June 05, 2019
By Julie Gould
Jean Liew, MD, senior fellow in the Division of Rheumatology at the University of Washington, discusses the health care burden patients with both cardiovascular disease and psoriatic arthritis experience and explains why the development of more guidelines in the future can help decrease health care utilization and costs.
First, please tell us a little about yourself and your research interests.
I’m currently a fellow in rheumatology at the University of Washington in Seattle. I first heard about rheumatology from my friend, who was diagnosed with ankylosing spondylitis; she thought this subspecialty would fit my personality. That turned out to be great foresight and great advice. I earned my MD from the University of Texas Medical Branch and went on to complete residency at Oregon Health & Science University in Portland, Oregon. I met great mentors in rheumatology along the way and decided that I wanted to do clinical research. My main area of interest is in cardiovascular diseases and ankylosing spondylitis. I’m currently working with Dr. Lianne Gensler, who runs the Axial Spondyloarthritis clinic at UCSF, on these research topics.
Briefly highlight the prevalence and incidence of cardiovascular disease among patients with AS and PsA. Is it common for this patient population to experience cardiovascular diseases?
Cardiovascular (CV) disease is pretty common among people with AS and PsA, as it is in the general population.
Several studies suggest that CV-related deaths, like from myocardial infarction (MI) and stroke, in PsA and AS may be elevated compared to that in the general population.
There is an increased incidence of MI and stroke in AS – this is from a meta-analysis done in 2018.
Traditional CV risk factors like hypertension, hyperlipidemia, diabetes, and obesity are common in AS and PsA and the prevalence of many if not all of these are increased compared to the general population. For example, in some study populations, the prevalence of hypertension among people with AS is greater than 30% (which is the prevalence in the US adult population, according to a CDC study, NHANES).
How do treatments for inflammatory diseases impact/increase cardiovascular disease risk?
This is a bit complex. On the one hand, treating inflammatory diseases with anti-inflammatory drugs should reduce the risk of cardiovascular disease. We currently think this is the case because, in studies of people without inflammatory disease, we’ve learned that chronic inflammation is a risk factor for MI and stroke. In observational studies in RA, being on biologics like TNF inhibitors is associated with decreased risk of cardiovascular events. Of course, we need to remember that these studies are not controlled trials and they’re observational – we can’t say for sure that being on the biologic causes cardiovascular risk to be reduced. But that’s the association we’re seeing. There aren’t a lot of studies on this in PsA and AS yet, but we expect to see the same trends.
However, other widely used medications for PsA and AS, specifically nonsteroidal anti-inflammatory drugs (NSAIDs) are known to increase blood pressure in the general population. Some studies have suggested an increased risk of cardiovascular events in people who chronically take NSAIDs for arthritis. The competing thought is that, perhaps reducing inflammation by taking NSAIDs might actually counter and mitigate that risk. But more studies are needed before we can draw firmer conclusions.
Can you highlight the findings of your study?
This is a review of prior studies and not a new study itself. We wanted to highlight the following:
- Patients with AS and PsA have an increased prevalence of traditional CV risk factors such as hypertension, dyslipidemia, DM, obesity, and metabolic syndrome.
- The traditional CV risk factors alone do not wholly account for the increased CV burden in these diseases.
- Some treatments, like TNF inhibitors, may decrease overall CV risk, but others like NSAIDs, may increase that risk.
How does increased cardiovascular disease risk among patients with PsA and AS impact health care utilization? Does increased risk for cardiovascular morbidity and mortality increase the cost of care for both the patient and the payer?
Absolutely, having more cardiovascular disease will increase health care utilization and costs. A lot of research effort has been spent on primary and secondary prevention, and we’ve come a long way in the last few decades in this regard. But we still don’t fully understand all the contributors to cardiovascular risk in disease like PsA or AS. It’s more than the traditional risk factors, like hypertension or diabetes. The available risk scores don’t factor in this additional risk, so we’re likely underestimating when we use those calculators. Even with traditional risk factors, there are studies showing that we are under-screening and under-treating conditions like hypertension and diabetes, in people with PsA and AS. We also need to gain better knowledge of the treatments that we use specifically for these conditions, and how they alter the cardiovascular risk profile. And finally, with increasing knowledge, the hope is that we can develop better guidelines on how best to manage cardiovascular risk. All of these things will, in the future, help decrease health care utilization and costs. Prevention is key.
What are the major takeaways from your study? How can clinicians take your findings and implement them?
I think clinicians are generally aware that a rheumatic disease like lupus is associated with increased cardiovascular disease, and they’re becoming more aware that this is true in rheumatoid arthritis as well. I would like to spread this awareness to include AS and PsA. Remember to screen for cardiovascular risk factors like hypertension and hyperlipidemia, and start treatment if indicated. Rheumatologists, cardiologists, and primary care doctors ought to work together for a common goal.
Liew JW, Ramiro S, Gensler LS. Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis [published online March 6, 2019]. Best Pract Res Clin Rheumatol. 2018;32:(3)369-389. doi: https://doi.org/10.1016/j.berh.2019.01.002