Rheumatology Advance Access originally published online on June 23, 2008
Rheumatology 2008 47(8):1252-1254; doi:10.1093/rheumatology/ken232
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LETTERS TO THE EDITOR |
An audit of recording cardiovascular risk factors in patients with rheumatoid arthritis and systemic lupus erythematosus in centres in East Anglia and the South East
1Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, 2Department of Rheumatology, St Albans and Hemel Hempstead NHS Trust, St Albans, 3Department of Rheumatology, The Edith Cavell Hospital, Peterborough, 4Rheumatology Department, Chase Farm Hospital, Enfield, 5Department of Rheumatology, Oldchurch Hospital, Romford, 6Rheumatology Department, Watford General Hospital, Watford, 7Department of Rheumatology, North Middlesex Hospital, London, 8Department of Rheumatology, Luton and Dunstable Hospital, Luton, 9Department of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, 10Department of Rheumatology, Ipswich Hospital, Ipswich and 11Department of Rheumatology, Hinchingbrooke Hospital, Huntingdon, UK
Correspondence to: F. C. Hall, School of Clinical Medicine, University of Cambridge, Box 157, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK. E-mail: fch22{at}medschl.cam.ac.uk
SIR, RA and SLE are known to be associated with a substantially increased risk of cardiovascular disease, with complex interactions between traditional and disease-related risk factors. As a prelude to implementing changes in cardiovascular risk management, seven centres which contribute to the East Anglian Rheumatology Society collaborated in an audit of existing cardiovascular risk reduction practice in patients with RA and SLE by assessing:
- the efficiency of recording risk factors and
- the frequency of patients with unmodified risk.
The records of 100 RA patients and 65 SLE patients across seven centres in East Anglia and the South East were audited. For each patient, an index visit prior to May 2005 was identified (in order to ensure that practice assessed was that prevalent prior to implementing new initiatives). Records from all specialties, including electronic records/results, were examined to assess whether the following information had been recorded at any time in the preceding year:
- Blood pressure
- Random total cholesterol
- Either random or fasting blood glucose, or HbA1c, or urinalysis
- Current corticosteroids equating to >7.5 mg prednisolone
- History of corticosteroids for >6 months.
Records of the following risk factors were sought in paper and electronic records over the preceding 5 yrs:
- Smoking history
- Family history of premature cardiovascular disease (first degree relatives: males <55 yrs, females <65 yrs)
- Coronary heart disease (CHD)
- Diabetes mellitus
- Stroke
- Transient ischaemic attack (TIA)
- Peripheral vascular disease (PVD)
- Aortic aneurysm
- Carotid artery occlusion (>50%).
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From the data recorded, the proportion of patients with unmodified risk was calculated for modifiable risk factors (hyperglycaemia, hypercholesterolaemia, hypertension, current corticosteroid usage and smoking) (Fig. 1b). Unmodified risk was defined as a value of categorical or continuous variable (e.g. current smoking or blood pressure (BP)
140 mmHg, respectively) which is associated with increased cardiovascular risk. Hyperglycaemia was defined as either random blood glucose >10.0 mmol/l or fasting blood glucose >6.7 mmol/l or HbA1c >6.3% or glycosuria on urinalysis. Hypercholesterolaemia was defined as a total cholesterol >5.2 mmol/l. Hypertension was defined as either a systolic BP 140 mmHg and/or a diastolic BP 85 mmHg. Current corticosteroid usage >7.5 mg prednisolone (or equivalent) was recorded as an unmodified risk factor. The use of this threshold dose is, to some extent, arbitrary. Cardiovascular risk may be increased, even by low doses of corticosteroids [1]. However, risk increases with cumulative corticosteroid exposure and low-dose corticosteroids are frequently prescribed for their disease-modifying effects in the joints [2]. The dose threshold below which the patient derives net benefit therefore remains unclear. Smoking, at any level, was considered a modifiable risk factor. Wherever several records exist for a given field over a 5-yr period, data from the most recent record were used for the audit. Figure 1a indicates that a substantial proportion of patients have no secondary care record of cardiovascular risk factors, despite the inclusion of electronic and paper records from all specialties. Figure 1b demonstrates that, where modifiable risk factors have been recorded, a substantial proportion of patients have unmodified risk. This is based on the numbers of patients indicated in the figure.
