People with rheumatoid arthritis (RA) are also at higher risk for other serious conditions including atherosclerotic cardiovascular disease (ASCVD).1-4 Cholesterol testing is one of several preventive health screenings recommended for adults to assess their ASCVD risk. A primary care provider (PCP) usually performs these regular screenings and assessments. Screening for elevated cholesterol can result in early and optimized treatment of high cholesterol, which can result in prevention of ASCVD and cardiovascular events.5
PCPs, including general internists and family medicine doctors, typically manage and coordinate most of the health care a patient receives.6,7 This includes wellness check-ups and critical screening, such as for cancer and risk factors for heart attack and stroke.8 PCPs also provide lifestyle counseling and pharmacological treatment for conditions such as hypertension, hyperlipidemia, and type 2 diabetes.7,8 PCPs assess all of a patient’s medical problems and refer and defer to specialists, when needed, for the treatment of complex or chronic conditions.7
Patients with RA usually require a specialist called a rheumatologist who has special training to manage their disease.9 In the best case, a patient’s PCP and rheumatologist communicate and work together to provide streamlined and comprehensive care. However, the rheumatologist does not usually perform the types of regular screening, such as lipid testing, for which PCPs are primarily responsible.8
The 2018 American College of Cardiology/American Heart Association Guideline for the Management of Blood Cholesterol identifies chronic inflammatory conditions including RA as “CVD risk-enhancing factors”.5 These are factors that are not accounted for in the standard ASCVD risk calculation and carry a greater lifetime risk than is reflected by the 10-year risk pooled cohort equation prediction model. (This model is discussed in detail in other PALS articles about ASCVD risk and its calculation.) The guideline states that risk-enhancing factors need to be considered independently when determining the level of risk and decision to treat. This is particularly true for those with an intermediate ASCVD risk (7.5% to ≤20% 10-year risk) in whom the chronic inflammatory condition would likely tip the balance towards initiating a statin. This guideline also recommends a fasting lipid test and ASCVD risk assessment for monitoring lipid-lowering drug therapy (LLT) before and 4 to 12 weeks after starting inflammatory disease therapy. It also recommends these steps for adults with RA two to four months after their RA is controlled. These are all steps that make sense for the rheumatologist who is managing the RA disease management to manage, too.
References
- Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 2008; 59 (12): 1690-1697.
- Bartels CM, Buhr KA, Goldberg JW, et al. Mortality and cardiovascular burden of systemic lupus erythematosus in a US population-based cohort. J Rheumatol 2014; 41 (4): 680-687.
- Crowson CS, Matteson EL, Roger VL, Therneau TM, Gabriel SE. Usefulness of risk scores to estimate the risk of cardiovascular disease in patients with rheumatoid arthritis. Am J Cardiol 2012; 110 (3): 420-424.
- Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 2017; 76 (1): 17-28.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol. Circulation 2018: Cir0000000000000625.
- U.S. National Library of Medicine. Choosing a primary care provider. 2017; https://medlineplus.gov/ency/article/001939.htm. Accessed June 7, 2019.
- Shi L. The impact of primary care: a focused review. Scientifica (Cairo) 2012; 2012: 432892.
- Curry SJ, Krist AH, Owens DK. Eighth Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services. U.S. Preventive Services Task Force; Nov 2018.
- Rat AC, Henegariu V, Boissier MC. Do primary care physicians have a place in the management of rheumatoid arthritis? Joint Bone Spine 2004; 71 (3): 190-197.
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