How do you risk stratify patients with rheumatoid arthritis?

Risk Stratification in Rheumatoid Arthritis Patients

Patients with rheumatoid arthritis (RA) should be risk stratified using a 1.5 multiplication factor applied to standard cardiovascular risk assessment tools when they meet specific disease criteria, with assessment performed at least every 5 years. 1

Cardiovascular Risk Assessment

Rheumatoid arthritis significantly increases cardiovascular disease (CVD) risk, with patients having approximately 70% higher risk of myocardial infarction compared to the general population - equivalent to the risk of non-RA individuals who are 10 years older 1. This elevated risk necessitates systematic risk stratification.

Primary Risk Assessment Protocol:

1. Frequency of Assessment:

   • Perform CVD risk assessment at least once every 5 years 1
   • Reassess after major changes in antirheumatic therapy 1
   • More frequent assessment for patients with intermediate risk or rapid disease progression 1

2. Risk Calculation Method:

   • Use SCORE risk calculator or national guideline-recommended tool 1
   • Apply 1.5 multiplication factor to the calculated risk when specific criteria are met 1

3. Multiplication Factor Criteria - Apply 1.5 multiplier when patient meets two of these three criteria:

   • Disease duration >10 years
   • Rheumatoid factor (RF) or anti-CCP antibody positivity
   • Presence of extra-articular manifestations 1, 2

4. Lipid Assessment:

   • Measure total cholesterol (TC) and HDL cholesterol (HDLc) 1
   • Use TC/HDL ratio when using SCORE model 1
   • Perform measurements when disease activity is stable or in remission 1
   • Non-fasting lipid measurements are acceptable 1

Risk Categorization

After applying the multiplication factor, categorize patients as:

• Low to moderate risk: SCORE <5%
• High risk: SCORE ≥5% and <10%
• Very high risk: SCORE ≥10% 1

Disease-Specific Risk Factors

Beyond traditional risk factors, consider these RA-specific factors that contribute to increased CVD risk:

1. Inflammatory burden:

   • Persistent elevated inflammation 1
   • Disease activity and duration of flares 1

2. Serological markers:

   • RF and anti-CCP positivity 1, 2
   • Dual positivity indicates higher risk for aggressive disease 2

3. Disease characteristics:

   • Extra-articular manifestations 1, 3
   • Functional disability 1
   • Disease duration >10 years 1

4. Comorbidities:

   • Hypothyroidism 1
   • Presence of carotid plaques 1

Management Based on Risk Stratification

1. For all RA patients:

   • Optimize disease activity control to lower CVD risk 1
   • Recommend healthy lifestyle (diet, regular exercise, smoking cessation) 1
   • Minimize corticosteroid use (lowest dose possible) 1
   • Use NSAIDs with caution, especially in those with documented CVD or risk factors 1

2. For high-risk and very high-risk patients:

   • Treat all present CVD risk factors according to existing guidelines 1
   • Consider statins, ACE inhibitors, and/or AT-II blockers as preferred treatment options 1
   • More aggressive monitoring and treatment of traditional risk factors 1

3. For patients with established CVD:

   • Aggressive secondary prevention according to national guidelines 1
   • Consider screening for asymptomatic atherosclerotic plaques using carotid ultrasound 1

Common Pitfalls and Caveats

1. Lipid paradox: Patients with highly active RA may have lower serum TC and LDL-c levels despite elevated CVD risk 1. Don't be falsely reassured by low lipid levels in active disease.

2. Medication effects:

   • Anti-inflammatory treatments may alter lipid profiles 1
   • DMARDs (methotrexate, leflunomide, sulfasalazine) and biologics may reduce CV risk 3
   • Corticosteroids and some NSAIDs may increase CV risk 1

3. Undertreatment: Studies show substantial undertreatment of lipid-associated cardiovascular risk in RA patients, with 58-95% of at-risk patients not receiving statins 4. Ensure appropriate treatment is initiated.

4. Responsibility gap: Ensure clear responsibility for CVD risk management, as this often falls between rheumatologists and primary care physicians 1. The rheumatologist should ensure that CVD risk assessment is performed regularly and coordinate care appropriately.