A multi-centre prospective study in the western part of the region was running concurrently to assess the burden of unmodified cardiovascular risk in RA. This study assessed clinical cardiovascular risk factors in consecutive outpatients with RA over a year in seven rheumatology units. At least one clinical cardiovascular risk factor was recorded in 146/337 (44%) patients. CHD was present in 8% patients, 21% had PVD, 5% had cerebrovascular disease and 7.4% had diabetes mellitus; these patients all have a high (>20%) 10-yr risk of a further cardiovascular event. In addition, 62% of RA patients were prescribed lipid-lowering medication, 34% were prescribed anti-hypertensive medication, 28% were current smokers, 50% had a BMI >25 and 9% had inadequately managed hypothyroidism. This study did not assess lipid profiles or blood pressure, so the efficacy of these therapies is unknown in this group.
This multi-centre audit suggests that cardiovascular risk is inadequately managed in patients with RA and SLE, despite appreciation that these conditions are associated with an increased burden of cardiovascular disease. This may reflect the complexity of managing chronic multisystem disease within limited consultation times. A North American study suggests that management of comorbidity by specialists is superior to generalists; however, both are suboptimal [3]. The General Medical Services contract highlights the importance of considering cardiovascular risk in individuals with hyperlipidaemia, diabetes mellitus or of 40 yrs. Corrections are suggested for smokers and for individuals with a family history of premature cardiovascular disease, with impaired glucose tolerance or with Indian subcontinent ancestry. However, no corrections are currently advised for individuals with RA or SLE. It is important to note that the retrospective East Anglian Rheumatology Society audit reported here is likely to underestimate attention to risk factors, since the outcome of verbal enquiries regarding history of established vascular disease, smoking, etc. may not have been recorded, especially if negative. However, examination of data for modifiable risk factors from both the retrospective audit and the concurrent prospective study suggest a substantial burden of inadequately managed cardiovascular risk.
Therefore, although cardiovascular risk factors are generally assessed and managed in primary care, the increased risks associated with RA and SLE are rarely considered. The complexity of these diseases is likely to further reduce the probability of a thorough cardiovascular risk assessment. It is important that rheumatology specialists highlight the need for vigorous cardiovascular risk reduction and provide guidance for primary care practitioners. We have previously proposed an algorithm for managing cardiovascular risk in patients with RA and SLE [4], available online at http://www.medschl.cam.ac.uk/medtools/chd1.php. In this algorithm, patients are stratified into high-, medium- and low-risk groups and targets for blood pressure and fasting LDL cholesterol concentration are set for each risk group.
Inevitably, a number of obstacles are likely to impede the ability of rheumatology teams to reduce cardiovascular risk in RA and SLE patients. The elevated cardiovascular morbidity and mortality in patients with RA and SLE is still not widely recognized in primary and secondary care. Limitation of clinic time and information technology, together with a lack of strategic clarity each hinder implementation of effective cardiovascular risk reduction. Many rheumatology departments have or are developing annual assessments for patients with RA. We advocate that a cardiovascular risk assessment, such as that offered by the algorithm above, be included in such schemes for both RA and SLE patients. Furthermore, we believe that cardiovascular risk reduction would most effectively be embedded in an integrated care pathway, which is implemented collaboratively by primary and secondary health care teams.
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Acknowledgement |
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 Top Acknowledgement References |
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The authors would like to thank Catherine Molyneaux for assistance with data collection.
Disclosure statement: F.C.H. has declared that Actelion funded research on biomarkers of vascular disease as well as the services of a part-time research nurse; Pfizer provided an unrestricted grant for the development of the Cardiovascular Risk Reduction website. J.G. received funding from Roche, Wyeth and Procter & Gamble. All other authors have declared no conflicts of interest.
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References |
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TopAcknowledgementReferences |
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- Davis JM, Maradit Kremers H, Crowson CS, et al. Glucocorticoids and cardiovascular events in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum (2007) 56:820–30.[CrossRef][Web of Science][Medline]
- Kirwan JR, Bijlsma JW, Boers M, Shea BJ. Effects of glucocorticoids on radiological progression in rheumatoid arthritis. Cochrane Database Syst Rev (2007) (1). CD006356.
- MacLean CH, Louie R, Leake B, et al. Quality of care for patients with rheumatoid arthritis. J Am Med Assoc (2000) 284:984–92.
[Abstract/Free Full Text] - Hall FC, Dalbeth N. Disease modification and cardiovascular risk reduction: two sides of the same coin? Rheumatology (2005) 44:1473–82.
[Abstract/Free Full Text]
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