What is the most likely complication to occur as a result of Rheumatoid Arthritis (RA)?

Ischaemic Heart Disease is the Most Likely Complication

The answer is (e) - Ischaemic heart disease. Patients with rheumatoid arthritis face a doubled risk of myocardial infarction compared to the general population, with cardiovascular disease representing the primary driver of excess mortality in RA. 1

Why Ischaemic Heart Disease is Most Likely

Magnitude of Risk

• RA patients are twice as likely as the general population to suffer a myocardial infarction, with this elevated cardiovascular risk appearing early in the disease course 1
• The excess cardiovascular risk extends beyond what traditional risk factors alone would predict, driven by systemic inflammation and a prothrombotic state 1
• RA patients experience 5-10 years shorter life expectancy than those without the condition, with cardiovascular disease being the predominant cause of this mortality gap 1
• Even after myocardial infarction occurs, RA patients have higher mortality rates compared to non-RA patients 1

Pathophysiologic Mechanisms

• Chronic systemic inflammation in RA directly promotes accelerated atherosclerosis through elevated inflammatory markers (C-reactive protein, interleukin-6, tumor necrosis factor-α) 1, 2
• The inflammatory burden causes endothelial dysfunction, abnormal coronary microvascular function, and enhanced plaque vulnerability independent of traditional cardiovascular risk factors 3, 2
• RF-positive patients (like many with established RA) carry particularly elevated cardiovascular risk, with RF positivity serving as an independent risk factor for cardiovascular morbidity and mortality 4

Clinical Evidence Base

• Population studies demonstrate a 2-fold increased risk of heart failure in RA patients compared to non-RA populations, even after controlling for traditional risk factors 1
• The increased risk for silent myocardial infarction and sudden cardiac death in RA patients makes cardiovascular complications particularly dangerous 5
• Approximately 50% increased risk of ischemic heart disease exists in RA patients compared to age-matched controls without traditional atherosclerotic risk factors 6

Why Other Options Are Less Likely

Hypertension (Option b)

• While hypertension can develop in RA patients, it represents a risk factor rather than a direct complication of the disease itself 3
• The inflammatory process may contribute to blood pressure elevation, but this is less specific and less clinically significant than the direct cardiovascular complications 3

Type 2 Diabetes, Colorectal Cancer, and Chronic Lymphocytic Leukemia

• These conditions are not established complications of rheumatoid arthritis based on the available guideline evidence
• No high-quality guidelines identify these as direct disease-related complications of RA

Clinical Implications for This Patient

Risk Assessment

• This 50-year-old woman requires cardiovascular risk assessment every 5 years minimum, with consideration of applying a 1.5 multiplier to standard CVD risk calculations for RA patients 4
• Screen for traditional cardiovascular risk factors (smoking, lipids, blood pressure) as these compound the RA-specific inflammatory risk 1

Disease Control as Prevention

• Aggressive RA disease control targeting remission is critical for cardiovascular risk reduction, as persistent inflammation drives atherosclerotic progression 4
• Treatment with methotrexate and other disease-modifying antirheumatic drugs has been associated with reduced cardiovascular event rates in observational studies 1
• Lifestyle modifications including smoking cessation, dietary modification, and increased exercise are particularly important in RA patients 1

Common Pitfall

• The most dangerous pitfall is failing to recognize that cardiovascular risk is elevated from early in the disease course, not just in long-standing RA 1
• Many RA patients experience silent ischemia, so absence of cardiac symptoms does not exclude significant cardiovascular disease 5