Rheumatoid Arthritis and Heart Health

February is American Heart Month and I would like to draw awareness to the cardiovascular risks that rheumatoid arthritis patients can experience. This can range from increased risk of heart attacks and strokes to inflammation of the lining around the heart and lungs.

Increased Risk of Heart Disease

Rheumatoid arthritis doesn’t just cause inflammation locally in the joints and musculoskeletal tissues. Research studies also show elevated systemic inflammation which is widespread in the entire body and affects the blood vessels. In fact, many studies have shown 48-50% higher risk of cardiovascular disease associated with rheumatoid arthritis. Higher levels of inflammation in the bloodstream can lead to faster development of atherosclerosis, which is abnormal plaque build-up on injured blood vessel walls that eventually lead to heart attacks and strokes.

Patients with RA can also have inflammation of the lining of the heart and lung tissue, resulting in pericarditis (inflammation of the heart lining) or pleural effusions (fluid build-up around the lungs). Typically, cardiovascular risks are higher when RA is uncontrolled and has higher disease activity level. Disease activity level can be reflected in the amount of joint pain, swelling, and stiffness a patient is experiencing, as well as certain lab markers of inflammation. Lowering the disease activity level of RA and reducing the frequency of flares can be beneficial for heart health.

Medication Side Effects

Patients living with RA have greater exposure to medications with side effects, such as prednisone or ibuprofen. Taking frequent courses of prednisone over long periods of time can cause complications like weight gain, diabetes, and increased coronary artery disease. Over-the-counter medications such as Advil and Aleve are safe for the average person in moderation, but when overused can also cause damage to organs such as the heart or kidneys.

Lowering Traditional Risk Factors

Traditional risk factors for cardiovascular disease should be lowered as much as possible. This could include steps such as quitting smoking, losing weight, controlling high blood pressure and/or high cholesterol, and management of diabetes. The anti-inflammatory diet for autoimmune diseases is very similar to the Mediterranean diet for heart health. This includes increasing fruits and vegetables consumption, while reducing red meats, sugars, and processed foods. Adding nuts and fish containing omega-3 fatty acids are also helpful. Antioxidant foods and beverages such as berries and green tea are recommended for both RA and heart health.

Reduce RA Disease Activity

Controlling the disease activity level of RA will not only help with reducing pain and improving the function of your joints, but it will also protect your heart and blood vessels against long-term damage from inflammation. Treatments such as methotrexate, hydroxychloroquine, and certain biologics have been found in research studies to have direct beneficial effects in reducing inflammation in blood vessel walls. This guards against damage and plaque build-up leading to heart attacks and strokes.

Patients living with RA often find it difficult to stay physically active and exercise. A sedentary lifestyle and lack of physical activity can be another risk factor for developing heart disease. As RA is treated to remission, exercise becomes more realistic and can further lead to better heart health.

P. S. One of my favorite uses for my juicer is to make freshly squeezed pomegranate juice at home. Pomegranates have high levels of antioxidants to help with both joint health and heart health. Using the juicer means I don't have to deal with the seeds and can enjoy all the anti-inflammatory benefits of the juice!

References:

1. England BR, Thiele GM, Anderson DR, Mikuls TR. Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications. BMJ. 2018 Apr 23;361:k1036. doi: 10.1136/bmj.k1036. PMID: 29685876; PMCID: PMC6889899.

2. Blum A, Adawi M. Rheumatoid arthritis (RA) and cardiovascular disease. Autoimmun Rev. 2019 Jul;18(7):679-690. doi: 10.1016/j.autrev.2019.05.005. Epub 2019 May 3. Retraction in: Autoimmun Rev. 2020 Sep;19(9):102601. PMID: 31059840.

3. Semb AG, Ikdahl E, Wibetoe G, Crowson C, Rollefstad S. Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol. 2020 Jul;16(7):361-379. doi: 10.1038/s41584-020-0428-y. Epub 2020 Jun 3. PMID: 32494054.

4. Bridges SL Jr, Niewold TB, Merriman TR. Is Rheumatoid Arthritis a Causal Factor in Cardiovascular Disease? Arthritis Rheumatol. 2022 Oct;74(10):1612-1614. doi: 10.1002/art.42236. Epub 2022 Aug 25. PMID: 35583794.

5. Murphy L. Cardiovascular disease risk in rheumatoid arthritis. Br J Nurs. 2022 Feb 24;31(4):190-192. doi: 10.12968/bjon.2022.31.4.190. PMID: 35220731.

6. Hannawi S, Hannawi H, Al Salmi I. Cardiovascular disease and subclinical atherosclerosis in rheumatoid arthritis. Hypertens Res. 2020 Sep;43(9):982-984. doi: 10.1038/s41440-020-0483-4. Epub 2020 Jun 1. PMID: 32483312.

7. Ozen G, Pedro S, Michaud K. The Risk of Cardiovascular Events Associated With Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis. J Rheumatol. 2021 May;48(5):648-655. doi: 10.3899/jrheum.200265. Epub 2020 Aug 15. PMID: 32801134.

8. Atzeni F, Rodríguez-Carrio J, Popa CD, Nurmohamed MT, Szűcs G, Szekanecz Z. Cardiovascular effects of approved drugs for rheumatoid arthritis. Nat Rev Rheumatol. 2021 May;17(5):270-290. doi: 10.1038/s41584-021-00593-3. Epub 2021 Apr 8. Erratum in: Nat Rev Rheumatol. 2021 Apr 16;: PMID: 33833437.

9. Dey M, Cutolo M, Nikiphorou E. Beverages in Rheumatoid Arthritis: What to Prefer or to Avoid. Nutrients. 2020 Oct 15;12(10):3155. doi: 10.3390/nu12103155. PMID: 33076469; PMCID: PMC7602656.

10. Chehade L, Jaafar ZA, El Masri D, Zmerly H, Kreidieh D, Tannir H, Itani L, El Ghoch M. Lifestyle Modification in Rheumatoid Arthritis: Dietary and Physical Activity Recommendations Based on Evidence. Curr Rheumatol Rev. 2019;15(3):209-214. doi: 10.2174/1573397115666190121135940. PMID: 30666911.