included around 73,000 patients with RA and 640,000 matched controls without RA and followed them up for an average of 8-9 years.

Primary outcome was incident aortic stenosis, a composite of aortic stenosis diagnosis, aortic valve intervention (including surgical aortic valve replacement and transcatheter aortic valve replacement) and aortic stenosis-related death. Secondary outcomes were these individual components.

Being mainly from the Veterans Health Administration database, the cohort was mostly male (around 87%), and had a mean age of 63.

There were 3.97 aortic stenosis events per 1000 person-years in the RA group, compared with 2.45 events per 1000 person-years in the controls, representing an absolute increase in risk of 1.52 aortic stenosis events per 1000 person-years. After adjusting for potential confounders, the adjusted hazard ratio was 1.48.

Age, BMI and hypertension were independently associated with an increased risk of aortic stenosis, while female patients and Black or Hispanic patients had a lower risk.

There was a modest increase in aortic stenosis risk among patients with elevated baseline ESR or CRP levels, with the authors suggesting that more severe disease activity might be linked with a higher risk of developing aortic stenosis.

Patients who received “more aggressive RA treatments”, such as b/tsDMARDs and glucocorticoids, were also more likely to develop aortic stenosis, adding further support to the association between disease severity and aortic stenosis, the authors said.

“These data were in line with results of preclinical studies suggesting that higher degrees of systemic inflammation were a risk factor for aortic stenosis in patients with RA and a factor in aortic stenosis progression in a prior RA cohort,” wrote the authors.

“Continued research is warranted to elucidate the inflammatory pathways mediating aortic stenosis risk and severity in RA cohorts.”

The main limitations of the study were the small absolute risk difference and the lack of generalisability to the RA population – as mentioned earlier, the cohort was mainly males, whereas RA is more common in females.

“While additional study is needed to understand whether we can accurately risk stratify patients for aortic stenosis, or if specific RA treatment strategies are more effective in reducing valvular heart disease risk, these data can perhaps be used as an additional argument to treat RA to a target low disease activity level,” Dr Johnson told TMR.

JAMA Internal Medicine 2023, online 31 July

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