Disease modification and cardiovascular risk reduction: two sides of the same coin?

Inflammatory rheumatic diseases are associated with a substantial increase in accelerated atherosclerosis, with complex interactions between traditional and disease-related risk factors. Therefore, cardiovascular risk reduction should be considered as integral to the control of disease activity in the care plans of patients with RA, SLE and, arguably any chronic inflammatory disease. Shared care structures, already established for the monitoring of DMARDs, could be adapted to communicate and monitor cardiovascular risk reduction objectives. We review the evidence for the efficacy of a range of therapeutic strategies, the majority of which impact on both disease activity and cardiovascular risk. The algorithm proposed here attempts to distil the latest advice from specialist panels at the National Cholesterol Education Program and the British Hypertension Society, as well as incorporating the existing data on SLE and RA patients. The algorithm is structured to minimize clinic time and resources necessary to stratify patients into groups for ROUTINE, SUBSTANTIAL or INTENSIVE risk management; the associated table summarizes optimal therapeutic objectives in each of these groups. The implication of this algorithm is that management of cardiovascular risk should be much more aggressive than is currently the norm in patients with chronic inflammatory diseases, such as RA and SLE. Long-term studies of such interventions are needed to further clarify the benefits of intensive cardiovascular risk management in these patients. A number of recent observations indicate that chronic inflammation is not merely associated with accelerated atherosclerosis but that aberrant cellular and humoral immune responses are integral to its pathogenesis (reviewed in [1]). Therefore, therapeutic objectives in chronic inflammatory and cardiovascular disease converge, and agents prescribed as either immune or lipid modulators may be modifying both inflammatory and cardiovascular disease. The recent report that atorvastatin has disease-modifying activity in rheumatoid arthritis (RA) [2] emphasizes the relevance of this concept to rheumatology practice. This article summarizes the evidence for excess risk of accelerated atherosclerosis in inflammatory rheumatic disease with particular reference to RA and systemic lupus erythematosus (SLE). Recent insights into therapies which may modulate both articular and vascular disease are discussed, and an algorithm for managing cardiovascular risk in the context of inflammatory rheumatic disease is proposed.